My Recent Calcium CT Scan

[audreyh1]

People have lowered their CAC score with a very low carb diet plus taking Vitamin K. It truly is not set in stone only to go up.

The whole targeting cholesterol is probably very outdated these days. But it’s so embedded in the medical and drug culture that changing will be extremely slow.

FWIW people above 60 with higher cholesterol levels have higher longevity.

 

[Hoosierman]

That is great. I think we will see 55 in the US soon, if not already in actuality by many doctors. DW has a CT score of 125 but no documented heart disease and she sees a Dr who specializes in cholesterol treatment. He told her we are going to get your LDL as low as we can because at 30 it actually begins to shrink the plague (slightly) and there are significant preventative effects.
My own PCP is agreeable to getting my LDL below 50 as a target.

 

[Trooper]

FWIW people above 60 with higher cholesterol levels have higher longevity.

Is that really true? Any studies you can share?

 

[audreyh1]

Is that really true? Any studies you can share?

There have been several studies. Sorry I don’t have that info at my fingertips anymore. Neither of my docs have cholesterol concerns for me anymore as long as my blood pressure low/normal, my triglycerides low, my HDL high (giving very good trig/HDL ratio) and my fasting blood sugar/A1C low.

It’s the kind of topic that means lots of online research and sifting through info. I did run across this abstract in a cursory google search. It’s about elderly hypertensives and whether they should be treated, but it does mention the cholesterol relationship for elderly. https://pubmed.ncbi.nlm.nih.gov/10999646/

 

[Trooper]

There have been several studies. Sorry I don’t have that info at my fingertips anymore. Neither of my docs have cholesterol concerns for me anymore as long as my blood pressure low/normal, my triglycerides low, my HDL high (giving very good trig/HDL ratio) and my fasting blood sugar/A1C low.

No problem about the studies, but I'll go ahead and ask the dumb question: If higher cholesterol is no longer an issue amongst seniors, then why the statins?

 

[audreyh1]

No problem about the studies, but I'll go ahead and ask the dumb question: If higher cholesterol is no longer an issue amongst seniors, then why the statins?

Inertia. It takes US medicine decades to change. There is a lot of built-in resistance to changing treatments. They’d rather subscribe the drugs “just in case” - they won’t get in trouble for that.

It’s been known for over 2 decades that insulin resistance and metabolic syndrome drive western chronic diseases such as diabetes, obesity, hypertension and heart disease. And that the first sign of insulin resistance/metabolic syndrome is elevated blood pressure decades before diabetes shows up. But that’s still pretty much ignored by most of the US medical establishment. Probably because insulin resistance can be treated by diet rather than by drugs. Many patients probably prefer drugs too - in that they are unwilling to make lifestyle changes instead.

 

[JBTX]

No problem about the studies, but I'll go ahead and ask the dumb question: If higher cholesterol is no longer an issue amongst seniors, then why the statins?

I’m not a doctor but from what I have read and heard, low LDL levels, and most specifically ApoB levels are highly indicative and predictive of cardiovascular health - assuming you control things like people who may be sick for different reasons and have low cholesterol as a result not a cause. Statins absolutely are effective in reducing cardiovascular disease. It has been proven over and over again.

Just found this. Apparently there was a study that showed high cholesterol lived longer but it has been discredited.

https://www.bhf.org.uk/informations.../behind-the-headlines/cholesterol-and-statins

 

[braumeister]

FWIW people above 60 with higher cholesterol levels have higher longevity.

Is that really true? Any studies you can share?

Here's one:
The Honolulu Study was a 20 year look at over 3,000 Japanese-American men aged 71-93 years. It concluded

A generally held belief is that cholesterol concentrations should be kept low to lessen the risk of cardiovascular disease. However, studies of the relation between serum cholesterol and all-cause mortality in elderly people have shown contrasting results.
...
Only the group with low cholesterol concentration at both examinations had a significant association with mortality.
...
We have been unable to explain our results.

Cholesterol and all-cause mortality in elderly people from the Honolulu Heart Program: a cohort study

 

[Katsmeow]

My score was 164, results went to my doctor who wants to put me on a statin. I'm otherwise very healthy, exercise daily - either weigh training, cycling, hiking, tennis.

I really don't want to be taking statins if I don't need to. My Total Cholesterol is 208 as of last June, which is a little on the high side, but not bad. Can I control this through diet and not take the statin?

You absolutely want to take a statin (or other lipid lowering medication if you are intolerant). There are several reasons for this. I calcium score of 164 is not good. A high calcium score is a sign of atherosclerosis. Heart disease needs to be treated.

1. If you have calcified plaque you almost certainly have soft plaque. Soft plaque is what causes heart attacks when it ruptures. Over a long period of time (years) soft plaques calcifies. You can't do anything about the calcified plaque you have. If LDL is low enough you can stop the development of new plaque and may be able to regress some (not all) soft plaque.

For many people with a positive calcium score the desired LDL is under 70. Most people can't get to that level without medication. If you want to have a chance of plaque regression you want LDL below 55. Hardly anyone can reach that level without medication.

I personally have a high calcium score (600s) and take a statin with a goal of under 50. Currently LDL is 39. As someone with heart disease I want to lessen my risk of a heart attack and medication is the way to do that. I also take a low dose aspirin each day. Having a high calcium score is a recommended reason for aspirin because you are no longer taking a statin for primary prevention of heart disease. You are taking it as secondary prevention.

2. When you have calcified plaque people almost always have soft plaque that hasn't calcified. Soft plaque is far more dangerous than calcified plaque. The rupture of soft plaque costs most heart attacks. One good thing that statins do is speed up the process of plaque stabilization thereby calcifying that dangerous soft plaque. This is good since calcified plaque is less dangerous.

Talk to a cardiologist about all this. I am not sure your doctor has properly explained to you how you are at such higher risk now that you know you have a lot of calcified plaque.

Your HDL to LDL ratio and TG to HDL ratio are very good.

They used to think that ratios were important. But, nowadays, not so much. It is of course good to have an optimum level of HDL and it is good to have low triglycerides. Absolutely none of that changes the danger that LDL poses to someone. In this case the OP has actually developed heart disease! It is not a good idea not to treat heart disease.

People have lowered their CAC score with a very low carb diet plus taking Vitamin K. It truly is not set in stone only to go up.

The whole targeting cholesterol is probably very outdated these days. But it’s so embedded in the medical and drug culture that changing will be extremely slow.

FWIW people above 60 with higher cholesterol levels have higher longevity.

People do not lower their CAC score. Calcified plaque does not go away. People can regress some soft plaque if their LDL is low enough (typically under 55).

So here is the thing about longevity and cholesterol levels. Take someone without heart disease and their LDL is 100 without medication. Now, take me. My LDL is 39! Yet, I am far more likely to die from a heart attack than the person without heart disease. Why? I have heart disease. I have 4 blockages in my arteries including a 60% to 70% blockage of my LAD. (I didn't need stents as my blood flow is fine). I am taking high intensity statin and low dose aspirin. So my risk of a heart attack now is much lower than it was. Great. But, I still have heart disease and I am sure that I still have some soft plaque that was there before I started medication. All of this is a long way of saying that many people with low LDL who have heart attacks or strokes were already at greater risk because they have established design. Medication can reduce the risk but not eliminate it.

And, yes, they absolutely do target lowering of LDL (or ApoB) as that one major thing that can be done to lower risk.

 

[big-papa]

The calcium score is an indicator that you have had plaque for a long time. While it's possible to have so much build up that you have poor blood flow, just having a good echocardiogram doesn't mean you have no problem. Plaque can break off and suddenly clog arteries, giving you a heart attack. The calcium itself is not the risk, in fact it helps stabilize the plaque at that spot, but in order to have an elevated score, you have enough plaque to be a serious risk factor.

I had a similar score and the write-up they gave me showed the statistics are very strong that people are better off with a statin than without. So I now take rosuvastatin, which costs just a few $ every 90 days and my cardiologist also told me to take a CoQ10 each day to help offset any side effects. If you do have side effects from the one your doctor prescribes, your doctor can switch you to other ones. Don't let the Luddites keep you from taking a medicine that has benefited millions of folks.

This! Thank you. Pretty much the same experience as me. When I first had the test, the cardiologist I went to told me that the test is really only good as a one-time thing and that there is little value in repeating the test unless you tested at 0. Lowering the calcium score isn't the goal - it's, as you say, an indicator that you've had plaque that has stabilized. I've been on the lowest dose atorvastatin for years, and no side effects. I realize that's not the case for everybody. Now if they'd just develop a cheap test to directly measure soft plaque...

Regarding blood tests, to get a more complete picture folks often add things like
- Direct LDL testing. The cheap tests usually ordered derive the LDL numbers rather than measuring them directly.
- LDL particle size (large = good, small = bad)
- Lp(a) aka Lipoprotein a test

Unfortunately for topics like this, the internet is a great source of information to confirm whatever biases we might have before we start our search. Best to try and keep an open mind and consider the source of information. Not always easy to do.

Cheers

 

[Flieger]

I did Calcium Scan due to family history. Came back 0 (I am 61). However, I have higher than normal cholesterol and take statins.

Flieger

 

[Happyras]

I did Calcium Scan due to family history. Came back 0 (I am 61). However, I have higher than normal cholesterol and take statins.

Flieger

After trying many statins with various side effects I went with straight Zetia 10mg. I got my calcium score which was a big ZERO. My doc was perplexed. My cardiologist identified an aortic valve murmur, and to this day I remain in the below 250 range total cholesterol, but a high HDL and good ratios.

I considered the injectable $500/month solution to reduce this, but still wonder if this is really the issue to address when the cal score was 0.

Drug companies really pushed statins hard, and it really makes me question with the current mortality findings and benefits to the brain chem.

 

[RS53576GG]

My cardiac calcium test score was 21. Not zero but pretty close. 7 months later I had 3 stents put in. LAD was 97% obstructed, Ramus Intermedius was 90% obstructed, Left Circumflex was 80% obstructed. Obviously I had lots of plaque and very little calcium. Who knew? Clearly my doctors didn't know.

A low score doesn't always mean you're in the clear and a high score doesn't always mean you're going to die tomorrow.

 

[Healthy Lifestyle]

I was asked to have a calcium score scan as a maintenance check.
Well just had my Cal Score result is 206. This is a surprise since I feel fine and live a very healthy lifestyle. Of all things to focus on, I am doing a deeper dive to understand what this means. I now know I need to see a cardiologist soon.

 

[Nash]

I did a CT Heart scan 5 years ago, yielded a calcium score of 0. I take no prescription drugs, but would definitely start a statin if my score was >0.

Also, shocked at all the people still getting stents since they were proven useless many years ago with the exception of emergency use during a heart attack.

"A pivotal clinical trial of 2,287 people with stable heart disease, published in the New England Journal of Medicine in 2007, found that having a stent implanted didn't reduce the risk of death, a heart attack, or other major cardiovascular events. Subsequent studies had similar results."

Apparently still a moneymaker for doctors and hospitals, I guess.

 

[audreyh1]

I did a CT Heart scan 5 years ago, yielded a calcium score of 0. I take no prescription drugs, but would definitely start a statin if my score was >0.

Also, shocked at all the people still getting stents since they were proven useless many years ago with the exception of emergency use during a heart attack.

"A pivotal clinical trial of 2,287 people with stable heart disease, published in the New England Journal of Medicine in 2007, found that having a stent implanted didn't reduce the risk of death, a heart attack, or other major cardiovascular events. Subsequent studies had similar results."

Apparently still a moneymaker for doctors and hospitals, I guess.

Why would people still get a stent? Maybe because it can alleviate uncomfortable symptoms? Thus improving quality of life.

DF in his early 70s was experiencing shortness of breath outside in hot afternoons and had it checked out. They found blockage and put in a stent. No more shortness of breath. He enjoyed another 18 years.

 

[JBTX]

You absolutely want to take a statin (or other lipid lowering medication if you are intolerant). There are several reasons for this. I calcium score of 164 is not good. A high calcium score is a sign of atherosclerosis. Heart disease needs to be treated.

1. If you have calcified plaque you almost certainly have soft plaque. Soft plaque is what causes heart attacks when it ruptures. Over a long period of time (years) soft plaques calcifies. You can't do anything about the calcified plaque you have. If LDL is low enough you can stop the development of new plaque and may be able to regress some (not all) soft plaque.

For many people with a positive calcium score the desired LDL is under 70. Most people can't get to that level without medication. If you want to have a chance of plaque regression you want LDL below 55. Hardly anyone can reach that level without medication.

I personally have a high calcium score (600s) and take a statin with a goal of under 50. Currently LDL is 39. As someone with heart disease I want to lessen my risk of a heart attack and medication is the way to do that. I also take a low dose aspirin each day. Having a high calcium score is a recommended reason for aspirin because you are no longer taking a statin for primary prevention of heart disease. You are taking it as secondary prevention.

2. When you have calcified plaque people almost always have soft plaque that hasn't calcified. Soft plaque is far more dangerous than calcified plaque. The rupture of soft plaque costs most heart attacks. One good thing that statins do is speed up the process of plaque stabilization thereby calcifying that dangerous soft plaque. This is good since calcified plaque is less dangerous.

Talk to a cardiologist about all this. I am not sure your doctor has properly explained to you how you are at such higher risk now that you know you have a lot of calcified plaque.




They used to think that ratios were important. But, nowadays, not so much. It is of course good to have an optimum level of HDL and it is good to have low triglycerides. Absolutely none of that changes the danger that LDL poses to someone. In this case the OP has actually developed heart disease! It is not a good idea not to treat heart disease.



People do not lower their CAC score. Calcified plaque does not go away. People can regress some soft plaque if their LDL is low enough (typically under 55).

So here is the thing about longevity and cholesterol levels. Take someone without heart disease and their LDL is 100 without medication. Now, take me. My LDL is 39! Yet, I am far more likely to die from a heart attack than the person without heart disease. Why? I have heart disease. I have 4 blockages in my arteries including a 60% to 70% blockage of my LAD. (I didn't need stents as my blood flow is fine). I am taking high intensity statin and low dose aspirin. So my risk of a heart attack now is much lower than it was. Great. But, I still have heart disease and I am sure that I still have some soft plaque that was there before I started medication. All of this is a long way of saying that many people with low LDL who have heart attacks or strokes were already at greater risk because they have established design. Medication can reduce the risk but not eliminate it.

And, yes, they absolutely do target lowering of LDL (or ApoB) as that one major thing that can be done to lower risk.

This is a very good post and consistent with my understanding of things.

My understanding is that higher APOb increases your risk of heart disease, period. There isn’t really any debate at this point. LDL is a reasonable proxy but not exact.

These studies that show these odd relationships to cholesterol and longevity either have problems lack context or are misinterpreted. You gave a good example. While it is no longer debatable that LDL increases risk of heart disease, it doesn’t always show decreases in all cause mortality - it depends on the size of the sample, the severity of the heart disease and the length of the study. It isn’t that it isn’t helping mortality, it is often the studies are not long enough to show a difference, or the results aren’t statistically significant.

Let’s say a statin decreases your chance of heart attack from 10% over 10 years to to 5% over 10 years. That’s significant and heart attack is leading cause of death, but still only 20% of deaths are heart disease. So you are 80% likely to die from something else. So that would roughly mean your increased risk of death is only 1 in 100 over 10 years and that would take a very large sample to be statistically significant. However if you looked at the impact over multiple decades it would be much more significant. But studies don’t last that long.

 

[RS53576GG]

That study was done between 1999 and 2004. They used stainless steel bare metal stents. Today's stents have a thinner wall (.004-.005 inch for present day platinum-chromium stents versus .015 inch for earlier 316L stainless steel stents) and are made from much more durable materials. Present stents are drug eluting (coated with a drug) which encourages the inner artery wall to completely envelop the stent. This essentially eliminates the blood clot problem that was seen in earlier stents.

Earlier stents made of stainless steel had a pretty poor fatigue life. They were known to suffer fatigue cracking and structural failure. Current stents are made from better alloys and due to better analytical techniques (Boston Scientific has done a fair amount of finite element analysis on their stent designs) they have a higher fatigue life and conform better to the irregular inner wall surface. Boston Scientific also tested various combinations of alloying materials to get the best fatigue life. Today's stents are good for the life of the patient. For example, over 50 years of use a stent will experience around two billion cycles.

The fundamental error in presenting this paper as being meaningful is that the stents used in this study are not representative of stents that are in use today. It would be valid to present this paper as being an accurate evaluation of technology at the turn of the century. It is not valid to say it's conclusions are applicable to current medical technology.

 

[JBTX]

That study was done between 1999 and 2004. They used stainless steel bare metal stents. Today's stents have a thinner wall (.004-.005 inch for present day platinum-chromium stents versus .015 inch for earlier 316L stainless steel stents) and are made from much more durable materials. Present stents are drug eluting (coated with a drug) which encourages the inner artery wall to completely envelop the stent. This essentially eliminates the blood clot problem that was seen in earlier stents.

Earlier stents made of stainless steel had a pretty poor fatigue life. They were known to suffer fatigue cracking and structural failure. Current stents are made from better alloys and due to better analytical techniques (Boston Scientific has done a fair amount of finite element analysis on their stent designs) they have a higher fatigue life and conform better to the irregular inner wall surface. Boston Scientific also tested various combinations of alloying materials to get the best fatigue life. Today's stents are good for the life of the patient. For example, over 50 years of use a stent will experience around two billion cycles.

The fundamental error in presenting this paper as being meaningful is that the stents used in this study are not representative of stents that are in use today. It would be valid to present this paper as being an accurate evaluation of technology at the turn of the century. It is not valid to say it's conclusions are applicable to current medical technology.

I didn’t look at the paper but my impression is the issue with stents, for some, is while they do help the stented area, if you need a stent that usually means you also have buildup elsewhere, and eventually that catches up with you, so sometimes in studies stents don’t have a materially better outcome than medication. But it certainly helps you live more normally, and if I had a blockage I’d prefer to get it assessed than do nothing.

 

[RS53576GG]

I didn’t look at the paper but my impression is the issue with stents, for some, is while they do help the stented area, if you need a stent that usually means you also have buildup elsewhere, and eventually that catches up with you, so sometimes in studies stents don’t have a materially better outcome than medication. But it certainly helps you live more normally, and if I had a blockage I’d prefer to get it assessed than do nothing.

What usually happens when you receive a bypass or a stent is they put you on medications to drive your LDL cholesterol as low as possible. If there's less LDL going through your arteries there's less LDL to seep through the inner artery wall and pile up behind it. My LDL was around 110 before stents. The last couple years it's been between 35-40. Another piece of the puzzle is the permeability of your inner artery wall. If it has low permeability it's less likely that LDL will seep through it. If it's very permeable you could have average or low LDL and still have LDL build up inside your artery wall. So it's a combination of several factors that results in whether a person has obstructed arteries or not. In my case my LDL wasn't stupidly high so my problem is likely to be excessively permeable inner artery walls. Fortunately it was only in a region downstream of where the left main artery split off into 3 smaller arteries. I needed stents in each of these arteries right where they split off from the left main coronary artery. (Most people have 2 arteries here, I happen to have 3.) Everywhere else is okey-dokey.

A bypass jumps over obstructed areas of the arteries that supply blood to the heart muscles. A stent works a little differently in that a balloon is expanded into the inner artery wall and pushes the plaque radially outwards (and sometimes axially as well) and then a stent is put in place to keep the pressurized plaque from closing it up again. Eventually the artery stays in it's new expanded shape permanently. The inner artery wall ends up enveloping the stent completely. Exposed stents are not a good thing because the red blood cells tend to pile up on the exposed metal and can become a clot. This is one reason why modern stents are so much more successful than the earlier stents had been. The result of either a bypass or a stent is that the blood flow path through your arteries is no longer obstructed to a dangerous extent. You might have a little obstruction here and there but nothing that's considered hazardous. If it was a problem they'd fix it while they were in there fixing the other obstructions.

If your arteries are open with a margin of safety (less than 70% obstructed is considered okay) and your LDL is down as low as possible it's less likely that you'll have similar problems in the future. And as you might expect it's very helpful to alter your eating habits to keep your LDL down. We want to stack the deck in our favor as much as possible.

So a stent (or bypass) is intended to keep you from dying from excessively obstructed arteries today. Medications and reasonable lifestyle changes will hopefully keep you from developing excessively obstructed arteries in the future.

 

[Trooper]

"My LDL was around 110 before stents. The last couple years it's been between 35-40."

How many years in between stents and now? How did you drive your LDL down from 110 to 35-40?

 

[RS53576GG]

"My LDL was around 110 before stents. The last couple years it's been between 35-40."

How many years in between stents and now? How did you drive your LDL down from 110 to 35-40?

You'll be pleased to hear that I have all this data on a spreadsheet. I had 3 stents in July, 2021. Here's the data.


Nov 2020 - LDL is 96
Dec 2020 - Cardiac calcium test, score is 21

Jan 2021 - Started 5 MG Rosuvastatin
Feb 2021 - LDL is 75
Apr 2021 - Stopped Rosuvastatin
Jun 2021 - LDL is 87
Jul 2021 - 3 stents, started 40 MG Rosuvastatin
Sep 2021 - LDL is 37 ALT and AST liver enzymes climbing
Nov 2021 - Changed to 20 MG Rosuvastatin due to high ALT and AST
Late Nov 2021 - LDL is 35 ALT and AST decreased a bit

Jan 2022 - ALT and AST increasing to dangerous levels
Feb 2022 - Stopped taking Rosuvastatin
Late Feb 2022 - LDL is now 81
Mar 2022 - Start taking Praluent to reduce LDL
Jun 2022 - LDL is 41 ALT and AST are back to normal low levels
Dec 2022 - LDL is 36

Feb 2023 - LDL is 37

Mar 2024 - LDL is 40

It's pretty interesting how my LDL and AST - ALT liver enzymes bounced around. Turns out Praluent works pretty well for me. Not cheap but the price of liver problems is too high to ignore.

Interesting Side Story: About 11 weeks after stopping Rosuvastatin I was hiking in the nearby hills and noticed that my thinking processes seemed more defined. For lack of a better description my thinking seemed to be sharper. I wasn't looking for it, I just happened to notice it. For the next few days I paid close attention to my thinking abilities. They were definitely sharper. No question. I looked into it and discovered that "mental fuzziness" is known side effect of statins. It doesn't happen to everyone but it definitely happened to me. The thing that struck me about this is that I didn't notice it while it was happening. I only noticed it when my mental processes got back to normal. (Or at least what's normal for me!) If I hadn't had the liver enzyme problem I could have spent the rest of my life being somewhat less sharp than I used to be and never realized it. That's pretty scary.

 

[Trooper]

That's great info, thanks. Did you make any dietary changes or was the LDL reduction solely due to the statins? I plan on also monitoring AST and ALT if I decide on statins (Rosuvastatin is what has been prescribed for me). But first I will get a lipid panel, liver levels, and A1C/Glucose test.

 

[JBTX]

My ALT and AST levels appear normal, on lower end of the range since taking 10mg rosuvastatin. I don’t think I’ve ever paid attention to them until now.

 

[RS53576GG]

That's great info, thanks. Did you make any dietary changes or was the LDL reduction solely due to the statins? I plan on also monitoring AST and ALT if I decide on statins (Rosuvastatin is what has been prescribed for me). But first I will get a lipid panel, liver levels, and A1C/Glucose test.

Most people seem to tolerate statins pretty well. From what I've heard maybe 1-2% of the population has a liver enzyme problem with statins. Both my cardiac doc and general doc said they hadn't seen this before. My gastroenterologist (I can't believe I spelled this correctly) said he sees it all the time. In the big picture of things I think I was fortunate to have the liver enzyme problem otherwise I might have been mentally fuzzy forever. It's hard to tell whether I would have eventually noticed my decline in mental ability. I can say for sure that I didn't notice it when it was present. I only noticed the improvement in mental abilities when they returned.

I think exercise and eating certain foods probably contributed to lowering my LDL. I'm a pretty plain eater so it's easy for me to eat the same rotating schedule of 3 or 4 meals for a long period of time. I like salmon and chicken so I tend to eat them fairly often. Once in a while I'll eat pizza or go out to eat with friends or something like that. I'm pretty big on salads. I think having low culinary standards makes it easy for me to handle what a lot of people might consider to be intolerably dull meals. Being a culinary simpleton has it's advantages.

My only guideline for cooking is that the time I invest in preparing a meal can't be longer than the time it takes me to eat it. The cooking process can sometimes take 30-40 minutes but the time I actually spend preparing it can't be longer than 10-15 minutes. My possibly warped perspective is that I have better things to do than spend a lot of time cooking and eating. This may sound crazy to more highly evolved members of society but it works for me.

I've made a point to never develop an addiction to anything so I've always avoided drugs, alcohol, cigarettes and Diet Coke. However I have to admit that I have failed miserably in one respect: chocolate milk. Chocolate milk is incredibly yummy. I usually drink a gallon of white milk one week and a gallon of chocolate milk the next week but occasionally I'll fall off the wagon and drink chocolate milk for two consecutive weeks. And I don't feel one bit guilty when doing so.