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Before I try to answer this questions I must say that Penis size is one of the greatest self-confidence battles that men deal with. Another important fact is that only 10% of all men are happy with their penis length or their sexual performance. Do you belong to the 90% that are unhappy? A lot of questions are asked everyday by the male population... Is my penis long enough? What is the average penis size? Approximately 75% of the male population has a penis that is 6" or greater. What does my partner thing about it? Will I be able to give more satisfaction to my partner with a larger penis? Penis size can have both a physical and psychological effect on the initial degree of sexual excitement for some women. And how about you? If you belong to the other 25% can you deal with it? If not, there are penis enlargement products and programs specifically developed to increase your penis size. These products were not only developed for people with underdeveloped penises, but those have an larger-than-average penis, who just want more. The existent methods are: 1.- Penis Jelging: Basically jelqing involves "milking" or stretching exercises involving the penis, with the ultimate goal of increasing the length of your penis. Jelqing has been found to have some disturbing effects when repeated for a period of time. 2.- Penis Enlargement Pumps and Electric Pumps: With the pumps you can make up to 2 inches gain but this gain is not permanent and only lasts for approximately 1 hour. It's not an effective method if you desire a permanent penis enlargement. 3.- Penis Enlargement Surgery: Although there has been great improvements in phalloplasty, also called cosmetic penile enhancement or augmentation surgery, the results remain unpredictable and there are some significant risks involved. 4.- Penile Weights: This method works by hanging small weights off the end of your penis to stretch the penis and in the process, make it longer. This method of penis enlargement has been around for some time and has worked in some cases, but comes with several potential risks. 5.- Penis Enlargement Pills: They are 100% natural pills, being blended with a combination of herbal component that very effectively enlarge both penis length and penis girth, as well as enhancing sexual performance. Some of them are developed in advanced laboratories and approved by the FDA. 6.- Penis Extenders: Though there are few people using this method in comparison to other types of penis enlargement, it is proving itself to be a very successful method. The device is used anywhere between 2 and 10 hours a day and causes your penis to build new tissue cells resulting in a longer, thicker penis. 7.- Penis Enlargement Patches: The transdermal patch ingredients are instantly absorbed into the skin and the product does not need to travel through your digestive system, beginning its work immediately for fast and effective sexual enhancement. Some experts recommend the use of combined methods, in order to achieve a better and faster result. Before you choose, please check carefully the advantages and disadvantages of each one them. free penis elargement penis enlargement forum penile enlargment patch vimax best penis enlargement pills penile enlargment technique plus vigrx penis enhancement surgery picture vimax natural penis enlargement and lengthening pennis enlargement herb

The Forest As we drove farther into the outskirts of Augsburg, looking out placidly across the top of cars, houses, and at the dogs running about, I got thinking, thinking how I felt being with Chris, about Chris. It was like I was cast into a spell, an enchantment, or perhaps a curse; very seldom did I ever feel like this. Normally I would feel like this only if I was in the presence of a great person, like my karate instructor in San Francisco, Gosei Yamauchi, or his father ‘The Cat’ Gogan, who was one of the few 10th degree black belts in the world. Normally I’d be high the whole next day. With Chris I felt the same way I knew tomorrow I’d be high all day, it was a natural high. Once—I can’t remember when—I had read something about the poet Emily Dickinson, she was something like a recluse, but she made a poem indicating nature was her high, and I always remember that. How true this can be, grabbing the moment and cherishing it, absorbing it as if there was no tomorrow, and at the same time absorbing nature: the sounds and the heart beat mother earth, and sky; others humans, and the dogs and birds, all such things that at that moment surround you; they are all somewhat magical. I was learning, how to be a listener if anything and it entailed all things within your presence. Chris was fully alive now, as I turned my head towards her delectation her steering wheel facing me, at which made the moment a little more interesting, as she felt good about me checking her out; a weary kind of sense, not defeat, just a good profile look; I thought dimly in my mind as she drove mile after mile: how could she afford to look so prim and proper all the time. Do her hair in a unique style, not a hair out of place, so it seemed. I guess in our own way we are all unique, I heard that someone say that someplace, not sure where. An hour and a half had passed on by and she was still driving, and it was getting dark. She pulled into a wooded area; she said it was the outer rim of the Black Forest (otherwise known as the Eyebrow of the Woods), I think I heard of that forest in a fairytale book or at least that is where my mind said I got it from. An enchanting name, I must had said it my second self, that little person inside of all of us that we talk to: Black Forest, Black Forest…! “So you see,” said Chris “…here we are!” She added her conclusive little smile to her face as she said that; as we entered the dark huge green forest, parking the car a little off to the side of a dirt road that lead into the deeper and more distant part of the forest, partly covered by trees and bushes now. There was a chill in the air so I rolled up the window, as she turned on the radio for some music. Very quickly and carefully she moved her thin reserved neck and shoulders into my area, she just starred at me, as if she was going to eat me up; as her left arm was lowered, it pulled out a bottle of Mosel-Saar-Ruwer wine, 1965 wine, -- I looked the bottle over 9.5% volume; I knew they had been making wine around this intriguing river and hilly area for close to 1700-years. It was good wine I had tasted it before, not sweat or dry, flowerily white wine to be exact. “Now,” said Chris indignantly, but with the air of a certain point, “…let’s see what we can do with this battle. We started to drink and laugh. “Ah, yes,” I said to her, “you have a lovely profile.” She smiled and threw her head back. “Well,” I thought out loud “… this is a good way to pass the night away, and begin romantic indecencies”-- she leaned over the center-divider of the bucket seats to kiss me. She opened her mouth, sunk her lips on mine, as she pulled her long legs to the under-part of the dash, she then started to unzip her zipper to her boots. “This,” commented Chris “passes everything…I never did it in a car before.” She had drunk down 1/5 of the wine like a person drinking water. “Chick,” said Chris, ”…come over here.” I moved my body closer to hers. Everything seemed to be in the way. I could not back out of whatever was going to happen; and I knew what was in the makings. She was starting to stretch her hands out: --her blouse went over her head, I just kept looking as she started to strip, I was growing, getting as hard as a pencil. “Oh, damn Chick,” said Chris heartily as she touched my item. Just her saying that aroused me; then pulling off her bra, and her skirt up I seemed to become tranquilized somehow, my mind slipped to King Solomon, of all things, as he once defined the beauty of a woman’s body and how it was to measured for one’s pleasure by enjoying it fully, and this was all I wanted to do now—enjoy it, and I think Chris was feeling the same way for even though we were both a bit on the tipsy side we were fully aware of our responses, I had lost complete focus of the uncomfortable situation, as she did… ◊…now that she was almost completely stripped only her panties on, she curled up in a fetus position holding her legs and leaning back, then opened up her legs slowly… I thought what every on earth possessed her, yet who can predict women I told myself, and started to take off my cloths, quickly…getting out of this spill of sorts. I guess it is true, men like to observe, and women like to touch. I liked both. This was not dirty sex, this was pure sex, at its height, one might even say, it was like a painting; she painted the picture, she taught me how to enjoy what she had to offer. “I’m going to get it all off in a minute,” I said, it was difficult working in this cramped space… she chuckled, “Slowly please, I can wait…”she softly said as she rested her head back and I caught my breath, that is what she wanted, that is, for me to calm down, yet remain hard and possessed with her offering: I think we both had multiorgasms “I feel fine now –“ I said, adding, “cramped but fine…☺” Chris opened up her arms I couldn’t back away after that, could I? I told myself: I have a private room at the barracks…. Then said it out loud to her: “Of course, -- next time…” said she, and we continued to make love for the third orgasm for me, for her, perhaps five or six. We seemed to flop around the front seat finding the right position…’she‘s looking at me eeeeeeeee’, I told myself, I’m cramped, nothing to grab a hold of, her head leaning against the glass of the window. Without a word we continued: --my body heavy onto hers, my heart beating two-hundred ticks a minute, we both were hot, enmeshed in the moment, a lustful, and burning moment; I wanted to open the door, but feared the light going on and someone would see us, plus the air was cool, too cool. I had no escape we met each other’s eyes as I penetrated her. She looked again deep into my eyes as she tried to catch her breath, to make sure I was still alive I think. It was seemingly unfair for me to put her through this I thought, but the thought only lasted a half second, I found myself exploding … as my heart dropped to my feet, and again, and again, I exploded and burned as if I had opened myself up to a volcano; I had learned at that moment, the difference between happiness and pressure: happiness was listening to her talk before, and then came her smile, now the pleasure, sex; I hurt, this had never happened before. “Nice evening, isn’t it?” I said as I started pulling her body closer to me. “I hope you are not offended I am taking the lead?” said Chris. “Not at all,” I said, adding, “I’ll catch up.” “There are times,” said Chris, “when rules are made to be broken like now, them...mmm damn silly rules…” she pulled herself up a bit, “I stopped believing in those rules… this is one of those moments I want to remember…remember for a long time, even after I am dead.” As we tried to untwist our bodies, we caught ourselves laughing at our odd situation. We had made love, and became a little more sensitive with each other…a little more possessive of each other, I guess that is the nature of things in a relationship, they are made to progress, or stop, one or the other, and it was never to take place again in the front seat of a Mustang I knew…. She laid her cheek against my hand. “Chick.” “Yes?” “You realize don’t you, this can’t end here?” “There’s no reason for it to end, is there?” “No.” She spoke some German words I didn’t understand, German mingled with English I should say: then somehow, she went silent…maybe she was taking time to remember the moment, digesting it; I didn’t know, nor did I want to try to guess, I just looked at her, her smile it seemed to promise something, grace; instinct was in it also, around her small enclosed eyes, as they opened and shut slowly they were weaving a web I do believe, “It won’t end here, I promise.” Pleasant and agreeable-like a well-cultured woman she was, maybe too much for me, she opened the door, and dressed quickly, then got back in. “Want a cigarette?” I asked, sitting up straight. “No and neither do you. We are both restless it seems. Come over to me,” she started kissing me. As she released her lips from mine, she sat upright now, pulled out a cigarette, lit it and started blowing smoke rings into the air. “You know perfectly well, I’m very much attracted to you…yoouuuu… right?” “I hope so, I feel the some way.” “Luckily the wine deadens the bruises (discoloration).” I commented, she laughed and kind of stretched her back to put it back in place…”Me to,” she replied. “I wish all relationships could start like ours, it is like saying let’s drop all the game playing and pretend we are on the fifth date, and cut the crap; I like you Chick, I like you very much…” “The bruises will show up tomorrow,” I told Chris. Kind of saying maybe we should go, but neither one of us seemed to be all that bothered with that so we simply started kissing again after her cigarette brake…it was a long and needed pause for me, for a second breathe, a refractory period I needed [from uninterrupted sex]; that is, having multiple orgasms drains a man. I’ve learned also, women don’t need this rest period; so in time I’d learn how to last longer, and perhaps stretch the orgasms thinner but again, longer (three hours at the most; and I did). I thought in my head, she was having sex with me, and then that rich boyfriend she had; she was getting her multiorgasmic pleasures indeed, perhaps a secret to some women, for once they discover this, it is hard for any man to keep up with them, lest he be a superman of sorts. I did not even at that young age have the capacity to pass six organisms; five was my limit I learned. I was limp now; my penis had been as pointed as a scorpions tail a while ago. As scary as it started out for me I thought my reactions afterwards was cool, I seemed to be letting things take their natural course. It was a dark and colorless evening. Grossly romanticized in such an unimpressive way (so I thought in the back of my mind), yet Miss Chris was perfect. I thought to myself: maybe she might be annoyed with my lovemaking… I guess every man wants to please the woman, wife, girlfriend, the one he is making love to, or should want to please her, but most don’t; how can they, they pop too quickly. This is a fact, I’ve talked to men, and when they say they go so quick, no woman could get it on in that time period. A woman taught me how to hold myself from climaxing too early, thus allowing the woman to catch up—and therefore, allowing my female mate to get it on and enjoy. I know this evening went a little fast, but Chris was modest about it, like that other woman who had taught me, helped me, to help her, so we both could enjoy each other more; as my slowing down kept my penis hard longer, allowing her pleasure zone to become wider. This was something of the case in hand, but not completely. Most men think they make love better drinking, but it’s far from the truth. Most men do not know how to make love, no one taught them, so all they do is f*ck, and that is not love, that is, if anything, a quick climax, like eating a big fat burger, and wiping your mouth in its enjoyment and then leaving the café only to find out: you got indigestion, and had you went to a nicer restaurant, ate slower, you’d never forget the meal. I have experimented with that theory, and it is nine-minutes verse four-hours, I say four hours, but I knew in my head it was only one time I lasted four hours, two and a half was the norm. I was thinking now—as Chris kissed me—how I owe some women a bit of gratitude for allowing me to have my pleasure and not returning it to them; that’s the caretaker in a woman I think. But women just don’t know men can learn. And men are too bull-headed to let women teach them what pleases them. I had learned a good lover was worth his weight in gold and even maybe a little more: sometimes they can be irresistible. One could hardly tell her it wasn’t hastily done, our sex (to me it was) for it was, but she seemed to understand the circumstances, and we need not prove anything today, only allow our bodies to be sanctioned to the other. So I think we both felt. Lovemaking would improve as time went on. “I’m afraid my lover, we will have to find better accommodations next time,” Chris said, smiling at me. “Yes,” I hesitated, “absently,” I hesitated-- “I feel the same way.” “It’s a little hard in such a cramped car luckily we are both a little tipsy….” “I’m afraid I’m not, somehow I sobered up when you took your blouse off.” She smiled, with a grin. “Yes. I sense you have, do you really like me Chick?” “You are growing on me. And what is there not to like?” She was like a schoolgirl at times, needing to be encouraged, to grow up, and needed to be admired. But she didn’t need permission to live, she was taking that—but I’m learning to appreciate women more, I told myself, and it seems the more I show appreciation, the more they respect me, and to be quite frank with myself, I need respect. And why not … the world will give it, if you demand it, and if not, let that part of the world go; so my second self, my mind’s eye, told me. But then as I looked at her, if she really felt she was on death row, with cancer, maybe I was just a remedy for a while, and if so, so what, maybe I needed a remedy to make it through my time here in Germany; so seemed just to me. 8 The Spider and The Web A warm-wind had picked up it seemed, and April and May in Germany was a paradise of light-cool sunrays, it was a spring never to forget, Chris and I were growing on one another, like white on rice. More community drinking fairs were picking up and Chris and I tried to make a few, drink it up and eat and just go with the flow; it was a good time for living. Chris and I were known throughout the guardhouse-barracks as lovers and a heat wave at that. She seemed to have a charm with my soldier friends, and often drove her German boyfriend’s Mercedes car to the gate, and about, showing off kind of, not only to me, but it seemed at times going out of her way to show it to the other guards. Most of my friends thought she had two cars, I simply did not up date them, if they were not in my way of thinking or inner circle—why squander my time; and in most cases they didn’t have a need to know; but Ski and a few other of my friends knew the truth. I felt: plus, I felt: why not let Chris make an impression at the guard shacks, if it helps her ego so be it. I do not think I was envious, rather amused. I’m sure somewhere along the line I’d have to deal with envy, but who at my age is envious, for what, I have a lifetime to catch up. She flirted with the guards, and they all thought it cool. At night, if I had to work, she would bring me by a sandwich while on duty; in one way she got the guys a little jealous, or in lack of a better word, annoyed. And sometimes she would simply walk into barracks, which had about fifteen-guards some running around half naked from the shower room to their room, while others went visiting. She’d come knocking on my door. She’d spend the night with me, it was an improvement from the car, and for some reason we only went over to her house once in the following two months. I knew we were not fooling anyone at the guard-barracks, but we pretended to be secret about it anyway. magna rx pills vimax cheapest penis enlargement pills penis enlarement pennis enlargement tool natural penis enargement technique herbal penis enlargment surgical pnis enlargement enlargment manhattan penile surgeon pennis enlargement herb

Breast massage as a method of natural breast enlargement and breast health has actually been used for years as a means of stimulating healthy breast growth and promoting breast tone, pliability and firmness. Breast massage is one of the best ways to help create a more beautiful bustline by helping to shape, tone and promote growth of the breast and the area surrounding the breast. Not only can moderate breast massage help to make your bustline more attractive and sometimes even grow larger, but it is also an excellent way to keep in tune to your breast health by creating awareness of any fibrous areas of possible indications of breast cancer and some have even claimed moderate breast massage can help to prevent cancer. Breast massage has been used in beauty parlors and massage parlors, especially in Asia, as a means of healthy lymphatic drainage, breast growth promotion, and as a post operative therapy for women who have undergone mastectomies, breast surgery, or other trauma to the breast area, since it helps break down scar tissues as well as stimulate healing and tissue regeneration. There has been much speculation that the practice of wearing a bra 12-15 hours per day by most women restricts lymph flow and healthy riddance of toxins, and apart from not wearing a bra, which is not an option for many women in today's societies, breast massage is the best way to help the lymphatic system drain these pent up toxins and help to prevent them from building up and contributing to cancer or other ailments. By massaging the breasts on a regular basis, many women is Asia have claimed it has enhanced the shape, size and overall attractiveness of their breast, while also giving them a sense of oneness with their femininity, and promoting relaxation and peace of mind, as other methods of body massage do. Many who practice breast massage for increased breast fullness and beauty also have utilized special herbal serums or creams formulated to further stimulate the breasts into "expanding", firming and toning, creating an overall larger look and correcting sagging, droopiness and other traits deemed unattractive by other individuals. Believe it or not, the Thai government has recently reported it supports breast massage as a means for breast enlargement and breast health, so there really must be something to this phenomena. Here are some guidelines for breast massage you may want to follow: 1.) Use a breast enhancing cream or lubricant - preferably a quality one with natural stimulating herbs and botanicals (see our reviews page for info on Benefil) - of your choice to help prevent friction and increase the enjoyment and relaxation of the massage for a more pleasurable and therapeutic experience. This can be an herbal mixture - there are some good ones out there that really do help to promote firmess and breast tone, while creating a larger and more rounded look. 2.) Light to moderate massaging using a gentle back and forth gentle “swishing” action is best. This can be in a counterclockwise circle around the breast to help promote maximum lymphatic drainage. 3.) To gain maximum benefit and therapeutic effects, breast massage should be practiced daily, as part of a routine - perhaps when fresh out of the shower, since the skin is still somewhat moist and the room may still be steamy, for a smoother massage which may be more easily lubricated since there will still be moisture in the air. If you prefer, even several times a day can be a great benefit. It depends on what fits into your schedule. A few minutes at a time should suffice. penile enlargment pills review magna rx results review vig rx penis enlargement pill vimax safe penis enlargement best penis enlarement surgery guide to pnis enlargement free penis enlarement tip vimax patch pennis enlargement herb

If you’ve ever witnessed someone suffer a stroke, you understand the humbling nature of this disease. It can reduce the mightiest human being to an immobile, helpless creature. Impairment of crucial functions like speech, walking, and control of bowel and bladder can wrench control from the body in a moment. Even perpetually youthful TV personality Dick Clark was struck down by stroke at age 75, despite the outward appearance of perfect health. Clark’s stroke resulted in a six-week hospital stay and, judging from fragmented reports, significant disability. Stroke can be like a devastating fire that strikes without warning, leaving only smoldering rubble. Stroke can so ravage basic bodily functions that often all you can hope for is to regain a portion through rehabilitation. The disease process that underlies stroke requires decades—30 or 40 years—to develop. With that much lead time, why aren’t we better able to detect or stop this crippling disease? The truth is that we are able to predict many, if not most, strokes. Advances in imaging technology allow detection of atherosclerotic plaque that cause stroke years before it becomes a threat. Progress in deciphering the causes of stroke has also leapt forward. Unfortunately, your neighborhood physician still focuses on diagnosing the crisis rather than anticipating it. Physicians prefer to deal with catastrophes and are just not that interested in prevention. Most physicians ask: “Is it time to operate or not?” The medical community obsesses over procedures like carotid endarterectomy (surgical removal of plaque) or carotid stents. Even when a person is afforded the warnings of a “mini-stroke”, or transient ischemic attack (TIA), little more is done once it’s determined that surgery is not necessary—even though this person has high risk for future stroke (50% over 10 years). Let’s flip-flop this approach to stroke. Procedures represent a failure of prevention! Where do strokes come from? Stroke develops when some portion of the brain is deprived of blood. This usually results from a tiny bit of debris that dislodges from an atherosclerotic plaque along the walls of an artery (the same sort that accumulates in coronaries causing heart attack). The sources of debris have been a subject of controversy, but new imaging technologies have settled the question. Any blood vessel that leads from the heart to the brain can be a source. The two carotid arteries on both sides of your neck are a frequent source, as these arteries are prone to develop plaque. (Our discussion will be confined to what are called thromboembolic, or ischemic, strokes, i.e, strokes that occur from plaque that fragments, sending debris to the brain, and will not include the far less common hemorrhagic strokes due to rupture of small vessels in the brain, nor will we discuss atrial fibrillation and other heart causes of stroke. The thromboembolic strokes we discuss cause around 88% of all strokes.) Over the last 10 years, the aorta has been recognized as another important source of stroke. The aorta is the main artery of the body whose branches go to the head, arms, and legs. Atherosclerotic plaque is a live tissue that, through poor diet, inactivity, high cholesterol, overweight, etc., grows and becomes progressively more unstable. At some point, plaque fragments. Little bits break away, traveling to the brain. Fractured plaque also exposes its deeper structures to flowing blood, triggering blood clot formation, which in turn can also fragment and go to the brain. Atherosclerotic plaque is a prerequisite for the most common causes of stroke. If the majority of strokes originate from plaque, why not measure plaque to determine if you’re at risk for stroke? How can we easily, safely, and accurately measure plaque in the carotid arteries and aorta? And if plaque can be measured, can it be shrunk or inactivated to reduce or eliminate risk for stroke? How can plaque be measured? Just 20 years ago, the only practical method of identifying plaque in the carotids or aorta was through angiography, requiring catheters inserted into the body to inject x-ray dye. Angiography was impractical as a screening measure. CT scanning and magnetic resonance imaging (MRI) are emerging as exciting methods of imaging both carotids and aorta. Unfortunately, most centers and physicians are much more focused on the diagnostic uses of these technologies for people who have already suffered stroke or other catastrophe, and application of these devices for preventive uses is still evolving. One exception is when aortic calcification or aortic enlargement is incidentally noted on the increasingly popular CT heart scans; this is an important finding that can signal presence of aortic plaque. The one test that is widely available and can be performed in just about any center is carotid ultrasound. It’s simple, painless, and precise. Two basic observations can be made: 1. Plaque detection—Atherosclerotic plaque can be clearly visualized. If plaque blocks more than 70% of the diameter of the vessel, or if there are “soft” (unstable) elements in plaque, then stroke risk may be high enough to justify surgery or stents. However, if there are plaques that are less severe, substantial risk for stroke may still be present that can be reduced with preventive measures. 2. Carotid intimal-medial thickness—This is a measure of the thickness of the lining of the carotid artery in areas not involved by plaque, but often precedes the development of mature plaque. Carotid intimal-medial thickness also provides an index of body-wide potential for atherosclerotic plaque that can place you at risk for stroke. The aorta, for instance, cannot be well imaged by surface ultrasound but can still be a source for stroke. Increased carotid intimal-medial thickness and carotid plaque are closely associated with likelihood of aortic plaque. The Rotterdam Study of 4000 participants demonstrated that if carotid intimal-medial thickness is greater than normal (1.0 mm), then you can be at risk for stroke (and heart attack), even if no carotid plaques are detected. Carotid ultrasound is the one test you should consider that provides the most information with least effort. Ultrasound is harmless, painless, and can be obtained just about anywhere. Even if your doctor disagrees with your request for a carotid ultrasound, an increasing number of mobile services are popping up nationwide that make this test available for around $100. One important point: many scanners and interpreters will only report whether plaque is present or not. While this is important information, you should request that the carotid-intimal medial thickness be made as well. Not all centers can make this simple measure (because of software requirements), but it doesn’t hurt to try. Any amount of carotid plaque is reason to follow a preventive program, even if the plaque is insufficient to justify surgery. Can plaque be reduced? Can we shrink plaque in carotid arteries and aorta and thereby reduce, perhaps eliminate, these sources of stroke? That question is gaining momentum as effective therapies become available that pack real punch for reducing plaque. Study after study has now documented that plaque can be reduced and, with it, risk for stroke. Reduction in plaque of 10–20% is possible within a year or two. Let’s consider the most potent influences on carotid and aortic plaque growth that need to be considered in a plaque-reducing program. (I assume that you are a non-smoker—if you are a smoker, you first need to concentrate on quitting.) Hypertension Considerable experience documents the power of blood pressure-lowering for prevention of stroke. The most recently updated guidelines, the JNC–VII, recommends a blood pressure of 407 mg/dl heightens stroke risk six-fold. C-reactive protein (CRP) This measure of inflammation is proving to be a useful marker for identifying people at risk for stroke, with increased risk beginning at a level of 0.5 mg/l. High CRP also predicts more rapidly growing carotid plaque. Homocysteine Homocysteine is an important marker of increased likelihood of both carotid and aortic plaque, as well as stroke. In 1997, the European Concerted Action Project reported more than a doubling of stroke when homocysteine levels exceeded 12 mol/l. As homocysteine increases to 20 μmol/l, risk for stroke and heart attack increases an amazing 10-fold over that at a level of 9 μmol/l. Asymmetric dimethylarginine (ADMA) ADMA is recently discovered amino acid whose blood levels can skyrocket up to 10-fold in the presence of hypertension, metabolic syndrome, diabetes, high cholesterol and triglycerides, obesity, and high homocysteine levels. ADMA blocks the action of the amino acid, l-arginine. This mimicry reduces the availability of nitric oxide, a powerful dilator and protector of arteries. ADMA levels in the top 10% predict a six-fold heightened risk for future stroke, and ADMA levels in people with strokes are double that in other people. A carotid ultrasound study in 116 subjects showed that higher blood levels of ADMA are associated with more severe carotid plaque. Because of ADMA’s shared role across a variety of abnormal conditions, correction or blocking the action of ADMA has been suggested as a unique therapeutic tool to reduce stroke risk. Cholesterol Data suggest that lowering cholesterol with statin cholesterol-lowering drugs slows carotid plaque growth and reduce stroke risk approximately 22%. An interesting study from the Cardiovascular Institute at Mt. Sinai School of Medicine in New York using the precise measuring ability of MRI of the carotids and thoracic aorta showed an impressive 20% regression of plaque area with simvastatin (Zocor®) taken for two years. Although guidelines for cholesterol treatment recommend reduction of LDL cholesterol to 100 mg/dl in high-risk persons, a report from the Walter Reed Army Medical Center in Washington, DC, showed that carotid plaque was more effectively reduced when LDL cholesterol of 70 mg/dl or lower was achieved with statin cholesterol drugs. Lower LDL cholesterol may, therefore, be better. Treatment Strategies to Reduce Carotid and Aortic Plaque The essential question: How do we reduce carotid and aortic plaque? If we make this the focus of our efforts, many pieces begin to fall into place. If you’ve had any measure of carotid or aortic plaque such as a carotid ultrasound or aortic calcification on a CT heart scan, you know that you’re at increased risk for stroke. You also have a baseline for future comparison to gauge whether your program is working or not. Because most people have not one but several causes of carotid and aortic plaque, there is no one single treatment that effectively eliminates risk for stroke. Instead, most people require a comprehensive program of healthy diet, exercise, supplements, and medication when indicated. Here, we focus on the nutritional supplements that can be critical components of your plaque-reduction program. Fish oil Fish oil is a cornerstone of your stroke prevention program. Epidemiological observations suggest a strong relationship of fish intake and reduction of stroke risk. Carotid ultrasound studies demonstrate less carotid plaque with greater intakes of fish. A cleverly designed University of Southampton study made the fascinating observation that fish oil transforms the structure of carotid plaque. 150 people with severe carotid plaque scheduled for carotid endarterectomy (surgical removal of the plaque) were given fish oil, sunflower oil, or no treatment over several months while waiting for their procedure. (Delays in the British health system permitted this unique design.) Plaque was removed at surgery and examined. Participants taking fish oil had reduced inflammation in plaque and thicker tissue covering the fatty core, markers of more stable plaque. Those taking sunflower oil or no treatment had unstable plaques with greater inflammation and thinner, less sturdy covering tissue. This suggests that fish oil stabilizes carotid plaque, making it less likely to rupture and fragment. A standard capsule of fish oil (containing 300 mg of EPA + DHA) contains the same amount of omega-3s as a 3 oz serving of cod or halibut; three capsules (900 mg DHA + EPA) contain the equivalent of a serving of farm-raised salmon. The dose that seems to provide greatest protection from stroke, lowers triglycerides (that form abnormal lipoproteins; see above), and reduces fibrinogen, is four capsules per day (1200 mg EPA + DHA). Coenzyme Q10 (CoQ10) Although there are no data specifically addressing whether CoQ10 reduces plaque, it is a marvelously effective way to reduce blood pressure, one of the crucial factors causing carotid and aortic plaque growth. A pooled analysis of eight studies showed that, on average, CoQ10 in daily doses of 50–200 mg reduced systolic blood pressure by 16 mm Hg, diastolic pressure by 10 mm Hg. Data suggest that CoQ10 can reverse abnormal heart muscle thickening (hypertrophy), another manifestation of high blood pressure, strongly suggesting that CoQ10 has benefits beyond just reducing pressure. Supplements to correct the metabolic syndrome Weight loss is, without question, the most immediate and direct path to correction of this dangerous pre-diabetic condition. A drop of even 10–20 lbs yields improvements across the board: increased sensitivity to insulin, increased HDL, and reductions in triglycerides, CRP, fibrinogen, small LDL particles, and blood pressure. Diet and exercise are fundamental components of an effort to lose weight; low carbohydrate or reduced glycemic index diets (e.g., South Beach or Mediterranean) rich in fibers are clearly effective. Several supplements can amplify weight-reduction efforts and be useful adjuncts to your lifestyle program. Among them: White bean extract White bean extract blocks intestinal absorption of carbohydrates by 66%. 1500 mg twice a day with meals yields, on average, 3–7 lbs of weight loss in the first month of use. The only side-effect is excessive gas, due to unabsorbed starches. Glucomannan This unique fiber taken prior to meals absorbs many times its weight in water and thereby fills your stomach. You consequently take in less food. Most people lose around four lbs per month using 1500 mg prior to each meal. Interestingly, glucomannan also blunts the rise in blood sugar after meals, an effect that, by itself, may lead to weight loss. Be sure to take with plenty of water. DHEA This adrenal hormone is key to maintaining physical stamina, mood, muscle mass in men, and libido in women. A recent randomized, placebo-controlled study at Washington University in 56 subjects showed a 13% decline in abdominal fat (fat that drives resistance to insulin) measured by MRI with 50 mg of DHEA per day at bedtime, along with improved sugar control and lower insulin levels. Pectin, beta-glucan Pectin is the soluble fiber in citrus rinds, green vegetables, and apples, also available as a supplement. Beta-glucan is the soluble fiber of oats and is also available as a supplement. Both are wonderful fibers that provide feelings of fullness, lower cholesterol, slow release of sugars, and can yield modest weight reduction. A USC study in 573 subjects using carotid ultrasound showed that greater intake of healthy fibers like pectin and beta-glucan is associated with less carotid plaque growth. Folic acid, vitamins B6 and B12 Dr. Daniel Hackam at the Stroke Prevention and Atherosclerosis Research Centre in Ontario conducted a study using carotid ultrasound in 101 participants treated with folic acid 2.5 mg, vitamin B6 25 mg, and B12 250 mcg per day. Treatment resulted in plaque reduction, especially when homocysteine levels exceeded 14μmol/l at the start, compared to untreated participants who experienced substantial plaque growth. An attempt to clarify the role of homocysteine treatment was made through a National Institute of Health-sponsored study of stroke prevention. 3680 participants with a prior history of stroke were enrolled and given either a “low-dose” (20 mcg folic acid, 0.2 mg B6, 6 mcg B12) or a “high-dose” (2.5 mg folic acid, 25 mg B6, 400 mcg B12) regimen. Although starting homocysteine levels showed a graded association with stroke risk (higher homocysteine levels predicted greater stroke risk), the treatment groups experienced, on average, only a 2 μmol drop in homocysteine levels and no reduction in stroke risk over two years. The study investigators as well as critics have suggested that the study failed due to an insufficient treatment period and that the doses were too low. (The doses we use in our plaque reduction program are folic acid 2.5–5.0 mg, B6 50–100 mg, B12 1000–2500 mcg.) L-arginine L-arginine can be used to overpower the adverse effects of ADMA. L-arginine is emerging as an important carotid plaque-reversing tool. Early reports in animals showed that l-arginine completely halted growth of aortic plaque, and did so more effectively than lovastatin (a cholesterol-lowering drug). In humans, L-arginine reduces blood pressure, abnormal constriction of carotid and coronary arteries, blocks entry of inflammatory cells into plaque, increases sensitivity to insulin, and heightens exercise capacity. Following coronary angioplasty or stent placement, l-arginine results in up to 36% reduction in plaque growth. The average American takes in 5400 mg of l-arginine through food every day. Supplementing with doses of 3000–12,000 mg per day has proven useful to correct many of these phenomena. (We use a dose of 6000 mg of l-arginine powder, twice a day on an empty stomach, dissolved in water, for our plaque regression program.) Does this result in a reduction of stroke risk? The emerging data suggest that l-arginine is likely to exert a powerful plaque-reducing and stroke-preventing benefit, but we await more clinical trial data. Conclusion Reducing stroke risk by reversing carotid and aortic plaque is becoming an everyday reality, with better tools becoming available. To know whether you’re at risk, the best and most available imaging tool is carotid ultrasound, aiming to identify intimal-medial thickness >1.0 mm, or carotid plaque. Any degree of calcification of the aorta, such as on a CT heart scan, is another useful measure of risk. Treatment to reduce risk is multi-faceted but is based on examining all your sources of risk, including metabolic syndrome, small LDL, lipoprotein(a), and C-reactive protein. Fish oil is the one absolutely crucial ingredient in any stroke prevention program. Other supplements can be used in a targeted fashion, depending on the causes identified for your carotid or aortic plaque. Ideally, repeat scanning of your carotids should be done sometime after your program has begun to assess whether you’ve successfully achieved reversal of plaque growth.