Thursday, April 22, 2010

Making Healthy Probiotic Yogurt

Sometimes being healthy requires an arduous discipline, but making and eating fresh homemade yogurt is one of the fun parts about good health. Below are the materials I use to make yogurt.

I prefer using an electric yogurt maker, but it is possible to make yogurt without one as many cultures have for centuries. The main ingredient is fresh milk. Organic whole milk is best if you can get it, but any milk will do that does not have antibiotics in it which can kill the organisms. Even UHT milk or powdered milk can work. I prefer to add about 1/2 cup of cream (125mL) to one quart (1 liter) of milk to make it richer, but the amount of milk fat is personal preference.

Yogurt makers can have one large bowl or several individual one serving size containers. I prefer one that has a large glass bowl, but stainless steel or plastic will also work. For best results, I sterilize the bowl with boiling water. Then, I fill it with the milk and cream mixture and place it the microwave. Through trial and error and use of a food thermometer, bring the milk to about 180-200° F (92-95° C). This serves two functions, it sterilizes the milk so there are no unwanted bacteria giving it an off taste, and it slightly modifies the milk so it is smoother when it ferments and does not curdle.

Using a food thermometer, let the milk cool to 108-112° F (42-44° C). Usually, a skin will form on the surface. Many people skim this off. It is milk protein and I prefer to blend it back in with a little battery powered hand blender. At this point, you may add one packet of probiotic yogurt starter. I picture the Yógourmet brand probiotic yogurt starter above which has five strains including the two normal yogurt strains and three probiotic strains. You can read about it here. There are several good probiotic yogurt starters in China but they are formulated to make a thinner drinking yogurt. I use two packets of the Chinese yogurt starters to get a thicker yogurt.

As you can see from the above chart, the length of the fermentation will affect (1) the amount of carbohydrate in the form of lactose (milk sugar), (2) the sourness of the yogurt determined by the amount of lactic acid, and (3) the amount of live micro-organisms. Commerical yogurt is only fermented for 4-5 hours. Most people ferment home yogurt for 8-10 hours. The Specific Carbohydrate Diet for people with autoimmune diseases recommends fermenting yogurt for a full 24 hours and then straining it to get the lowest possible lactose content as lactose is a potent allergen for many people. I generally ferment my yogurt for 20-24 hours to get the most probiotic organisms and the lowest carbohydrate. I like the tarter taste of a fully fermented yogurt, but some may prefer a more mild taste.

Dripping or straining yogurt will make it thicker and change the composition. Traditionally, cheese cloth is used to strain it, but I prefer to use a simple paper coffee filter or a reusable nylon coffee filter which I place in a cylindrical container to catch the liquid which drips off. The liquid portion that drips off will contain water, lactic acid and some residual lactose. Very little micro-organisms, protein or fat will drip through. A dripped yogurt will be slightly less sour, much thicker, lower carb (less lactose), higher protein and have more concentrated probiotic organisms.

If you drip the yogurt for about an hour, you will reduce the volume about 25% and get thicker Greek style yogurt. If you drip the yogurt over night in the refrigerator, you will reduce the volume over 50% and you will get thick yogurt cheese, which is almost like cream cheese in taste and usage.

Remember that yogurt is a live food and be sure to eat it fresh. Even when stored in the refrigerator, it can lose more than half of the live organisms within a week. And it tastes great fresh!

Probiotics: Wanted Dead or Alive?

Probiotics, the beneficial micro-organisms, are not very beneficial if they are dead on arrival. It can be a treacherous path from production of probiotic supplements and live probiotic yogurt to the creation of actual communities of beneficial micro-organisms improving gut ecolology. How do you protect and support the good guys in your gut?

About 99 percent of commercial yogurt is made with just two bacteria – S. thermophilus and L. bulgaricus. These two organisms are excellent for quickly fermenting the lactose in milk and thickening the milk. Once in the human body, however, they are not exactly probiotic superstars. Most are killed by the gastric acid in the stomach and the few that reach the gut are not able to multiply and colonize the gut. They quickly pass through with little lasting positive effect. These wimpy bacteria are also short lived in commercial yogurt. The live organisms in yogurt rapidly degrade and completely die off within three weeks of production. Another reason that fresh homemade yogurt is so much healthier.

There are several strains of Lactobacillus and Bifidobacterium micro-organisms that can live in yogurt and can survive in the gut to colonize with healthy bacteria. Why are these healthier probiotic bacteria not routinely used in yogurt? Unfortunately, they do not add much to the taste or texture of commercial yogurt, so commercial yogurt companies rarely incur the additional cost of adding them. They can only be found in a few specialty probiotic yogurts and probiotic yogurt starters. While probiotic strains flourish in the human gut, they are not as hardy as the commercial yogurt strains during the production process. If you attempt to make probiotic yogurt using an old batch for a starter, you will find that the commercial yogurt starters grow faster and will quickly crowd out the healthier bacteria in successive batches. To make probiotic yogurts, you must add fresh probiotic organisms to each batch.

Bifidobacterium, the bacteria that dominates in the gut of a breastfed baby, should always be added to probiotic yogurt. There are several popular strains with B. bifidum being most common. Other popular strains found in healthy human guts include B. infantis, B. adolescentis, B. longum and B. breve. While Bifido can live in both the small and large intestine, my Chinese microbiologist friends tell me they are most helpful in the large intestine where they promote good GI health.

Lactobacillus bacteria probably play a more important role in the small intestine where they seem to improve the immune function and help people who suffer inflammatory autoimmune diseases. L. acidophilus is the most common Lactobacillus probiotic organism which can colonize the gut. L. casei is transient micro-organism but some studies have shown it can assist the propagation of acidophilus. L. reuteri and L. rhamonous have been shown to be especially effective in preventing and lessening symptoms of eczema, asthma, allergies and other autoimmune diseases. I have postulated that improving the health of the small intestine may mediate any possible disturbance of the production of incretins produced in the lining of the small intestine, a condition which can impair first phase insulin response in Type 2 diabetics. Both Bifidobacterium and Lactobacillus promote healthy mucosal lining which will prevent leaky gut syndrome that can lead to chronic inflammation and result in increased insulin resistance.

I love my yogurt, but there are other reasons I prefer getting my probiotics from fresh yogurt rather than probiotic supplements. The live organisms in probiotic supplements are usually freeze dried. If kept in a cool, dry environment, they might maintain most of their efficacy for six months to a year, but they are extremely sensitive. Humidity is the main problem. Probioitcs sold in a bottle began rapidly degrading as soon as the bottle is opened. If you want to use probiotic supplements, be sure to only buy probiotics that are sealed in individually in blisterpack packaging and manufactured very recently. They are best stored in a freezer until they are used. Please be careful of condensation when cold probiotics are first removed from the freezer. Wait until the package is at room temperature before you open them.

Some probiotic supplements are enteric coated to help the micro-organisms survive the gastric acid and make it to the gut. Most manufacturers of probiotic supplements admit that they deteriorate rapidly after production and more than 80 percent of the remaining organisms will be killed in the body before they reach the gut. The survival rate of probiotic organisms in yogurt passing through the stomach is believed to be higher.

Like probiotic supplements, probiotic yogurt starters are fragile. They must be fresh, packaged in individual sealed packets, kept dry and not exposed to heat. It is still difficult to find good probiotic yogurt starters. Frankly, it is rare for commercial yogurt starters to contain more than 1-3 of the probiotic strains that I mention above. I have worked with Chinese microbiologists trying to develop yogurt starters that contain L. reuteri and L. rhamonous because I have not been able to find them commercially. Unfortunately, L. reuteri and L. rhamonous appear to not be stable in yogurt medium and not commercially viable.  They still must be consumed as expensive supplements like Culturelle and BioGaia.  The Yogourmet probiotic starter mentioned in my previous post on yogurt does contain L. acidophilus, L. casei and a strain of Bifidobacterium.

Homemade yogurt stored in the fridge is still a live food which is quite perishable. The half-life of the probiotic organisms is probably less than a week, so I recommend eating your homemade yogurt within a couple of days. This is no problem for my family. How wonderful that good gut health can be so tasty!

And remember – consuming lots of healthy probiotics will do you little good if you are eating bad food. Avoid simple carbohydrates, especially fructose, which feeds the bad gut bacteria and be sure to eat lots of soluble fiber to feed the good bacteria.

Monday, April 19, 2010

Tale of Two Rats – How Fiber Can Make You Beautiful and Healthy

Not an epic novel, my story concerns two rats – a fat rat and a thin rat. Some bored scientists analyze their fecal content and discover they are distinctly different. The gut flora in the fat rat has more of a bacteria called firmicutes (think F for fat) and the thin rat has more bacteriodes (think B for beautiful). Said scientists decide to amuse themselves by performing a fecal transplant. The unsuspecting thin rat gets the fecal content of the fat rat. It’s a tragic story. With no change in diet, the thin rat whose gut flora is now dominated by firmicutes gets fat.

Another two rats, another story. Two thin rats and each has more bacteriodes in the gut flora. The sadistic scientists put one of the healthy rats on a high fructose diet. Predictably, thin rat develops a new gut ecology with dominant firmicutes … and gets fat.

Final story. Some kind hearted scientists observe that bacteriodes are able to produce a short-chain fatty acid called butyric acid which seems to improve the gut ecology with many benefits. Being better scientists than cooks, rather than feed the rats some tasty food naturally high in fiber, they add 5% sodium butyrate to their laboratory rat chow. The rats that are supplemented with sodium butyrate do not get fat like their buddies on the same highly fattening diet. Check out the graph below:

Actually, the last story has a really happy ending. Not only do these rats not get fat, their post prandial blood glucose levels are much better with the butyrate and their insulin resistance improves as measured by HOMA-IR.

Moral of the story? Nope, I am not recommending fecal transplants for all my chubby T2 friends and I am not suggesting you use sodium butyrate as a condiment in all your favorite foods. Let me tell you how the same healthy gut environment can be achieved in the human species.

The way bacteriodes are supposed to work in people is that they ferment fiber to produce butyrate. Nope, I am not talking about your raisin bran cereal. The sugar in it will feed the evil firmicutes and hasten your demise while the insoluble fiber from the wheat bran going through your gut like sawdust will likely providing more irritation than health. But isn’t fiber supposed to help diabetics? As it turns it, only soluble fiber is the diabetic’s friend.

Soluble fibers from rich sources like low carb veggies, flax meal, chia seeds and supplements like pectin, beta-glucan, FOS, inulin, etc. are the healthy nutrients that the good bacteria love. The bacteriodes will thrive on this stuff and you will look and feel great.

While you are are savoring your broccoli and enjoying a flax meal muffin, don’t forget the bad guys. Do not feed the firmicutes! NO FRUCTOSE! If you dare consume any unhealthy quantities of sugar, HFCS or fruit juices (and any quantity is unhealthy) please contact me immediately to learn how you can schedule that fecal transplant.

OK, most of my readers already know that I am no doctor or scientist … and certainly not a pillar of virture. Seems I succumbed to temptation only this morning when my wife offered me a piece of nice dark chocolate. Should perfection elude you, too, please refer to my earlier posting and eat lots of low carb, probiotic yogurt daily. Having more probiotic bacteria in the neighborhood will help keep out the bad guys.

Breaking News -- According to an article in ScienceNews, my Venti-sized Americano coffee may have as much as 2 grams of that soluble fiber that is so beloved by bacteroides. Discussion continues at the Da Mu Zhi Guangchang Starbucks.

Wednesday, April 14, 2010

Bifidobacterium – Have You Lost Your Birthright?

One of the most precious gifts your mother gave you was the first bacteria that inhabited your gut. The trillions of micro-organisms in our intestine form a community that begins the day we are born. You were born empty with no organisms in your gut. In a normal vaginal birth, a baby will pick up a healthy dose of its mother’s micro-flora. In birth by C-section, however, the babies will slowly be influenced by many environmental factors and it may be months before their gut ecology is firmly established.

As advocates of breastfeeding know, breastmilk is a rich source of probiotic bacteria, specifically, the species Bifidobacterium or bifidus. A child develops the most healthy gut ecology at its mother’s breast. In a breastfed child, about 80-90 percent of the bacteria in their intestine are Bifidobacterium, and that’s why breastfed kids are healthier. Unfortunately, the proportion of our gut flora that are this Bifidobacteria begins to diminish as we grow older, and, by the time we become an adult, may virtually vanish … if not by the ravages of time, than by overused antibiotics.

So, you may ask, why should you care about the bacterial zoo in your gut? About 70 percent of cells involved with immunity are in the lining of the intestine. A healthy gut is the key to overall good health. If the lining of your intestine becomes inflamed, it may become more permeable allowing the inflammation to leak out into other parts of the body. This can lead to the chronic inflammation condition that is present in most chronic diseases. I believe that gut inflammation is one of the root causes of Type 2 diabetes and its complications.

Since I have just been writing on making your own yogurt, you might guess that I am going to tell you that yogurt is the best way to replenish the healthy probiotic bacteria in your gut. Well, yes and no. It is possible to make yogurt that contains Bifidobacterium, but 99.9 percent of commercial yogurt does not have it and very few yogurt starters contain it. Commercial yogurt usually just has L. Bulgaricus in it for a nice consistency and S. thermophilus to ferment the milk to a pleasant tartness. The S. thermophilus will not survive your stomach acid. The L. bulgaricus will make it to your gut where it will discourage the growth of some harmful bacteria for a short time, but it passes through without colonizing the gut or making any long-term improvement.

Bifidobacterium is a colony forming bacteria. It improves the neighborhood so the thugs of bacteria world like E. coli and salmonella do not take over and any Helicobacter pylori that are still around are better behaved. Your gut will be very happy with Bifidobacterium back on the block. So, how to restore it if time and antibiotics have vanquished your old childhood friend?

Maybe you can pop some pills. There are many varieties of Bifidobacterium that can be found in commercial probiotic supplements. Remember, however, that these are live organisms and life in a gelatin capsule in a bottle stored in a warehouse, store shelf or medicine cabinet for months may not be that hospitable. Probiotics deteriorate rapidly in less than perfect conditions. What was an excellent product when it was produced may have few if any live organisms in it when you take it. Any remaining Bifodobacterium will need to run the gauntlet from mouth to intestine. Some can survive harsh stomach acid, but they do much better if there is food present to lower the pH of the stomach acid a little. Which brings me back to my favorite food.

Yes, you can make yogurt that contains Bifidobacterium. You still use the standard two yogurt making strains, but you can find specialized cultures that have some Bifidobacteria and other probiotic strains. Usually, they will also add some Lactobaccillus strains, too, especially L. acidophilus. The Yógourmet line of home yogurt making cultures has one specialized product with three added probiotic strains.

Yogourmet Yogurt Starter with Probiotics

You can find Yógourmet probiotic starter here.

Personally, I like the taste of yogurt fermented with a little bifidus added to the culture. It seems to have a slightly more cheese-like flavor. In the interest of full disclosure, however, I must say that consistency is not quite like the "swirly goodness" of the Pinkberry Frozen Yogurt store. It can be a little slimy. If you drip it to make a Greek style yogurt, it improves the unusual viscosity and I find it quite OK. More importantly, my family’s main yogurt aficionado, my two-year-old son, greatly prefers Daddy’s yogurt to Dannon’s or Yoplait’s. And, my son’s impeccable taste is only exceeded by his radiant health.

Thursday, April 8, 2010

Are Your Dining Companions Making You Sick?

“You never dine alone,” according to biologist Jeff Gordon of the Human Gut Microbiome Initiative (HGMI). About 10-100 trillion gut microbes join you every time you eat. The reaction of your dinner guests greatly affects your health which depends not just on what you eat but also on how your intestinal microflora react to it.

Most of us think of diabetes as having a genetic component. Could it be that the genetic makeup of the microbes that have come to inhabit our gut affects us as much or more than our own DNA?

We are born with no microbes in our gut. They are all acquired after birth from our mothers, families, friends and communities. What we eat can radically alter the balance of our microbial communities, sometimes in ways that are very difficult to change. There are over 500 varieties of bacteria in our intestines, but their different attributes are not still fully understood. Science is just beginning to map the genetic code of our intestinal bacteria.

Already, a clear link has been established between obesity and our gut microflora. Fat people have very different gut microbes. Why? It seems to be a function of the bacteria we have been exposed to, what we eat and our degree of obesity. Some of the foods that I rant about in my blog can radically change your gut ecology in a rather short period of time. These changes are not easily reversed. We do know that the gut microflora changes some when people lose weight, so there is hope for improving our gut health and overall health.

Some intestinal bacteria are associated with inflammation and autoimmune disease, including diabetes. Because the role of gut bacteria in disease is complex and our understanding is still incomplete, most scientists caution against attempts to radically change gut ecology by using powerful antibiotics to eliminate intestinal bacteria and then attempting to re-colonize our guts with a healthier microbiological environment. Let me give an example of a man-made disease where tampering with the intestinal environment my lead to more serious risks.

Asthma has become much more prevalent in recent decades. After WW II, our overuse of antibiotics destroyed the common bacterium Helicobacter pylori in the guts of many people. People without H. pylori are much more likely to have asthma, allergies, and acid reflux. Writing on the ecology of human disease, one scientist has postulated that the destruction of this ancient microbe may also be a factor in the post-modern Type II diabetes and obesity epidemics. So, why not reintroduce H. pylori into our GI tracts? As it turns out, this microbe can also lead to ulcers and stomach cancer if it becomes too dominant. Tipping the scale to the other side might be even more damaging. Modern medicine’s weapons of mass microbial destruction are hardly adequate to preserve delicate balances.

Wholistic medicine has suggested that probiotics and prebiotics might help bring GI tracts ravaged by processed foods and modern drugs back into balance. Maybe, but do we really know which probiotic organisms and probiotic substances our bodies need?

Probiotics are micro-organisms which are believed to be beneficial to the human body. Yogurt with its lacto acidophilus and other live cultures has long been believed to strengthen immunity and improve health in general. Many other probiotics have been developed as nutritional supplements but our knowledge about the specific benefits of the hundreds of varieties of bacteria in our gut is currently at best partial. Anyway, yogurt tastes great and makes me feel good.

Prebiotics like fructo-oligosaccharides (FOS), inulin, and beta-glucan are believed to feed the good bacteria in the gut and improve gut health. They can be found in infant formula, nutritional supplements and some foods. I have tried them and found the short-term effects to be more embarrassing than life changing. As they ferment in your intestine, you can become quite pneumatic. One can only hope that these are the sounds of beneficial bacteria feeding well. Prebiotics, however, are not without critics. Some believe that they may also support some strains of harmful bacteria in your gut.

Here’s what we know for sure. High carbohydrate consumption, especially fructose, feed the bad bacteria and can seriously damage your gut ecology. We can also assume that healthy, fresh foods with abundant nutrients and natural fiber will improve the balance of the gut microflora.

Monday, April 5, 2010

Supplements - A Stepwise Approach

Before being diagnosed with diabetes over 14 years ago, the only supplement I was taking was a multi-vitamin. I added a couple of capsules of fish oil daily and, as I read more, I experimented with more supplements. Usually, I will start with a smaller dose and gradually build to a larger therapeutic dose. By adding new supplements one at a time gradually, I am able to ascertain how the supplements are working for me.

Only once did I have a strongly negative reaction to a supplement. That was the herbal extract ephedra which contains ephedrine, a powerful stimulant that greatly benefits weight loss but with some very negative side effects. I figured out it was not for me ... long before FDA banned it. I cannot think of any other supplement in the last two decades which has been implicated in seriously negative side effects. Supplements do not have a record of serious side effects like pharmaceuticals which have even resulted in death in rare cases. Nonetheless, sensitive people may find they have problems with mega doses of some supplements. Alpha lipoic acid is an example of an excellent supplement for diabetics that I need to be careful with. I used to take 3 x 600mg a day which I regard as the maximum reasonable dose. ALA is very acidic and I found that large 600mg capsules sometimes gave me a little heartburn. Now, I take 4 x 300mg/day with no problems.

I do take many supplements. I do believe that therapeutic doses are often mega doses. I do not think that anybody should add more than one new supplement at a time and it is best to increase dosage gradually.

Will supplements dramatically improve your health? I do hear accounts of significant improvement related to supplements, especially fish oil and Vitamin D3, but most supplements are an act of faith. I take my supplements regularly and I notice nothing. It seems as if nothing has happened -- nothing at all. No heart disease, no neuropathy, no retinopathy, no kidney disease -- nothing at all.

And that's why I take supplements.

Friday, April 2, 2010

Supplements for Diabetics

I do not know anybody who takes more supplements than me. Frankly, supplements are the realm of charlatans and weak science, so it is not easy to ascertain what really works. The industry is not nearly as profitable as the pharmaceutical industry and rarely is there commercial motivation to fund serious scientific research. I do contract manufacturing of supplements for Chinese companies at a California facility, so there's my bias ... and the source of a little bit of expertise.

My personal philosophy is that if there is convincing research suggesting a supplement may be helpful in meeting my health goals, if the supplement is not toxic or harmful at doses anywhere near what I take and it is not cost prohibitive, I will use it. I do not do this lightly. All my decisions are well researched and I urge friends to do the same. Supplements are certainly not as risky as pharmaceuticals with their many known side effects, but one must still consider the benefits and risks. I have used supplements since being diagnosed with diabetes more than 14 years ago and still have no diabetic complications ... despite some questionable lifestyle choices over the years. Maybe supplements work.

Below are the supplements which are commonly used by diabetics. I list them in priority order based on how effective I believe they are in promoting diabetic health.

Supplements which may prevent Diabetic Complications –

Omega-3 from fish oilAt least 4000mg a day of EPA & DHA omega-3 in divided doses. Reduces high triglycerides and C-reactive protein levels which are associated with the onset of heart disease and neuropathy in diabetics.

Vitamin D3 – Most diabetics are deficient in Vitamin D3 and should be tested. Generally, diabetics need to supplement with 4000-10,000 IU a day to attain optimal serum D3 levels which are known to prevent diabetes, improve insulin sensitivity, reduce heart risk and prevent many other chronic diseases.

Alpha Lipoic Acid – 600-1800mg a day in divided doses. Highly acidic, it may result in heartburn is some people. Known to prevent neuropathy and some claim it relieves symptoms of neuropathy. May lower BGs in some people. Strong inhibitor of of advanced glycation end-products (AGEs).

Biotin – 8-18mg a day in divided doses. Should be taken with Alpha Lipoic Acid as taking either individually may result in a deficiency of the other. May lower BGs in some people.

Vitamin B1 (thiamine) – 300-1200mg a day in divided doses. Mega-doses of B1 have been shown in some clinical studies to prevent diabetic neuropathy and kidney disease. As thiamine is water soluble, it quickly washes out of the body and is not very bio-available. The lipid soluble version of B1, benfotiamine is believed to be more bio-available but is relatively expensive.

Quercetin – About 500mg a day. This common flavonoid reduces levels of sorbitol which may accumulate in diabetics leading to neuropathy, nephropathy or retinopathy.

Vitamin K2 as menaquinone – 45-200mcg a day. Assists the body in effectively utilizing calcium. Prevents arterial calcification which leads to heart disease.

Vitamin B12 – 1000-2000mcg a day. Mega doses taken sublingually under the tongue as a lozenge may relieve symptoms of neuropathy and chronic fatigue. Some doctors administer it intravenously. Methylcobalamin is the form believed to be best absorbed and utilized. Those taking Metformin are more likely to have a deficiency if not supplementing.

Evening Primrose Oil – 1-4 grams a day. EPO is one of the richest sources of GLA which may prevent and/or ease the symptoms of diabetic neuropathy. EPO also lowers BGs in some people.

N-Acetyl Cysteine (NAC) 500-1800mg a day in divided doses. NAC is a very effective inhibiter of AGE formation. Some studies found that NAC protects pancreatic beta-cells from glucotoxicity.

Lycopene – 10-20mg a day of this powerful antioxidant is very cardioprotective and inhibits the formation of AGEs. The main dietary source is cooked tomatoes, but you would need to consume an entire 6 oz. can of tomato paste to get 16mg of lycopene (and 32g of carb including 13g of fructose!), so I go for the 20mg softgels with zero carb.

Carnosine – 100-1000mg a day in 1-3 doses before meals. One of the strongest inhibitors of the advanced glycation end-products (AGEs) which lead to many complications. In the diet, this amino acid is found only in animal protein.

Supplements with may help Lower BGs –

Chromium – 200-1000mg a day may improve glucose tolerance in pre-diabetics and T2 diabetics, especially if they have a chromium deficiency. Improves lipid profile in some people.

Zinc – 15-25mg a day. Many diabetics are deficient in zinc. May improve glucose metabolism, especially in people with a known deficiency.

Magnesium – 500-600mg a day. May improve insulin sensitivity.

Vitamin D3, ALA, Biotin, EPOMentioned above, also may help lower BGs in some diabetics.

Supplements for General Health –

Multi-Vitamin and Mineral – Choose a product that requires at least two tablets or capsules per day to get an adequate dosage. Choose one high in B vitamins but no more than 400mg of folic acid. Vitamin A should be from betacarotene not retinol. Do not get MVMs with iron unless you have a known deficiency.

CoQ10 – 100-200mg a day, 200-300mg a day for people taking statins. Especially important for people who take statins which deplete CoQ10.