New York Buyers’ Club - The Blog

Below we give the abstract of a recent (2005) assessment of acetyl-l-carnitine’s effectiveness in the management of neuropathy (tingling, pain due to nerve damage) in people with diabetes.

For additional information on the use of this nutrient for neuropathy and other conditions, see the NYBC entry on Acetylcarnitine.

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Acetyl-L-Carnitine Improves Pain, Nerve Regeneration, and Vibratory Perception in Patients With Chronic Diabetic Neuropathy: An analysis of two randomized placebo-controlled trials

Anders A.F. Sima, MD, PHD, Menotti Calvani, MD, Munish Mehra, PHD and Antonino Amato, MD

OBJECTIVE—We evaluated frozen databases from two 52-week randomized placebo-controlled clinical diabetic neuropathy trials testing two doses of acetyl-L-carnitine (ALC): 500 and 1,000 mg/day t.i.d. [tid = 3 times per day]

RESEARCH DESIGN AND METHODS—Intention-to-treat patients amounted to 1,257 or 93% of enrolled patients. Efficacy end points were sural nerve morphometry, nerve conduction velocities, vibration perception thresholds, clinical symptom scores, and a visual analogue scale for most bothersome symptom, most notably pain. The two studies were evaluated separately and combined.

RESULTS—Data showed significant improvements in sural nerve fiber numbers and regenerating nerve fiber clusters. Nerve conduction velocities and amplitudes did not improve, whereas vibration perception improved in both studies. Pain as the most bothersome symptom showed significant improvement in one study and in the combined cohort taking 1,000 mg ALC.

CONCLUSIONS—These studies demonstrate that ALC treatment is efficacious in alleviating symptoms, particularly pain, and improves nerve fiber regeneration and vibration perception in patients with established diabetic neuropathy.

Citation: Diabetes Care 28:89-94, 2005

The Linus Pauling Institute at Oregon State University provides a good review of research on fish oil (omega-3 fatty acids) and Type 2 diabetes (see excerpt below). Although there was some concern that fish oil supplements might interfere with glycemic control (= control of blood sugar levels) in diabetics, that does not seem to be the case. Moreover, fish oil supplementation can significantly lower triglycerides in people with diabetes, and there is good epidemiological evidence that over the long term higher omega-3 fatty acid intakes may also decrease the risk of cardiovascular disease in diabetics.
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Cardiovascular diseases are the leading causes of death in individuals with diabetes mellitus (DM). Hypertriglyceridemia [...] is a common lipid abnormality in individuals with type 2 DM, and a number of randomized controlled trials have found that fish oil supplementation significantly lowers serum triglyceride levels in diabetic individuals. Although early uncontrolled studies raised concerns that fish oil supplementation adversely affected blood glucose (glycemic) control, randomized controlled trials have not generally found adverse effects of fish oil supplementation on long-term glycemic control. A systematic review that pooled the results of 18 randomized controlled trials including more than 800 diabetic patients found that fish oil supplementation significantly lowered serum triglycerides, especially in those with hypertriglyceridemia. A more recent meta-analysis that combined the results of 18 randomized controlled trials in individuals with type 2 DM or metabolic syndrome found that fish oil supplementation decreased serum triglycerides by 31 mg/dl compared to placebo, but had no effect on serum cholesterol, fasting glucose or hemoglobin A1c concentrations. Although few controlled trials have examined the effect of fish oil supplementation on cardiovascular disease outcomes in diabetics, a prospective study that followed 5103 women diagnosed with type 2 DM, but free of cardiovascular disease or cancer at the start of the study, found that higher fish intakes were associated with significantly decreased risks of CHD over a 16-year follow up period. Thus, increasing EPA and DHA intakes may be beneficial to diabetic individuals, especially those with elevated serum triglycerides. Moreover, there is little evidence that daily EPA + DHA intakes of less than 3 g/day adversely affect long-term glycemic control in diabetics. The American Diabetes Association recommends that diabetic individuals increase omega-3 fatty acid consumption by consuming two to three 3-oz servings of fish weekly.

See also the NYBC entry on DHA Max, a DHA/EPA supplement from Jarrow.

This is an excellent guide to managing the side effects of prescription drugs through better nutrition and nutritional supplements. Published in 2007 by Basic Health Publications, it synthesizes much recent research on how the most frequently prescribed drugs for Type 2 diabetes, cardiovascular disease, osteoarthritis, and depression often cause nutrient deficiencies that can lead to additional health problems. Dr. Cass, who is a practicing physician and a specialist in integrative medicine, provides clear analyses of these damaging side effects and offers recommendations on how to address them.

The first condition discussed by the book is Type 2 Diabetes/insulin resistance/metabolic syndrome. For those who are taking the most commonly prescribed drug for Type 2 Diabetes, metformin, Dr. Cass stresses the importance of supplementing with Vitamin B12 (200-1000mg/day) folic acid (400-800mg/day) and CoQ 10 (30-200mg/day) to make up for the nutrient-depleting effects of the medication. Vitamin B12 and folic acid, together with Vitamin B6, are crucial for keeping levels of an amino acid called homocysteine in check in the body. Since elevated levels of homocysteine are associated with heart disease, stroke, hypertension, neuropathy, and Alzheimer’s, it’s a top priority to keep the body supplied with the B vitamins that can control it.

Dr. Cass also provides a “Diabetes Supplement Program” especially directed to pre-diabetics who may be able to address their condition with diet, exercise, and supplements (the B vitamins and CoQ 10 mentioned above, plus alpha lipoic acid, antioxidants, and the trace minerals chromium and vanadium, which are needed in blood sugar processing).

Much more to discuss in this very useful book, so we will come back to it again!

We were interested to see a report from last month on a study of chromium plus biotin to help in managing diabetes.
The study, conducted by Yale University researchers, found that daily supplementation with these two items improved glucose tolerance by 15 per cent, compared to placebo. The investigation focused on the glycemic control and blood lipids of 36 overweight or obese people with type 2 diabetes. Reporting the results in the journal Diabetes Technology and Therapeutics, lead author Gregory Singer concluded that supplementing with chromium and biotin on a daily basis improved blood sugar control and cholesterol metabolism in diabetes patients on an antidiabetic treatment regimen, and could be considered as an adjunct to conventional oral diabetes therapy.

We also note that biotin and lipoic acid have recently been investigated for their potential in helping manage diabetes. See the NYBC entry on biotin for further details.

A New York Times piece on Vitamin D as the “Nutrient of the Decade” caught our eye. In addition to reporting on recent studies on Vitamin D’s anti-cancer properties, this article reviewed investigations linking higher Vitamin D levels to decreased risk of developing multiple sclerosis or diabetes in some populations.

Here’s a short excerpt:

The incidence of autoimmune diseases like Type 1 diabetes and multiple sclerosis has been linked to low levels of vitamin D. A study published on Dec. 20, 2006, in The Journal of the American Medical Association examined the risk of developing multiple sclerosis among more than seven million military recruits followed for up to 12 years. Among whites, but not blacks or Hispanics, the risk of developing M.S. increased with ever lower levels of vitamin D in their blood serum before age 20.

A study published in Neurology in 2004 found a 40 percent lower risk of M.S. in women who took at least 400 I.U. of vitamin D a day. Likewise, a study of a national sample of non-Hispanic whites found a 75 percent lower risk of diabetes among those with the highest blood levels of vitamin D.

Vitamin D 3 1000IU

and

Vitamin D3 400IU

This is a brief overview on alpha lipoic acid, a much-studied antioxidant that holds special interest to those with chronic liver disease and/or HIV. If you’re one of those people who like their information in capsule summary form (with further details and references attached), this may be just the ticket to get you started. The full entry can be found on the University of Maryland Medical Center’s website –another in a growing set of mainstream medical information resources that host serious information on “integrative medicine,” including dietary supplements.
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This post runs a little long, but we think it’s worthwhile to put up the FAQ about nutritional supplements recently posted by the New York Buyers’ Club. It answers a lot of (sometimes anxious) queries about supplements, and also gives a quick rundown on some of the top uses of supplements among the NYBC membership.

What are supplements?
A nutritional or dietary supplement (or just plain supplement), as defined by the Dietary Supplement Health and Education Act (DSHEA) of 1994, is “a product (other than tobacco) that is intended to supplement the diet and that contains one or more of the following: vitamins, minerals, herbs or other botanicals, amino acids, or any combination of the above ingredients,” and can be taken in tablet, capsule, powder, or liquid form.
NYBC specializes in supplements for those with HIV, hepatitis C, and other chronic conditions. Our Supplement Fact Sheets contain information on more than 100 supplements commonly used by our Members. Our nonprofit purchasing co-op stocks these supplements on a regular basis, and can also special-order many other supplements on request.
Why take supplements?
There is a great deal of research showing that supplements can help people manage serious chronic conditions such as HIV and hepatitis. Supplements can also be useful in addressing many common health issues, such as high cholesterol, diabetes, depression, arthritis pain, gastrointestinal disorders, etc. (see our short list of specifics below). Some supplements are derived from ancient traditions of use (for example, the botanicals of India’s Ayurvedic tradition), while other items (such as vitamins or amino acids) have been isolated and used as supplements much more recently. The scientific study of supplements has blossomed in recent decades, so we now have better evidence about many of them—even traditional botanicals—than we ever did in the past.
Are supplements considered “medicine”?
While supplements may have medicinal properties, they are not regulated in the same way that prescription drugs are, and are therefore accompanied by the disclaimer: “These statements have not been evaluated by the Food & Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.”
The fact that supplements are not regulated in the same way that prescription drugs are naturally gives rise to concerns about purity, efficacy, and safety – so it’s good to have a knowledgeable ally like NYBC on your side! Collectively, we have many years of experience in using supplements, in researching information on them, and in evaluating suppliers to obtain the best quality product.
Are supplements “safe”?
Under current US regulations, supplements are assumed to be safe on the basis of their history of use, or because they are found in the food supply (like the microorganisms in yogurt or the vitamins and minerals in foods). The US Food and Drug Administration is responsible for removing supplements from the market if it finds evidence that they are unsafe, but it’s worth noting that this happens quite rarely. (The removal from the market of ephedra [aka the Chinese herb Ma huang], used at high dosage as a diet pill, is practically the only significant example since 1994). However, while supplements may be “assumed to be safe,” everyone who takes them needs to pay attention to the recommended dosage and any cautions or warnings. If you exceed the recommended dosage of certain supplements, there may be side effects, sometimes serious. Furthermore, a supplement may have negative interactions with other medications you are taking, or a particular supplement may not be a wise choice for you due to other health concerns. That’s why it’s always important to discuss your supplement use with your doctor.

Here are just a few examples of potentially dangerous supplement-medication interactions (from the National Center for Complementary and Alternative Medicine’s website) - further proof that consulting your physician about supplement use is crucial:

• St. John’s Wort can increase the effects of prescription drugs used to treat depression. It also dangerously interferes with drugs used for HIV, cancer, birth control, and rejection of organ transplants

• Ginseng can increase the stimulant effects of caffeine (as in coffee, tea, and cola). It can also lower blood sugar levels, creating the possibility of problems when used with diabetes drugs

• Ginkgo, taken with anticoagulant or antiplatelet drugs, may increase the risk of bleeding. Ginkgo may also interact with certain psychiatric drugs and with certain drugs that affect blood sugar levels

Of course, doing your own “homework” is also encouraged. Be sure to bring any notes or printouts from your research to share with your healthcare provider. That way, you’ll both be literally on the same page.
Identity, Purity and Potency
Safety is also a matter of product quality. Is the product what it claims to be on the label (that is, is it really fish oil)? This is the product Identity. Does the product contain any unwanted contaminants like heavy metals, insect parts, rodent droppings? All foods and medicinal products face these issues of Purity. And finally, does it have as much of the claimed amount of a substance? For example, if it says 100 mg of niacin, does it have that amount? This is the product’s Potency. These issues are of ongoing concern. NYBC has done everything possible to assure that products meet these standards. Websites such as www.consumerlab.com can help. Also indications of quality such as USP or other labels further add assurance. The good news is that the vast majority of products tested by consumerlab, for example, pass their tests. Still, NYBC believes an appropriately funded agency of the FDA could do more rigorous, routine and comprehensive testing.
What is CAM?
CAM is an acronym for complementary and alternative medicine. The use of supplements is considered CAM. Some prefer the term integrative medicine.
The National Center for Complementary and Alternative Medicine (NCCAM), a division of the US National Institutes of Health, defines CAM as “a group of diverse medical and health care systems, practices and products that are not presently considered to be part of conventional medicine.” NCCAM, like the US Office of Dietary Supplements, came into being after passage of DSHEA, and marks the federal government’s decision to commit funding to research and education about CAM. Over a billion dollars in your tax dollars have been spent by these agencies since their start.

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Using Supplements
What supplements can I use to improve my immune system?
Agents such as a potent multivitamin, NAC (N-acetyl cysteine), alpha lipoic acid and whey can all help offset oxidative stress and nutrient losses caused by HIV as well as the free radical generation and inflammation-related damage that some antiretroviral drugs cause.
For those with HIV, supplementation can be a valuable assist in restoring the body’s immune system, as evidenced by many studies, such as Dr. Jon Kaiser’s HIV Micronutrient Study, which showed a significant increase (26%) in the CD4 counts of the subjects who maintained a supplement regimen in addition to their regular medications. FYI: NYBC offers a “MAC Pack” (Micronutrient - Antioxidant Combination Pack), a product very similar to the one used in the study.
What supplements can be used to improve gut function?
Acidophilus or bifidus, glutamine, whey proteins, Saccharomyces boulardii (Florastor) and a good multi can all be important to offset gastrointestinal problems, whether HIV-related or of other origin.
What supplements can I use to manage my blood fats (cholesterol and triglyceride levels)?
“Bad cholesterol” (LDL) and triglycerides can be reduced with agents such as carnitine, pantethine, and fish oils. Niacin may be an excellent option which can also help increase HDL (“good cholesterol”). For heart health in general, aside from diet and exercise, CoEnzyme Q10 may also be of help (may also be useful in countering statin-related side effects).
What supplements are used to improve mental function and/or mood?
Acetylcarnitine, 5-HTP, tyrosine, ginkgo biloba, fish oils, SAM-e, DHEA, theanine, or St. John’s Wort may help mental function and alleviate depression, though each of these must be taken with some care (and not all together!)
See also: a full dossier on Memory Loss and Other Brain Problems from our Health+HIV section of Recommended Reading on the website www.newyorkbuyersclub.org; also recommended is the NYBC info sheet on Depression and supplements on this blog, under “Depression.”
What supplements can I use to combat fatigue?
Various conditions can cause fatigue, but in general, B12 (methylcobalamin) and Eleuthero (used to be “Siberian ginseng” - don’t use with high blood pressure!) may all help to improve energy. A good start may also be as simple as a good multivitamin!
For more information about the causes and treatments for fatigue, see our Fatigue Fact Sheet on the NYBC website.
What supplements can I use to stabilize my weight?
For those experiencing weight loss, whey proteins, carnitine and creatine plus CLA may all help - but of course especially in conjunction with a good diet and routine exercise! And we agree with Dr. Jon Kaiser and many others: resistance exercise remains an important component of a successful HIV management plan.
What supplements are used to treat nausea?
NYBC recommends ginger; marijuana, while effective, is not carried by the NYBC, as it is not yet approved for medical use in New York. For detailed information about the causes and treatments for nausea, see Health+HIV section of Recommended Reading on the NYBC website.
What supplements are used to improve liver function?

Liver function can be impaired due to several reasons, including disease, alcohol abuse, and the effects of some cholesterol-lowering drugs (statins).
While making sure there aren’t any interactions with your meds, supplements like milk thistle (Silymarin), NAC, alpha lipoic acid, Hepato-C or Hepato-Detox, Hepatoplex I or II, Ecliptex, SAM-e and Clear Heat are options to consider (again, not all at once!)
What supplements can be used to treat diarrhea?
NYBC suggests supplementing your diet with glutamine and calcium. For more information about the causes and other possible treatments, see our Fact Sheet about diarrhea in Recommended Reading, at www.newyorkbuyersclub.org.
What supplements can combat neuropathy?
Much scientific evidence now points to acetylcarnitine as an effective approach to countering neuropathy (numbness, tingling, or pain, usually in the extremities, which can be caused by HIV, diabetes or by some medications).

We were impressed by the lead article on Vitamin D in the February 2008 issue of the University of California, Berkeley’s Wellness Letter (a “newsletter of nutrition, fitness, and self-care”). The Wellness Letter is usually quite conservative about recommending nutritional supplements, but in this case it finds the recent wave of research on Vitamin D promising enough to recommend that people “consider taking 800 to 1000 IU of supplemental D a day.”  As the newsletter reports, studies have now gone much beyond the well-known benefit of this vitamin in working with calcium to keep bones strong; recent research has ranged over a much broader field, focusing on Vitamin D’s “potential to reduce risk of everything from some common cancers and multiple sclerosis to diabetes, hypertension, and age-related muscle weakness.” 

Although not going so far as to suggest testing blood levels of D for the general population, the Wellness Letter does recommend talking to your doctor about testing, “especially if you are over 60 [...] or have low bone density.”

A further recommendation: “When shopping for a supplement, read the fine print: look for D3 (also called cholecalciferol), which is more potent than D2 (ergocalciferol).”

For other commentary on recent Vitamin D research, see the “Vitamin D” category on this blog.

And you can also read the Vitamin D3 entry on the New York Buyers’ Club website.

This was the title of a New York Times article by Jane Gross published on January 6, 2008.  Focusing on several case studies, the piece highlighted “a constellation of ailments showing up prematurely or in disproportionate numbers among the first wave of AIDS survivors to reach late middle age.”

There’s no doubt that the article is timely: the number of people 50 and older living with HIV has increased 77 percent from 2001 to 2005, according to the federal Centers for Disease Control, and they now are a quarter of all cases in the United States (about 116,000). And, it’s certainly true, as the piece suggests, “the graying of the AIDS epidemic has increased interest in the connection between AIDS and cardiovascular disease, certain cancers, diabetes, osteoporosis, and depression.”

The New York Buyers’ Club (like its predecessor DAAIR) has always been engaged in looking ahead in order to size up and respond to the special health issues faced by people with HIV, whether those issues derive from the virus itself, or from medication side-effects. So if you’d like to know more about how our membership has used dietary supplements over the longer haul to maintain and improve their health, and to counter symptoms and medication side-effects, please do continue to consult this blog, as well as our website, found at www.newyorkbuyersclub.org. Also–if you’d like to be included the mailing and/or email list for our quarterly publication THE SUPPLEMENT, just drop a line to contact@newyorkbuyersclub.org. NYBC doesn’t claim to have all the answers to the health concerns of people with HIV, but you might be surprised at how many useful recommendations and suggestions (based on much reviewing of the science and many years of accumulated experience) our nonprofit information exchange has to offer.

Since there are a number of federally funded research studies dealing with chromium supplementation and blood glucose levels (see other posts under “Chromium” on this blog), we’d be very interested in hearing about the experience of our members in using this product.

Jarrow Chromium GTF
Here’s an extract of the manufacturer’s product description:

Chromium GTF (Jarrow) Each bottle, 100 caps. Each capsule, 200 mcg of chromium (in a food matrix of 100 mg of Saccharomyces cerevisiae nutritional yeast).

Chromium has been shown to be deficient in populations that consume high carbohydrate diets and especially high in simple sugars. Chromium is an important component in eliciting the glucose tolerance factor (GTF) action upon serum glucose and more importantly enhancing the effectiveness of insulin in glucose disposal into the cell. This makes sense. The more carbs you eat, the more your body will need the chromium to manage them. This could help offset the losses of chromium used up in that effort to take care of the carbs. Of course, this points to another logical step: reduce carb intake!! Check out the glycemic index of the foods you eat and focus on those with lower numbers. This index tells you how rapidly a particular carbohydrate turns into sugar. Check out the URL below for more information on the glycemic index:
http://www.hsph.harvard.edu/nutritionsource/carbohydrates.html

We noticed with interest that Dr. Todd T Brown, a Johns Hopkins researcher who has studied body fat changes in people with HIV, has recently started a wide-ranging investigation of fish oil / omega-3 fatty acid supplementation as a way of preventing/treating metabolic complications associated with highly active antiretroviral therapy (HAART). Metabolic complications, including fat wasting, central body fat build-up, insulin resistance, high cholesterol and triglycerides, and bone loss, have been some of the major side effects experienced by people with HIV on medication, so it’s quite interesting to see research that may “connect the dots” and find links between these various problems. 

Furthermore, this is a study that focuses on fish oil / omega-3 fatty acids, which have quite recently gained more respect in US medical circles, especially as a means of preventing/treating cardiovascular disease, but also for a surprising effect on depression. (You can read more about this aspect of fish oil supplementation in the “depression” category on this blog.)

 Here’s the description of Dr. Brown’s research, as provided on the website of NCCAM/NIH, one of the major sponsors of the study:

Abstract: DESCRIPTION (provided by applicant): The overall goal of this proposal is to understand the role of inflammatory cytokines in the metabolic and skeletal abnormalities in HIV disease and to determine whether omega-3 fatty acid supplementation, in the form of fish oil, will alter the pathophysiology of these clinical disorders. Complementary and alternative medicines (CAM) are used widely among HIV-infected patients, often with the hope of preventing or treating complications associated with highly active antiretroviral therapy (HAART). Metabolic abnormalities, including peripheral fat wasting, central adiposity, insulin resistance, and dyslipidemia, and skeletal abnormalities (reduced bone mineral density and high bone turnover), are common in HIV-infected patients on HAART, yet their relationship is unclear. We hypothesize that these metabolic and skeletal abnormalities are related by abnormal inflammatory cytokine expression and that these conditions can be improved with fish oil, a widely-used CAM agent with anti-inflammatory properties. We have the following specific aims: 1) To understand the association between the metabolic and skeletal abnormalities in HIV-infected subjects and their relationship to inflammation, 2) To determine whether treatment with omega-3 fatty acids will have hypotriglyeridemic, anti-inflammatory, and anti-bone resorptive effects in a randomized trial of HIV-infected patients, and 3) To clarify the mechanisms of action of omega-3 fatty acids, namely the effect on lipolysis and bone turnover using stable isotope infusion techniques. To accomplish our specific aims, I intend to do a secondary analysis of data from two cohorts of HIV-infected subjects, and to then perform a randomized trial using a standardized fish oil product. These results will help to define the pathophysiology of the metabolic and skeletal abnormalities in HIV and evaluate the efficacy and potential mechanisms of action of an important complementary treatment [...]

(According to the published information, the clinical trial of fish oil is scheduled to run from 2006-2010.)

Note: An interview with Dr. Brown on body fat changes in people with HIV can be found on the website of our friends at www.thebody.com.

Here’s another federally-funded study of chromium supplementation to counter insulin resistance and potentially help prevent the development of Type 2 Diabetes and Coronary Artery Disease.

Investigator: Dr. UMESH MASHARANI, Univ. of California at San Francisco

Sponsor: NCCAM/National Institutes of Health

Abstract: DESCRIPTION (provided by applicant): Background: Chromium is an essential nutrient for the maintenance of normal glucose tolerance. While studies of chromium supplementation in patients with type 2 diabetes (T2D) have indicated that this agent lowers glucose and insulin levels, its cellular mechanism of action is not welt understood. Studies both in humans and in cell culture suggest that chromium enhances the insulin signaling pathway. We propose, therefore, to study chromium’s effects on insulin-stimulated glucose uptake in a well characterized population of non-obese, non-diabetic subjects with insulin resistantance. This population is ideal for an analysis of the effects of chromium on insulin action, because they are as insulin resistant as T2D patients but do not have the important confounder of hyperglycemia. Because these insulin resistant subjects are at risk for the development of T2D, the Metabolic Syndrome, and coronary artery disease (CAD), a demonstration of the beneficial effects of chromium on insulin action could ultimately have important public health consequences. Hypotheses: (1) Chromium will improve insulin sensitivity in a general population of non-obese, insulin-resistant, non-diabetic subjects; and (2) The improvement of insulin action by chromium is due to its effects on the major components of the insulin signling pathway (insulin receptor, IRS proteins, PI 3-kinase, PKB/AKT and GLUT4); and/ or regulators of the insulin signaling pathway (PTP 1B, PC-1, IKK, NF-KappaB and PKC) Methods: The insulin sensitivity of 180 subjects will be initially estimated by homeostasis model assessment. The most insulin resistant subjects will then be randomized to 16 weeks of therapy with either chromium or placebo. To quantitate chromium-induced improvements in both in insulin sensitivity and the insulin signaling pathway, euglycemic hyperinsulinemic clamps with muscle biopsies will be performed before and after treament. Anticipated Results and Significance: We believe these studies will (1) confirm the beneficial effect of chromium on insulin sensitvity; (2) further our understanding of the molecular mechanisms of chromium action; and (3) form a basis for a larger project examining the long term efficacy of chromium in preventing the developement of T2D and CAD.