Wednesday, November 30, 2011

Vitamin D - How Strong is the Evidence? Part 3

How ironic.  What with all the articles that get published along w/the upcoming holidays, I forgot that I had started this month writing about vitamin D for 3 consecutive days.  Well, I tried to remind everyone that while vitamin D is the latest bandwagon upon which everyone appears to be hitching their non-osteoporotic health conditions, based upon observational studies, correlation is not causation.

The more conservative Endocrine Society published their clinical practice guideline on the evaluation, treatment & prevention of vitamin D deficiency back in July in their JCEM.  They're comfortable with the use of 25OH vitamin D as the initial screening assay but don't recommend its use in those not at risk for deficiency.  

On the surface, this is a reasonable statement but realistically, there are very few of us who are low risk and get enough sun exposure daily throughout the year without an sunscreen or sunblock.  Studies of the general population in traditionally sunny geographic areas such as Arizona, Florida & Hawaii demonstrate a higher than expected rate of vitamin D deficiency.

Ironicially, a systematic review & meta-analysis published in the same issue of JCEM found no cardiovascular benefit from vitamin D in 51 randomized controlled trials.  And a quick summary published earlier this week reviewed the paucity of randomized controlled trials demonstrating non-osteoporotic benefit.

So what's the take home message?  Well, it depends upon whether you see the proverbial glass as half full or half empty.  If you're only comfortable with the results of randomized controlled trials, you'll have a ways to wait.  On the other hand, if you're comfortable with the current set of observation studies (despite the lashing received from the public & lay press over the last several years), start popping vitamin D supplements.  The only problem is that we don't know how much is enough and we now have to worry about poor manufacturing leading to toxicity.



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Tuesday, November 29, 2011

Mediterranean Diet & Vascular Events in Non-Caucasians

One of the major issues when attempting to practice evidence-based medicine (aside from assessing the quality of the study) is making sure the group studied matches the patient in front of you.

Which is why I refuse to write about, propagate & otherwise hype animal trials and how the latest finding might one day have some meaningful impact on our health.  You know what I mean.  The ads describe how some supplement (which they happen to sell) made such a difference in rats, nematodes, drosophilia flies, etc, so you & I should jump on the bandwagon and start taking this very same supplement for which they've managed to corner the market in its latest, most pure, most natural, most organic form, right?

So many chemicals have failed to make the leap of faith from animal model to phase I to phase III to FDA-approval, that I'd rather focus on those w/human data supporting its use.  Don't get me wrong - we need basic science research to advance the cutting edge of medicine.  However, I personally don't see any reason to hype some finding in other life forms decades before we have an equivalent solution in humans.

But is that enough?  Clearly, women don't have to worry about prostate cancer studies.  Likewise, men shouldn't have to worry about ovarian cancer, Chaz Bono notwithstanding.  But what about age?  We specialize our training into pediatrics, adults & geriatrics (that's me), claiming that each age group has its own niche.  Trickier still is the question of race which is fraught w/political overtones.  Having been born & raised in the States in a Western culture, I suspect that my thinking process is closer to my Caucasian colleagues than my ethnic counterparts across the Pacific.  But what about ethnic physiology?  Is there a difference?

For instance, we know that following the Mediterranean diet, based upon Caucasians, is associated with lower risk of vascular events.  But while this way of eating might not come easily to blacks & Hispanics due to culture differences, would the Mediterranean diet make a difference in these non-Caucasian races?  In a population-based cohort study of 2,568 participants, average 69yo, 55% Hispanic, 24% black, and 64% female, followed for 9yrs published early online this month prior to print next month in the American Journal of Clinical Nutrition, the authors noted that the closer one followed the Mediterranean diet, the lower one's risk for vascular death.

Based upon this study, we can comfortably recommend eating more fish & legumes, fruits & vegetables, plus whole grains & monounsaturated fat as well as drinking alcohol (wine) in moderation to patients regardless of ethnicity in an attempt to decrease vascular mortality.



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Monday, November 28, 2011

What's In Your (Parents') Medicine Cabinet?

Medications are a double-edged sword.  Used properly in the right dose for the right purpose, they can decrease pain and all-cause mortality.  Used improperly in the wrong dose or for an "inappropriate" purpose, they can cause harm.  Ideally, we would take better care of ourselves than we currently do such that we no longer require oral hypoglycemic, anti-hypertensive, and lipid lowering agents.  Unfortunately, most of us choose the easier path, which is to say, we pop pills.

On the other hand, there are many situations in which medications play a key role, no matter our lifestyle.  For instance, antibiotics are appropriate for strep throat (when it's truly due to streptococcus and not a virus) and urinary tract infections (not just asymptomatic bacteriuria in a non-pregnant patient).

However, what's "appropriate" to one person (patient, physician or both) might not be considered "appropriate" to someone else.  For instance, beta blockers are standard of care in those with heart disease.  However, they are also anathema to those with asthma.  But what about patients who have both conditions?  Family physicians regularly see and help these complicated but real patients decide which disease process gets higher priority when it comes to conflicting medications.

Complicating this issue is that of polypharmacy, rightly/wrongly prescribed in those with multiple comorbidities.  8 years ago, the Beers list of potentially inappropriate medications (PIM) for use in the elderly was updated from its original expert opinion consensus.  Unfortunately, even in its updated form, the list did not have an evidence-base upon which to support it.  Worse, the list of PIMs did not coincide with studies of adverse drug events (ADE).  But at least it made us think twice about our prescribing habits for the elderly.

Earlier this summer, STOPP (the Screening Tool of Older Persons' potentially inappropriate Prescriptions) was developed based upon 329 ADEs in 600 patients requiring hospitalization.  Ironically, the medications noted in STOPP were not found to be the cause of hospitalization in 5,077 cases identified by the National Electronic Injury Surveillance System as published last week in NEJM.  Instead, the authors noted that warfarin (33.3%), insulin (13.9%), oral anti-platelet agents (13.3%), and oral hypoglycemic agents (10.7%) accounted for the vast majority of ADE-related hospitalizations.  In fact, medications on the Beers & STOPP list accounted for only 1.2% of hospitalizations.  

So as part of your annual family tune-up, review your parents' medications list with them and make sure they need what they're taking, especially if their list includes any of the four classes mentioned above.



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Sunday, November 27, 2011

Q&A Session at Wellsphere.com

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Saturday, November 26, 2011

Speaking English is apparently what kills you . . .

Some of you may already have read this medical Q&A, but just in case you haven't, my thanks go to Dr. E. who forwarded it.

Q: Doctor,  I've heard that cardiovascular exercise can prolong life.  Is this true?
A: Your heart only good for so many beats, and that it...don't waste on exercise.  Everything wear out eventually.  Speeding up heart not make you live longer; it like saying you extend life of car by driving faster.  Want to live longer?  Take nap.

Q: Should I cut down on meat and eat more fruits and vegetables?
A: You must grasp logistical efficiency.  What does cow eat?   Hay and corn.
  And what are these?   Vegetables.  So steak is nothing more than efficient mechanism of delivering vegetables to your system.  Need grain?  Eat chicken.  Beef also good source of field grass (green leafy vegetable).  And pork chop can give you 100% of recommended daily allowance of vegetable product.

Q: Should I reduce my alcohol intake?
A:  No, not at all.  Wine made from fruit.  Brandy is distilled wine, that mean they take water out of fruity bit so you get even more of goodness that way.  Beer also made of grain.  Bottom up!

Q: How  can I calculate my body/fat ratio?
A: Well, if you have body and you have fat, your ratio one to one.  If you have two bodies, your ratio two to one, etc.

Q: What  are some of  the advantages of participating in a regular exercise program?
A: Can't think of single one, sorry.  My philosophy is: No pain...good!
 

Q:  Aren't fried foods bad for you?
A:  YOU NOT LISTENING!  Food are fried these day in vegetable oil.  In fact, they permeated by it.  How could getting more vegetable be bad for you?!?

Q:  Will  sit-ups help prevent me from getting a little soft around the middle?
A: Definitely not!  When you exercise muscle, it get bigger.  You should only be doing sit-up if you want bigger stomach.

Q:  Is chocolate bad for me?
A:  Are you crazy?!?  HEL-LO-O!!  Cocoa bean!  Another vegetable!  It best feel-good food around!

Q:  Is swimming good for your figure?
A:  If swimming good for your figure, explain whale to me..

Q:  Is getting in shape important for my lifestyle?
A:  Hey!  'Round' a shape!

Well, I hope this has cleared up any misconceptions you may have had about food and diets.

And  remember:

Life should NOT be a journey to the grave with the intention of arriving safely in an attractive and well-preserved body, but rather to skid in sideways -- Chardonnay in one hand, chocolate in the other -- body thoroughly used up,  totally worn out and screaming "WOO-HOO, what a  ride!!"
 
AND....

For  those of you who watch what you eat, here's the final word on nutrition and health.  It's a relief to know the truth after all those conflicting nutritional studies.

1. The Japanese eat very little fat

     
and suffer fewer heart attacks than us.

2 The Mexicans eat a lot of fat

     
and suffer fewer heart attacks than us. 

3. The Chinese drink very little red wine 

     
and suffer fewer heart attacks than us.

4. The Italians drink a lot of red wine

     
and suffer fewer heart attacks than us.

5. The Germans drink a lot of beer and eat lots of  sausages and fats
     and suffer fewer heart attacks than us. 


CONCLUSION:


Eat and drink what you like.
Speaking English is apparently what kills you.



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