heart health

  • A Healthy Heart At Every Age

    A Healthy Heart At Every Age Ann Louise Gittleman

    Even if heart disease “doesn't run in your family,” this article is for you. Even if you have low cholesterol levels and your blood pressure is normal, this article is for you, too. This information doubles as both prevention and treatment— and its knowledge is critical for us all.

    In the past, you may have thought of heart disease as an illness that you associated predominately with men. These days, we know that more than one in three women have some form of cardiovascular disease. As of the 2016 fact sheet from the American Heart Association, 398,086 females passed away from cardiovascular disease or congenital cardiovascular disease, with 402,851 males passing away from the same. Further, they've found that 90 percent of women have one or more risk factors for heart disease or stoke and that fewer women survive their first heart attack than men. This illness clearly does not favor one gender.

    So, what causes heart disease? Simply put, cardiovascular disease results when the lumens of the coronary arteries, which carry blood, oxygen, and nutrients to the heart, become smaller. This constriction can be caused by excess salt in the blood pulling fluid from the arteries. Arteries are further constricted by a buildup of fats, oxidized cholesterol, excess calcium, and plaque in the artery walls. Angina, or chest pain, occurs when the heart fails to receive enough oxygen through these narrowed arteries. When these arteries become obstructed, a heart attack can occur, resulting in damage to the heart tissue. This process of plaque buildup and obstruction is known as atherosclerosis, or hardening of the arteries.

    What Are the Risks?
    There are over 250 risk factors for heart disease that have been identified. However, you'll be relieved to know that a large number of these factors—including many that are especially dangerous—can be lowered with lifestyle choices and changes. However, two risk factors associated with heart disease are beyond your control: heredity and age. For both men and women, the closer your blood-tie to a relative who suffered from heart disease, the greater your risk of developing it. In addition, age is a factor for women. As women reach menopause, their risk factor of developing heart disease rises significantly. Regardless if your family history predisposes you to a higher risk or not or your current age, there are certain risk factors that you should be mindful to pay close attention to. Let's touch on a few that you can begin making changes to reduce today.

    High Blood Pressure
    Hypertension, or high blood pressure, is both a cause and an effect of cardiovascular disease. The exact cause of hypertension is generally unknown, but what we do know is that high blood pressure often accompanies heart disease. The excessive force of the blood against the arteries weakens the cellular walls, allowing LDL (“bad”) cholesterol, excess calcium, and other toxic substances to form deposits that eventually block the arteries. Almost 50 percent of all midlife women are diagnosed with hypertension by age 50. Most who have hypertension are unaware of it because it usually produces no physical symptoms. Routine blood pressure checks, at least every two years, can detect potential hypertension; blood pressure readings above 140/90 may spell danger. Because so many test results have shown a direct relationship between high salt intake and hypertension, removing the salt shaker from your table would be wise. Sodium is a factor in hypertension because it causes fluid retention, which adds stress to both the heart and the circulatory system. Hypertension, left undiagnosed or untreated, can result in stroke, heart attack, kidney failure, and other serious diseases.

    Let's face facts: if you still smoke, your chances of dying from heart disease are almost three times as great as those of dying from lung cancer. The negative effects of smoking on your cardiovascular system are related to several actions. Nicotine causes blood platelets to become sticky, increasing plaque formation. Smoking also has been shown to decrease levels of HDL (“good”) cholesterol and increase LDL (“bad”) cholesterol. Cigarettes are high in cadmium, a toxic mineral that damages heart tissue. The Nurses' Health Study, conducted by Harvard researchers, found that women who smoked just one to four cigarettes a day had nearly two and one-half times the rate of heart disease of nonsmokers. Keep in mind that even secondhand smoke increases your risk of heart disease, so make your home and car smoke-free environments.

    Unfortunately for us, weight appears to be a more significant risk factor for women than it is for men. A study by Harvard researcher JoAnn Manson, MD, found that in obese women, seven out of ten cases of heart disease resulted from their excess weight. Even women who are at the high end of their “normal” range seem to have an increased risk. To compound the problem, overweight women tend to be sedentary; they are also more likely to develop hypertension, high LDL cholesterol and triglycerides, and type 2 diabetes, all of which increase the likelihood of heart disease. How the weight is distributed on your body also seems to have an impact.

    Women with an apple body shape—who have a proportionally higher amount of fat around their abdomen than elsewhere on their body—have higher rates of heart disease, hypertension, and diabetes than their pear-shaped sisters, who carry their excess fat in their hips and thighs. Scientists believe this association relates to the hormone cortisol, which causes fatty acids to be released into the bloodstream from the central fat cells. These cells are located close to your liver; the released fatty acids stress the liver, causing cholesterol, blood pressure, and insulin levels to rise. Psychology researcher Elissa S. Epel has also discovered that apple-shaped women feel stress more and produce more cortisol as a result than do pear-shaped women.

    For us women, diabetes is an additional risk factor for heart disease. Blood platelets in diabetics seem to stick together more readily than in non-diabetics, causing clogging of the arteries. Diabetics also have higher total cholesterol and lower HDL cholesterol levels. Research shows that women over the age of 45 are twice as likely as men to develop type 2 (formerly known as adult-onset) diabetes, and female diabetics are at double the risk of heart disease of male diabetics. The good news is that type 2 diabetes can be managed with diet and exercise.

    A Sedentary Lifestyle
    Movies depicting life on the nineteenth-century American frontier and Canadian wilderness are harsh reminders of just how physically demanding everyday life once was. We might enjoy watching someone else chop wood, carry buckets of water long distances, and walk behind a plow horse, but few of us would trade in our computers, microwave ovens, and central heating to live that life. All our muscles, including our heart, need exercise, however. Exercise helps lower LDL cholesterol and raise HDL cholesterol. Regular aerobic exercise—such as walking, running, jumping rope, and dancing—reduces the risk of heart disease by about 30 percent in postmenopausal women. It also influences several other risk factors.

    People who exercise regularly have a 35 percent lower risk of hypertension, as well as a lower risk of diabetes. Exercise stimulates production of serotonin, endorphins, and other brain chemicals that reduce anxiety and stress and create a balanced sleep-wake cycle, helping to control cortisol levels. When you exercise, you also aid calcium metabolism, triggering the calcification process within your bones so excess calcium does not build up in your blood vessels. And you don't even need to spend one to two hours a day in strenuous activity to achieve cardiovascular benefits. Do keep in mind that over exercising can be just as harmful as being a couch potato. Moderate exercise, performed regularly, significantly decreases your risk of heart disease.

    No matter your age, stage, and gender, it's import to make daily choices that love your heart and your health.

  • Kyolic Aged Garlic’s Hypertension Benefits Confirmed

    Kyolic Aged Garlic’s Hypertension Benefits Confirmed Hypertension. It's a primary risk factor for stroke and heart attack—and it affects nearly one in three Americans. 1,2 Among those who have been diagnosed with hypertension, about half don't have their condition under control.1 Of more concern, an estimated 18 percent of those with the condition are unaware that they suffer from high blood pressure.3 That's not surprising since hypertension often has no tangible symptoms. And nearly 30 percent of American adults suffer from pre-hypertension, a condition that puts them at risk of developing clinical hypertension.2 While pharmaceuticals can bring the pressure down, recent studies show that a daily dose of Kyolic aged garlic extract (AGE) safely and effectively reduces blood pressure and benefits a number of other cardiovascular risk factors.

    Findings slated to be presented at the 5th Science of Nutrition in Medicine and Healthcare Conference in Australia, provide clear evidence that supplementing with AGE can effectively reduce blood pressure levels. In addition, AGE has a positive impact on arterial stiffness. The double-blind, placebo-controlled study, which was jointly conducted by Australia's National Institute of Integrative Medicine, Bond University, and the University of Australia, divided 88 patients with uncontrolled hypertension into two groups. One group was given 1.2 grams of AGE daily and the other was given a placebo. After 12 weeks, the researchers found that the patients taking AGE saw an average 11.5 mmHg reduction in their systolic blood pressure and an average 6.3 mmHg drop in their diastolic blood pressure compared to placebo. In addition, the study's authors note that AGE improved pulse wave velocity, a measure of arterial stiffness. The study also flushed out smaller benefits to the inflammatory marker TNF-α, total cholesterol, LDL cholesterol, and apolipoproteins—all factors that increase the risk of a future heart attack.4

    Another study recently presented at the American College of Cardiology's 64th Annual Scientific Session & Expo lends further evidence to Aged Garlic Extract's ability to lower blood pressure. During the study, which was conducted at the Harbor-University of California, Los Angeles Medical Center, four placebo-controlled, double-blind, randomized studies were pooled to examine AGEs effect on blood pressure. The studies involved a total of 161 people who were randomized to take either 1,000 mg of AGE or a placebo daily for one year. All of the subjects had their blood pressure checked at the beginning and the end of the study. Testing was also done to determine the progression of coronary artery calcification. One year later, the UCLA researchers noted marked reductions in diastolic blood pressure among the participants who took AGE. Coronary artery calcification was also significantly lower in those who had taken the AGE supplements. In fact, AGE inhibited the progression of coronary artery calcification an average 1.78 fold compared to the placebo over the course of the study.5 These findings build upon previous research in the journal Maturitas which found that AGE reduced systolic blood pressure an average of 10.2 mm Hg compared to placebo, leading the researchers to conclude that AGE offers benefits similar to first-line medication used to treat uncontrolled hypertension.6


    1. CDC: Vital signs: awareness and treatment of uncontrolled hypertension among adults—United States, 2003–2010. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6135a3.htm.
    2. CDC: Deaths: Final data for 2009. www.cddc.gov/nchs/data/nvsr60/nvsr60_03.pdf.
    3. Yoon SS, Burt V, Louis T, et al. Hypertension Among Adults in the United States, 2009–2010. NCHS data brief, no 107. Hyattsville, MD: National Center for Health Statistics. 2012.
    4. Ried K, Travica N, Sali A. Aged Garlic Extract for hypertension and arterial stiffness: The AGE at heart trial. Scheduled for presentation at The 5th Science of Nutrition in Medicine and Healthcare Conference. Pullman Melbourne on the Park, Australia. May 2–3, 2015.
    5. Hom C, Luo Y, Budoff M. The Effects of Aged Garlic Extract on Coronary Artery Calcium Progression and Blood Pressure. Presented at ACC.15 64th Annual Scientific Session & Expo. San Diego, CA March 14–16, 2015.
    6. Ried K, Frank OR, Stocks NP. Aged garlic extract lowers blood pressure in patients with treated but uncontrolled hypertension: a randomized controlled trial. Maturitas. 2010;67(2):144–50.
  • Optimizing Energy Production with Ribose

    Feel Like You Could Use More Energy?
    One of the consequences of our stressful modern life is an increased need for energy. With less sleep and the depletion of nutrients in our food supply, however, it is getting harder and harder for our bodies to keep up.

    There is a lot out there about how competitive athletes can up their energy. Although the approach we’ll discuss below is also excellent for athletes, it was developed, and is outstanding, for the rest of us. Whether you are a mom trying to juggle a fast paced hectic life, a student on a fast food diet, or just trying to optimize your day to day energy, here’s how to get from being fatigued to feeling fantastic!

    Having spent the last 30 plus years specializing in treating chronic fatigue and chronic pain, we have learned about the keys to energy production. As an unexpected fringe benefit, these treatments have also offered enormous benefits to those suffering from heart disease.

    Optimize energy production with the “SHINE Protocol” Ribose (and our overall approach to treating fatigue) has been highlighted by Dr. Oz, “America’s Doctor” on Oprah, in his wonderful new book YOU: Being Beautiful—The Owner’s Manual to Inner and Outer Beauty.

    In addition, our research has shown that severely fatigued people with Chronic Fatigue Syndrome (CFS) and Fibromyalgia can increase their energy by an average of 90 percent (see the published study at www.Vitality101.com) by treating with “SHINE”: Sleep, Hormonal support, Infections, Nutrition and Exercise. For mild fatigue, the physical keys to optimizing energy are Nutrition, Sleep and Exercise, while the emotional key is to start paying attention to what feels good—while letting go of things that don’t.

    How Do I Start?
    Given my hectic schedule as an educator and physician, people often ask me what I do to keep my energy turbo charged. I like to keep it simple, so here is what I do personally. All of the vitamins, minerals and other essential nutrients are important to health, and the American diet is so highly processed that people have widespread deficiencies. Because of this, I like to use vitamins that make supplementation simple.

    Why Ribose—And What Is Ribose?
    Ribose, also called D-Ribose, is the key to your body’s energy production. Ribose is a special, five-carbon sugar (known as a pentose by biochemists) that is found naturally in our bodies. But ribose is not like any other sugar. Sugars we are all familiar with, such as table sugar (sucrose), corn sugar (glucose), milk sugar (lactose), honey (predominantly fructose), and others are used by the body as fuel. These sugars are consumed and, with the help of the oxygen we breathe, are “burned” by the body to recycle energy. Because they are used excessively, they become toxic— acting as energy loan sharks.

    Ribose, on the other hand, is special. When we consume ribose, the body recognizes it is different from other sugars and preserves it for the vital work of actually making the special “energy molecules” (called ATP, NADH, and FADH) that power our hearts, muscles, brains, and every other tissue in the body. These represent the energy currency in your body, and are like the paper that money is printed on. You can have all the fuel you want, but if it cannot be converted to these molecules, it is useless. For years, I talked about the importance of B vitamins, which are a key component of these molecules. These helped improve energy to a degree, but it was clear that a key component was missing. In looking at the biochemistry of these energy molecules, they are also made of two other key components-adenine and ribose. Adenine is plentiful in the body and supplementing with adenine did not help energy production. We then turned our attention to Ribose.

    Ribose is made in your body in a slow, laborious process and cannot be found in food. We knew that severe fatigue and stress causes your body to dump other key energy molecules like acetyl-L-carnitine. We then found that the body did the same with Ribose, making it hard to get your energy furnaces working again even after the other problems were treated.

    This was one of those “Eureka!” moments where things came together. Not having Ribose would be like trying to build a fire without kindling—nothing would happen. We wondered if giving Ribose to people with fatigue and even CFS would jumpstart their energy furnaces. The answer was a resounding yes! Our recently published study (see the study abstract at www. Vitality101.com) showed an average 44.7 percent increase in energy after only three weeks (improvement began at 12 days) and an average overall improvement in quality of life of 30 percent. Two-thirds of the study patients felt they had improved. Usually a 10 percent improvement for a single nutrient is considered excellent. A 44.7 percent increase left us amazed, and I am now recommending Ribose for all of my chronic fatigue, chronic pain and fibromyalgia patients, for athletes, and for any one with fatigue or heart problems. Ribose recently became available (over the counter) to physicians, and is one of the few natural products actually starting with physicians and then moving out into supplement companies and health food stores. It is critical to use the proper dose for the first three weeks, which is five grams (5000 mg) three times a day. It can then be dropped to twice a day (and often even once a day in the morning with the vitamin powder to maintain optimized energy for those that are otherwise healthy).

    Normal, healthy heart and muscle tissue has the capacity to make the ribose it needs. But when we are chronically stressed by life or illness, it helps to have extra ribose to help boost energy production.

    The Scientific Link Between Ribose, Energy, And Fatigue
    Clinical and scientific research has repeatedly shown giving ribose to energy deficient hearts and muscles stimulates energy recovery. Research in Ribose and fatigue began with a case study that was published in the prestigious journal Pharmacotherapy in 2004. This case study told the story of a veterinary surgeon diagnosed with fibromyalgia. For months, this dedicated doctor found herself becoming more and more fatigued, with pain becoming so profound she was finally unable to stand during surgery. As a result, she was forced to all but give up the practice she loved.Upon hearing that a clinical study on ribose in congestive heart failure was underway in the university where she worked, she asked if she could try the ribose to see if it might help her overcome the mind-numbing fatigue she experienced from her disease. After three weeks of ribose therapy she was back in the operating room, practicing normally with no muscle pain or stiffness, and without the fatigue that had kept her bedridden for many months. Being a doctor, she was skeptical, not believing that a simple sugar could have such a dramatic effect on her condition. Within two weeks of stopping the ribose therapy, however, she was out of the operating room and back in bed. So, to again test the theory, she began ribose therapy a second time. The result was similar to her first experience, and she was back doing surgery in days. After yet

    Several of the patients participating in the study have contacted me regarding the relief they found with ribose therapy. Most importantly, they speak to the profound joy they feel when they are able to begin living normal, active lives after sometimes years of fatigue, pain, and suffering. Here is a sample of what one patient, Julie (Minnesota), an elementary teacher, wrote: “I had so much pain and fatigue I thought I was going to have to quit teaching. When I take [ribose], I feel like a huge weight is being lifted from my chest, and I’m ready to take on those kids again!” The relief patients feel with ribose therapy is heartwarming, and goes directly to the dramatic impact ribose has on increasing energy, overcoming fatigue, enhancing exercise tolerance, and raising the patient’s quality of life.

    a third round of stopping (with the return of symptoms) and starting (with the reduction of symptoms) the ribose therapy, she was convinced, and has been on ribose therapy since that time. I found this report intriguing and decided to design a larger study in patients with fibromyalgia or chronic fatigue syndrome which I began to discuss earlier. Our study included 41 patients with a diagnosis of fibromyalgia or chronic fatigue syndrome who were given ribose at a dose of five grams three times per day for three weeks. We found the ribose treatment led to significant improvement in energy levels, sleep patterns, mental clarity, pain intensity, and well being. Of the patients participating in the study, 65.7 percent experienced significant improvement while on ribose, with an average increase in energy of 44.7 percent and overall well being of 30 percent- remarkable results from a single nutrient! The only significant side effects were two people felt too energized and hyper/anxious on the ribose. This is simply dealt with by lowering the dose and/or taking it with food.

    The good news is that we now have a wonderful tool to increase energy naturally. Take five grams of ribose three times per day for three weeks, then twice a day (can be mixed with any liquid or food) for two to three weeks, and then one to two times per day to see what it will do for you. You’ll be amazed!

  • The B Vitamins For Stress, Energy, Heart Health & More

    What are they?
    The water-soluble B vitamins are collectively referred to as "B-Complex." They include thiamine (B1), riboflavin (B2), niacin or niacinamide (B3), pyridoxine (B6), folic acid, vitamin B12 (cyanocobalamin or methylcobalamin), biotin and pantothenic acid (B5). In addition, choline, inositol and PABA (paraaminobenzoic acid) are compounds that are not technically B vitamins but which have related functions and so are often included with B-Complex products.

    B vitamins are found in whole unprocessed foods. Processed carbohydrates such as sugar and white flour tend to have lower B vitamins than their unprocessed counterparts. B vitamins are particularly concentrated in meat such as turkey and tuna, in liver and meat products. Other good sources for B vitamins include kombucha, whole grains, potatoes, bananas, lentils, chili peppers, tempeh, beans, nutritional yeast, brewer's yeast, and molasses.1

    What Does It Do?
    Each of the B vitamins has their own functions to serve in the body, but in general they may be considered to play a role in energy metabolism and helping to promote homeostasis when the body is under stress. The use of the entire B-Complex is recommended since the individual B vitamins affect one another's absorption, metabolism, and excretion.2

    B-Complex And Energy
    Each of the B vitamins is converted into coenzymes in the body. These B vitamin coenzymes are involved, directly or indirectly in energy metabolism. Some are facilitators of the energy-releasing reactions themselves within the mitochondria; others help build new cells to deliver the oxygen and nutrients that permit the energy pathways to run. Thiamin is essential for the oxidative decarboxylation of the multienzyme branched-chain ketoacid dehydrogenase complexes of the citric acid cycle. Riboflavin is required for the flavoenzymes of the respiratory chain, while NADH is synthesized from niacin and is required to supply protons for oxidative phosphorylation. Pantothenic acid is required for coenzyme A formation and is also essential for alphaketoglutarate and pyruvate dehydrogenase complexes as well as fatty acid oxidation. Biotin is the coenzyme of decarboxylases required for gluconeogenesis and fatty acid oxidation.3 Folic acid and choline are believed to be central methyl donors required for mitochondrial protein and nucleic acid synthesis through their active forms. Vitamin B12 is necessary for the biochemical reaction that plays an important role in the production of energy from fats and proteins.4 One of vitamin B6's coenzyme forms, pyridoxal 5'-phosphate, works with glycogen phosphorylase, an enzyme that catalyzes the release of glucose from stored glycogen.5

    Active individuals with poor or marginal nutritional status for a B vitamin may have decreased ability to perform exercise at high intensities. Exercise stresses metabolic pathways that depend on thiamine, riboflavin, and vitamin B6. Consequently, the requirements for these vitamins may be increased in athletes and active individuals.6 In fact, exercise could increase the need for these micronutrients in several ways: through decreased absorption of the nutrients; by increased turnover, metabolism, or loss of the nutrients; through biochemical adaptation as a result of training that increases nutrient needs; by an increase in mitochondrial enzymes that require the nutrients; or through an increased need for the nutrients for tissue maintenance and repair. Other research7 also suggests that exercise may increase the requirements for riboflavin and vitamin B6, and possibly for folic acid and vitamin B12. Biochemical evidence of deficiencies in some of these vitamins in active individuals has been reported, including riboflavin and vitamin B6.8 Exercise appears to decrease nutrient status even further in active individuals with preexisting marginal vitamin intakes or marginal body stores. Thus, active individuals who restrict their energy intake or make poor dietary choices are at greatest risk for poor B vitamin status, and should consider supplementing with B-complex vitamins.

    B-Complex And Stress
    The B-complex vitamins are intimately involved in the function of the nervous system,9 and so can play a role in helping to counter some of the negative effects of stress. In fact, the ability of humans to respond to stresses can be influenced by nutritional status—including the status of key B vitamins.10 In one study, vitamin B1 (thiamine) and vitamin B6 (pyridoxine) together were found to be especially necessary for workers whose activity is associated with nervous-emotional stress.11 Similar results were seen in a previous study.12

    Research on individual B vitamins has also revealed important roles where stress and the nervous system are concerned. For example, vitamin B1 was found to reduce the effects of catabolic (i.e., breaking down tissues) stress hormones, which resulted from surgery. It also protected the adrenal glands (the "stress glands") from functional exhaustion.13 Pantothenic acid is intimately involved in adrenal function, and the production of adrenal hormones associated with stress.14Niacinamide has been found to reduce certain neurological damage caused by oxidative stress,15 as well as to prevent heart disturbances that resulted from emotional-painful stress.16,17 Vitamin B6 deficiency has been found to be related to increased psychological distress in recently bereaved men;18 and supplementation with vitamin B6 is suggested as part of an overall program for stress.19 Vitamin B12 is also necessary for nervous system functioning, and a deficiency can lead to fatigue and degeneration of peripheral nerves.20 Finally, the concurrent use of B vitamins (i.e., B-complex) together is recommended since they affect one another's absorption, metabolism, and excretion.21

    B-Complex And Homocysteine
    A substantial body of scientific evidence suggests that generous intakes of three B vitamins may help improve cardiovascular health in the United States. The particular B vitamins involved are folic acid, vitamin B6 and vitamin B12. Research indicates these vitamins help promote healthy levels of homocysteine, the amino acid byproduct of metabolism. This is important since high homocysteine levels are a risk factor for cardiovascular disease, on par with high cholesterol levels. Numerous studies indicate that homocysteine levels can be normalized, using vitamin B6, vitamin B12 and folic acid; either individually or in combination.22,23,24,25,26,27,28,29,30

    Folic Acid And Preventing Birth Defects
    One of the most exciting scientific developments in the past several decades is the finding that folic acid plays a critical role in protecting against some serious birth defects, including neural tube defects, when taken by women of childbearing age before and during pregnancy. The Food and Nutrition Board of the Institute of Medicine recognized these findings when it issued new dietary recommendations for the B vitamins in 1998 recommending, "that women capable of becoming pregnant use supplements, fortified foods, or both in addition to consuming food folate from a varied diet." The Food and Nutrition Board added, "At this time the evidence for a protective effect from folate supplements is much stronger than that for food folate."31 The Centers for Disease Control and Prevention (CDC) started even earlier by issuing a public health recommendation in 1992 urging all women of childbearing age to get 400 mcg of folic acid daily to help neural tube defects.32

    Who should use it?
    Anyone and everyone should be using the B-complex vitamins. This is especially true of people who need energy to work out in a gym, or participate in a sport. B vitamins are a fundamental part of basic nutritional needs, and research has shown Americans don't always consume sufficient amount of some B vitamins.33 For example, in a large national survey, 71 percent of males and 90 percent of females consumed less than the recommended daily allowance for vitamin B6.34

    The two products that typically contain the B-complex vitamins are B-complex supplements and multivitamins. In the case of many low-potency, drug store brand type multivitamins, Daily Value levels of the individual B vitamins are used; for example, 1.5 mg of vitamin B1 and 1.7 mg of vitamin B2. Sometimes these levels are doubled, so now there is 3 mg of vitamin B1, etc. While these levels have value and are likely sufficient for preventing a nutrient deficiency disease, experience and empirical evidence suggests they wouldn't be likely to have much of an effect on noticeably increasing energy levels or helping to reduce symptoms of stress. Rather, increasing the dose so that there is at least 10–15 mg (or more) of each B vitamin is more realistic for purposes of energy and stress. For individuals who are under significant amounts of stress and/or who have higher energy needs, higher doses of each vitamin might even be used.

    Since B vitamins are commonly used for energy and stress, it makes sense to use them in the earlier part of the day rather than in the evening. In fact, taking them in the evening may cause an increase in energy before bedtime, making it more difficult to fall asleep. Ideally, B vitamins should be taken with breakfast or lunch. It is important to take them with food for two reasons. First, B vitamins work with food and cellular enzymes to help produce ATP, the primary cellular energy molecule. Second, taking B vitamins on an empty stomach may cause some stomach upset (e.g., mild nausea).

    Also, keep in mind that when first taking B vitamins it may take a few weeks until you notice a substantial increase in energy. The reason for this is that your body needs time to produce more cellular enzymes to work with the B-vitamin coenzymes.

    Adverse Reactions/Interactions
    Folic acid may reduce serum levels of phenytoin in some patients, and may increase seizure frequency,35 so patients concurrently taking medications such as Cerebyx, Luminal, Dilantin, and Mysoline should be carefully monitored. A characteristic flushing reaction can occur with doses of niacin as low as 30 mg/day (but not with niacinamide), but occurs more commonly with the larger doses commonly used for treatment of hyperlipidemia. PABA inhibits the antimicrobial activity of sulfonamide antibiotics, and might inhibit the antibacterial effects of dapsone; avoid concurrent use.36

    1. Whitney E, Rolfes S. Understanding Nutrition, Ninth Edition, Belmont, CA: Wadsworth/Thomson Learning; 2002.
    2. Whitney E, Rolfes S. Understanding Nutrition, Ninth Edition, Belmont, CA: Wadsworth/Thomson Learning; 2002.
    3. Depeint F, Bruce WR, Shangari N, Mehta R, O'Brien PJ. Mitochondrial function and toxicity: role of the B vitamin family on mitochondrial energy metabolism. Chem Biol Interact 2006;163(1-2):94-112.
    4. Shane B. Folic acid, vitamin B-12, and vitamin B-6. In: Stipanuk M, ed. Biochemical and Physiological Aspects of Human Nutrition. Philadelphia: W.B. Saunders Co.; 2000:483-518.
    5. McCormick DB. Vitamin B6. In: Bowman BA, Russell RM, eds. Present Knowledge in Nutrition. Vol. I. Washington, D.C.: International Life Sciences Institute; 2006:269–277.
    6. Manore MM. Effect of physical activity on thiamine, riboflavin, and vitamin B-6 requirements. Am J Clin Nutr 2000 Aug;72(2 Suppl):598S–606S.
    7. Woolf K, Manore MM. B-vitamins and exercise: does exercise alter requirements? Int J Sport Nutr Exerc Metab 2006 Oct;16(5):453-84.
    8. Manore MM. Effect of physical activity on thiamine, riboflavin, and vitamin B-6 requirements. Am J Clin Nutr 2000 Aug;72(2 Suppl):598S-606S.
    9. Whitney E, Rolfes S. Understanding Nutrition, Ninth Edition, Belmont, CA: Wadsworth/Thomson Learning; 2002.
    10. Sauberlich HE. Implications of nutritional status on human biochemistry, physiology, and health. Clin Biochem 1984; 17(2):132–42.
    11. Bondarev GI, Martinchik AN, Khotimchenko SA, et al. [Correlation of the actual vitamin B1, B2 and B6 consumption with the biochemical indices of their body allowance] Korreliativnaia vzaimosviaz' fakticheskogo potrebleniia vitaminov B1, B2 i B6 s biokhimicheskimi pokazateliami obespechennosti imi organizma. Vopr Pitan 1986; (2):34–7.
    12. Bogdanov NG, Bondarev GI, Piatnitskaia IN, et al. [Vitamin status of diamond cutters] Vitaminnyi status rabochikn, zaniatykh promyshlennoi obrabotkoi almazov. Vopr Pitan 1984; (2):28–31.
    13. Vinogradov VV, Tarasov IuA, Tishin VS, et al. [Thiamine prevention of the corticosteroid reaction after surgery] Optimizatsiia tiaminom korticosteroidnoi reaktsii pri khirurgicheskikh vmeshatel'stvakh. Probl Endokrinol 1981;27(3):11–6.
    14. Kutsky R, Handbook of Vitamins and Hormones. New York: Van Nostrand Reinhold Company; 1973:208.
    15. Mukherjee SK; Adams JD Jr. The effects of aging and neurodegeneration on apoptosis-associated DNA fragmentation and the benefits of nicotinamide. Mol Chem Neuropathol 1997; 32(1-3):59–74.
    16. Meerson FZ, Manukhina EB, Dosmagambetova RS. [Disorders of contractile function and adrenoreactivity of the portal vein in emotionally-painful stress and experimental myocardial infarct and their prevention by means of membrane protectors] Narusheniia sokratitel'noi funktsii i adrenoreaktivnosti vorotnoi veny pri emotsional'no-bolevom stresse i eksperimental'no-bolevom stresse i eksperimental'nom infarkte miokarda i ikh preduprezhdenie s pomoshch'iu membranoprotektorov. Kardiologiia 1984; 24(4):104–8.
    17. Meerson FZ, Pshennikova MG, Rysmendiev AZh, Vorontsova EIa. [Prevention of stress disorders of myocardial contractile function using membrane protectors] Preduprezhdenie stressornykh narushenii sokratitel'noi funktsii miokarda s pomoshch'iu membranoprotektorov. Kardiologiia1983;23(7):86-90.
    18. Baldewicz T, Goodkin K, Feaster DJ, et al. Plasma pyridoxine deficiency is related to increased psychological distress in recently bereaved homosexual men. Psychosom Med 1998; 60(3):297–308.
    19. Teggin AF, van Niekerk JP. Manifestations and management of stress. S Afr Med J 1981;59(21):751–2.
    20. Whitney E, Rolfes S. Understanding Nutrition, Ninth Edition, Belmont, CA: Wadsworth/Thomson Learning; 2002.
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  • The Sinatra Solution, Metabolic Cardiology Part III

    So far we have learned a good deal about how the “Awesome Foursome” of Coenzyme Q10, L-carnitine, D-ribose, and magnesium helps our hearts metabolize energy more efficiently and protects them from the stress of cardiovascular disease. This powerful combination of nutrients goes directly to the basic biochemistry of cellular energy metabolism. Now let’s take a closer look at how Coenzyme Q10, L-carnitine, D-ribose, and magnesium work in synergy to promote cardiovascular health.

    We’ll start our discussion on the important synergy of Coenzyme Q10, L-carnitine, D-ribose, and magnesium with a short summary of how each works individually. Let’s begin with Coenzyme Q10.

    Coenzyme Q10: Energy Recycling through the Electron Transport Chain
    Coenzyme Q10 is a powerful antioxidant that helps protect the mitochondrial membrane, mitochondrial DNA, and cell walls from free-radical attack. But its most important function in the body is its central role in energy metabolism.

    Most—about 90 percent—of the ATP used by cells is recycled as food (fuel) and oxidized in the mitochondria. Fatty acids, carbohydrates, and, occasionally, proteins are carried across the mitochondrial membrane and enter the Krebs cycle, moving from step to step and spinning off electrons. These electrons are then handed off to the electron transport chain, where, in the presence of oxygen, the energy from the electrons is captured as a phosphate group is added to ADP to form ATP. This recycling of ATP is called oxidative phosphorylation, and the by-products of these pathways are CO2 and water.

    Coenzyme Q10 is the “electron clearing house” in the mitochondria. Coenzyme Q10 accepts electrons coming out of the Krebs cycle and passes them off to other constituents of the electron transport chain called cytochromes. In this fashion, Coenzyme Q10 acts as a gatekeeper of electrons, making sure they are carried to just the right place to pass on their life-giving energy.

    The activity of the electron transport chain is highly complex and beyond the scope of our discussion. What is critical, however, is the simple fact that without Coenzyme Q10 the electron transport chain would totally break down. And since the electron transport chain is (by far!) the largest contributor to cellular energy turnover, its loss would be catastrophic. It is also important to know that there has to be an excess of Coenzyme Q10 in the mitochondria to be maximally effective. Having just enough isn’t sufficient to do the job properly, and having a deficiency seriously affects the mitochondria's ability to supply the cell with energy.

    To keep the electron transport chain running at peak efficiency, there must be enough Coenzyme Q10 to accept electrons immediately as they are spun out of the Krebs’ cycle, carry them to the cytochromes where they are passed off, and then return to wait in line for yet another electron. If there is not enough Coenzyme Q10 waiting in this queue, electrons will not be captured and their energy will be lost.

    Think of this process in terms of a warm-up drill before a basketball game. During these warm-ups basketball players stand in a line at the free-throw line. One of their coaches stands under the basket and throws the ball to the first player in line to start the process going, much like the Krebs cycle throwing off an electron. The first player in line quickly carries the ball to the basket, hands it off to the basket in a lay-up, and runs back to the end of the line. The coach then throws another ball to the next player in line, and the cycle continues. However, if there is no player waiting in line to collect the throw, the ball will spin out of control to the other end of the court and will never make its way to the basket.

    The same is true with Coenzyme Q10. Electrons are passed out of the Krebs cycle and accepted by the next Coenzyme Q10 in line. Coenzyme Q10 then carries the electrons to the basket (the cytochromes), passes them off, and returns to the back of the line. If you can imagine this as a continually moving line with millions of basketballs in play you can visualize why so much Coenzyme Q10 is needed to keep the process running smoothly. When there is a Coenzyme Q10 deficiency, many of the electrons spin out of control and never make their way down the energy pathway.

    Cellular stress can cause Coenzyme Q10 deficiency, which places a severe strain on Coenzyme Q10 availability. People with heart disease, hypertension, gingival disease, Parkinson’s disease, and the other disorders we’ve discussed are known to be deficient in Coenzyme Q10. Whether these deficiencies are the cause or the effect of these varied medical problems, the end result is that they sap the life out of their mitochondria and reduce their energy supplies. You see, Coenzyme Q10 cannot function properly if electrons are not coming out of the Krebs’ cycle, and the Krebs cycle won’t work without the fuel that’s transported into the mitochondria by L-carnitine.

    L-Carnitine: Transporting the Cellular Energy Fuel
    Fatty acids are the preferred energy fuel for hearts and most other cells in the body. Fatty acids are long-chain molecules that are broken down by beta oxidation into two-carbon fragments. These two carbon fragments are used to fuel the Krebs’ cycle so electrons can be extracted to run down the electron transport chain. The two-carbon fragments plucked from long-chain fatty acids are picked up by Coenzyme A (CoA) forming activated CoA esters. The mitochondrial inner membrane is almost totally impermeable to these CoA esters, and that’s where L-carnitine comes in.

    L-carnitine resides in the mitochondrial inner membrane and works like a ferry carrying freight across a river. L-carnitine picks up two-carbon fragments on one side of the mitochondrial membrane and transports them to the other side. The primary job of L-carnitine in energy metabolism is the transport of these fuels into the mitochondria, making them available for ongoing energy metabolism in the Krebs’ cycle. In this process Coenzyme A “hands off” the two-carbon fatty acid fragment to L-carnitine, forming acetyl carnitine. Acetyl carnitine then moves across the membrane and again passes off the two-carbon fragment to another CoA living inside the mitochondria. So, like a ferry, L-carnitine picks up the two-carbon fatty acid fragment, gives it a ride across the inner mitochondrial membrane, and delivers it to another CoA waiting on the other side. The CoA receiving the fatty acid fragment then delivers it to the Krebs’ cycle for processing into energy.

    L-carnitine facilitates the beta oxidation of fatty acids as energy fuel. And since fatty acids are the preferred fuel for energy recycling in cells, this action is critical to cell and tissue function. Unfortunately, L-carnitine is deficient in people with heart disease, peripheral vascular disease, lipid metabolic disorders, mitochondrial disorders, and many other disease syndromes we reviewed earlier. This L-carnitine deficiency disrupts the normal metabolism of fatty acids, reducing available energy supplies and leading to the accumulation of toxic by-products of fatty acid metabolism. L-carnitine supplementation revives fatty acid metabolism and restores normal mitochondrial function. But even this powerful improvement in cellular energy metabolism cannot make up for the energy drain that comes from the loss of energy substrates caused by low oxygen delivery to the tissue. Only D-ribose can do that.

    D-Ribose: Rebuilding the Cellular Energy Pool
    As long as cells and tissues have plenty of oxygen, the pool of energy substrates in the cell remains high. And as long as there is enough L-carnitine and Coenzyme Q10 available, the process of energy utilization and supply can proceed unimpeded. However, the cellular supply of oxygen can be restricted by acute or chronic heart disease, peripheral vascular disease, any number of skeletal- or neuromuscular diseases, or even high-intensity exercise.

    When cells are deprived of oxygen the mitochondrial energy turnover becomes inefficient. Remember, oxygen is required to let the oxidative pathway of energy recycling work properly. If the mitochondria are not able to recycle energy efficiently, cellular energy supply cannot keep pace with demand. But the cell has a continuing need for energy, so it will use all its ATP stores and then break down the by-product, adenosine diphosphate (ADP), to pull the remaining energy out of this compound as well. What’s left is adenosine monophosphate (AMP). Since a growing concentration of AMP is incompatible with sustained cellular function it’s quickly broken apart and the by-products are washed out of the cell. The net result of this process is a depletion of the cellular pool of energy substrates. When the by-products of AMP catabolism are washed out of the cell, they are lost forever. It takes a long time to replace these lost energy substrates even if the cell is fully perfused with oxygen again.

    Ribose is the only compound used by the body to refill this energy pool. Every cell in the body has the capacity to make ribose, but hearts, muscles, and most other tissues lack the metabolic machinery to make ribose quickly when the cells are stressed by oxygen depletion or metabolic insufficiency. Ribose is made naturally in the cells from glucose. In stressed cells, however, glucose is preferentially metabolized for energy turnover and is not available for ribose synthesis. So when energy pools are drained from stressed cells, the cells must first wait for the slow process of ribose synthesis before they can begin to replace their lost energy stores.

    Acute ischemia, like that which takes place during a heart attack, heart surgery, or angioplasty, drains the cell of energy. Even when oxygenated blood flow returns, refilling the energy pool may take ten or more days. But when oxygen deprivation is chronic, or when energy metabolism is disrupted by disease, there may be so much continual strain on the energy supply that the pool can never refill without the assistance of supplemental ribose. Conditions like ischemic heart disease or congestive heart failure fall into this category. In these situations, supplementing the tissue with exogenous ribose is the only way the cell can keep up with the energy drain.

    Magnesium: Switching on the Energy Enzymes
    Magnesium is an essential mineral that's critical for energy requiring processes, in protein synthesis, membrane integrity, nervous tissue conduction, neuromuscular excitation, muscle contraction, hormone secretion, maintenance of vascular tone, and in intermediary metabolism. Deficiency may lead to changes in neuromuscular, cardiovascular, immune, and hormonal function; impaired energy metabolism; and reduced capacity for physical work. Magnesium deficiency is now considered to contribute to many diseases, and the role for magnesium as a therapeutic agent is expanding.

    Magnesium deficiency reduces the activity of important enzymes used in energy metabolism. Unless we have adequate levels of magnesium in our cells, the cellular processes of energy metabolism cannot function. Small changes in magnesium levels can have a substantial effect on heart and blood vessel function. While magnesium is found in most foods—particularly vegetables—deficiencies are increasing. Softened water and a trend toward lower vegetable consumption are the culprits contributing to these rising deficiencies.

    Clearly, each member of the “Awesome Foursome” is fundamental to cellular energy metabolism in its own right. Each plays a unique and vital role in supplying the heart with the energy it needs to preserve its contractile force. Each is independently effective in helping hearts work through the stress of disease. And while each contributes immeasurably to the energy health of the cell, in combination they are unbeatable. Allow me to reiterate the step-by-step, complicated cellular processes involved to be sure that you really understand the rationale for using these nutrients.

    The cell needs a large, sustained, and healthy pool of energy to fuel all its metabolic functions. Contraction, relaxation, maintenance of cellular ion balance, and synthesis of macromolecules, like proteins, all require a high energy charge to carry their reactions to completion. The energy pool must be preserved, or these fundamental cellular functions will become inefficient or will cease to operate altogether. To keep the pool vibrant and healthy, the cell needs ribose. But even with supplemental ribose, the cell needs the efficient turnover of its energy stores to balance ongoing energy utilization with supply. That's where Coenzyme Q10 and L-carnitine come into play.

    The converse is also true. Even if the cell is fully charged with energy, cellular energy supply will not keep pace with demand if the mitochondria are not functioning properly. Coenzyme Q10 and L-carnitine work to keep mitochondrial operations running at peak efficiency, and one side cannot work effectively without the other. Even though Coenzyme Q10 and L-carnitine can make the energy turnover mechanisms work more efficiently, they cannot increase the cell's chemical driving force, and their action will be only partially effective. Ribose, on the other hand, can keep the energy pool supplied with substrate, but the value of energy pool repletion cannot be fully realized if the substrate cannot be maximally utilized and recycled. Ribose fills the tank; Coenzyme Q10 and L-carnitine help the engine run properly.

    Magnesium is the glue that holds energy metabolism together. By turning on the enzymes that drive the metabolic reactions, magnesium allows it all to happen. These four nutrients must be utilized by cardiologists and other physicians as they treat patients day-to-day. On my own journey, using Coenzyme Q10 for two decades, L-carnitine for more than ten years, D-ribose for two years, and magnesium equally as long, I've seen this “Awesome Foursome” reduce suffering and improve the quality of life for thousands of patients.

    The future of nutrition in conventional medicine is very bright, although the integration of nutritional supplements has been a slow and, at times, lonely process. For example, the Canadian government has just placed a warning on their HMG-reductase statin labels, warning that these drugs can diminish ubiquinone (Coenzyme Q10) levels, which can cause heart failure. This is a mammoth step for the Canadian government, and I applaud them for raising this issue with their population. Unfortunately, our own Food and Drug Administration is not so enlightened yet. Now that governments are getting involved in doing the right thing, perhaps the traditional medical community will follow suit. But first we have to educate them to do so.

    As most of you may know, representatives from pharmaceutical companies make regular rounds to the offices of prescribing medical professionals such as physicians, physician assistants (PAs), advanced practice nurses (APRNs), and nurse practitioners (NPs) to keep them informed about the latest drugs their companies are releasing. This is called “detailing” a pharmaceutical because it involves educating the practitioner about all the various “details” of the drug, from how it works and interacts with other medications, to dosing and possible side effects. Drug companies obviously spend a lot of money on this one-to-one approach in order to bring this level of education to each individual health care practitioner, but it does let them get more comfortable with drugs new to the market.

    Not so with nutraceuticals. There just isn't anyone “detailing” health care providers about nutrients and supplements in this manner, so many doctors don't believe in their effectiveness. As research continues, the mysterious relationship of ATP and energy in the heart will be recognized by more and more physicians who will then be comfortable recommending these life-saving supplements.

    L-carnitine and Coenzyme Q10 are finally gaining the recognition they deserve. Dribose is emerging as a new player in the complex understanding of metabolic cardiology, and doctors are beginning to discuss the important role of magnesium deficiency in heart patients. As a practicing cardiologist for over thirty years, I see metabolic cardiology as the future for the treatment of heart disease and other complex disease conditions, as well.

    The Sinatra Solution, Metabolic Cardiology by Stephen T. Sinatra, M.D. is published by Basic Health Publications, Inc. and is available at health food stores and bookstores or call 1.800.575.8890 to order.

  • Vitamin K2: The Missing Nutrient for Heart and Bone Health

    “If calcium is so bad for my heart, why should I be taking a calcium supplement for my bones?”

    This is a question I hear frequently in my office and one that causes me great concern.

    Bone health is important throughout your life. Osteoporosis and bone fractures, similar to cardiovascular disease, are not just the problems of old age. Like the heart and the blood vessels, the health of our bones is something we usually do not think about much. Then, a problem arises—such as a hip fracture—and just like the cardiovascular system, it is too late to make any real impact.

    The one thing most people will do to support their bone health is take a calcium supplement, which is important due to the fact our bodies cannot produce calcium on their own, and calcium plays a role in many of the body’s systems. But too much calcium in the body left unattended can have a negative effect, such as depositing in the arteries and blood vessels causing calcification. This calcification causes stiffening that puts a strain on the cardiovascular system.

    When my friend, an integrative general practitioner, asked if I was recommending vitamin K2 to my patients, I was surprised. What is vitamin K2? I decided to find out. I was shocked—and excited—at how much good research supported this nutrient for bone and heart health.

    The discovery of this amazing body of research was the motivation behind my new book, “Vitamin K2: The Missing Nutrient for Heart and Bone Health.” It is important that patients as well as health care professionals understand the benefit of this important nutrient and the scientific evidence supporting it.

    What is Vitamin K2?
    Vitamin K2 is part of the vitamin K family, a group of fatsoluble vitamins. Vitamin K is split into two groups: vitamin K1 and vitamin K2. The difference lies on a molecular level. Vitamin K1 has one molecule, so it is a phylloquinone. The K2 group has multiple molecules and known as menaquinones.

    While K vitamins are crucial for blood clotting, vitamin K2, unlike K1, is utilized by the liver and then is available to tissues beyond the liver, such as the bones, arteries and blood vessels. So why is vitamin K2 so valuable?

    Simply put, vitamin K2 is the body’s light switch. It activates or “turns on” important proteins in the body such as osteocalcin for strong bones and the matrix Gla protein (MGP) in the arteries and blood vessels. By turning on these vitamin K2 dependent proteins, calcium is kept out of the arteries (where it can cause hardening of arteries and blockages) and transported and kept in the bones where it belongs.

    Although vitamin K2 is a relative newcomer to the supplement arena, I believe there is now enough scientific evidence to make you take notice and add it to your list of essential nutrients. While I will focus on vitamin K2’s proven cardiovascular benefits, a multitude of studies have also demonstrated vitamin K2’s effectiveness for bone health and children’s health. And more research is being done every day to support its benefits in these crucial areas to the general population.

    Undeniable Evidence
    Let’s start with the evidence of vitamin K2’s role in calcification. The landmark Rotterdam population cohort study examined vitamin K2 in a normal human population, and was the first large clinical study to suggest the huge impact vitamin K2 may play in reducing cardiovascular events and mortality. Results among 4,807 healthy individuals (at the start of the study) age 55 and older, suggested a strong protective effect of the highest dietary vitamin K2 intake on arterial calcification. The study showed a reduction in risk for cardiovascular diseases and cardiovascular disease-related deaths by as much as 50 percent for subjects who ingested more vitamin K2. High intakes of vitamin K2 also reduced the all-cause mortality by 25 percent.

    Dietary vitamin K1, obtained from green vegetables, had no influence on excessive calcium accumulation, even when consumed in much larger quantities than K2.

    Another study in Nutrition, Metabolism, & Cardiovascular Diseases looked at the effect of vitamin K2 on arterial function, or the ability to contract and relax blood vessels. A group of 16,057 women (all free of cardiovascular diseases at baseline) aged 49–70 years were followed for eight years. The final results were again really promising: K2 vitamins were shown to reduce the risk of cardiovascular diseases. The risk of coronary heart disease dropped nine percent for every 10 micrograms of vitamin K2 (MK-7, MK- 8, and MK-9) subjects consumed. Vitamin K1 intake had no effect.

    If you are still not convinced that vitamin K2 delivers important cardiovascular benefits, there is one exciting clinical study that has really captured my attention recently and was published this year in the journal Thrombosis and Haemostasis. It shows a nutritional dose (180 mcg) of specific vitamin K2 called MenaQ7 taken daily for three years not only inhibited age-related stiffening of the artery walls, but also made significant improvements in artery flexibility—meaning calcification was actually regressed, leaving arteries healthier and more flexible.

    This study is a breakthrough because it is the first intervention trial where the results confirm the association made by previous population-based studies: that vitamin K2 intake is linked to cardiovascular risk. According to the researchers, the data demonstrated that a nutritional dose of vitamin K2 can in fact promote cardiovascular health.

    Completing the Health Picture
    The four keys to good health for everyone are nutrition (including supplements), exercise, stress management and sleep. Pills alone are not the solution, but I feel very strongly that supplements fill the nutritional gaps our diets are lacking. Vitamin K2 should be taken along with vitamin D and calcium, and it’s best to look for one supplement that contains all three ingredients combined, especially the clinically studied MenaQ7 form of vitamin K2 that can be found listed as such on the nutritional label.

    Finally, I want to emphasize that you must be proactive with your health, and I encourage you to make your doctor an active partner in your pursuit of well-being. Discuss your health goals and concerns with your physician for a personal roadmap on how to get there.