Often when physicians talk to each other, they are often inclined to discuss things that cannot be proved absolutely, but common sense often trumps high intelligence when a situation is quite complex such as treating patients with differences that cannot always be established by tests or known scientifically.
Creative doctors who think from parallel memory instead of the slow prefrontal cortical approach linear approach often don’t need absolute proof to start using a procedure or changing their diet approaches. Here Dr. Greg Hood, Internal Medicine, decided that possible drawbacks are minor compared to getting their patients to use higher levels of vitamin D3 has so many possible positive effects that he does not have to get official approval to start using higher levels of Vitamin D3 supplements to improve the health of his patients. The pluses are so enormous that he figured out that it would be irresponsible to not give his patients vitamin D3 advice.
My Internist also saw the benefits of vitamin D3 supplements very early to treat me and it had an enormous benefit in treating my usually deadly skin autoimmune disease, a previously incurable disease.
I might add that many times the diet recommendations by officials of our government often seem to be stupid. One famous Chef tried to change the eating habits of the most obese Americans in the USA in Huntington, West Virginia. The school cafeterias did everything possible to sabotage his efforts including the government. He failed.
Now they are going the other way by recommending six fruits and vegetables a day! Many are going to fruit juices to try to conform with this recommendation while ignoring the high amount of fructose taken in this way. That is what Letterman was trying to do to lose ten pounds. www.DoctorOz.com told him you are taking in too many calories so it is no wonder you are not losing weight. Letterman was embarrassed and soon said goodbye.
Want to lose weight? I wanted to lose internal belly fat which is mostly made up of triglycerides which are now considered a deadly fat. So I did a two week fructose fast according to the recommendations in the book The Sugar Fix by Dr. Richard J. Johnson, MD. Then I keep my daily fructose level to less than 40 grams daily. He has a table of most foods and their fructose content. Unless the container says cane sugar or beet sugar, it is high fructose corn syrup. I still eat all I want, but I am now not constantly hungry. That is what Letterman complained about. I easily lost ten pounds without hunger!
Jim Kawakami, Jan 18, 2011, http://jimboguy.blogspot.com
Blog: Weekend Call: Office protocols: Vitamin D ñ one physicianís experience
Greg Hood, MD, Internal Medicine, 10:21PM Jan 15, 2011
http://firstname.lastname@example.orgOUDaZOvGud@.2a064aab!comment=1 Office protocols can significantly streamline and ease the work which needs to get done in the day's work. Having a protocol for evaluation and management of vitamin D deficiency and vitamin D insufficiency is an excellent example of individualizing management of a medical issue for your office.
Vitamin D has been discussed in a number of recent articles on Medscape. My particular interest in vitamin D goes back 8-10 years. Having received the traditional education in medical school about vitamin D I managed it just as everyone did during my residency and years in practice in San Diego. However, within a couple years of practicing in Kentucky I had noticed that some conditions, notably osteoporosis, did not respond as favorably to treatment in Kentucky as they had in southern California.
The only logical conclusion when treatment outcomes for patients of the same demographics and treatment recommendations were significantly different was that there was a difference based in the geography. In this case latitude and average temperature differences make a significant difference in the amount of ambient Sunlight to which patients were being exposed.
As a number of studies and reports have stated over the last several years there are many indications that the level of vitamin D reported to be "normal" and the amount of vitamin D required to achieve this from supplementation have been woefully inadequate.
I also think the recent calls for a reduction in calcium supplementation appear prudent. From my reading, a patient who is vitamin D deficient absorbs roughly 15% of their ingested calcium. As the vitamin D levels improve the corresponding increases in calcium absorption should mitigate what may have been excessive calcium recommendations, in essence putting the milk cart before the horse.
Recently, there have been recommendations to increase the RDA of vitamin D. The proposed increases are conservative to say the least. The lower limit of normal, 32 from our lab, and the new recommendations for intake are merely sufficient to avert rickets and osteomalacia, hardly the harbingers of good health.
As implied by the seminal NEJM article I have seen between a third and forty percent of my patients who came to me thinking that they had fibromyalgia resolve their symptoms when treated to vitamin D levels in the 70s, and another third report their symptoms lessen in intensity. Over 85% of the MS patients I see have been vitamin D deficient.
I agree that there is not concrete, double blind validated proof of many of the assertions about correcting vitamin D levels. However, when one considers the potential that something as simple as this may move the needle on the incidences of pancreatic cancer, breast and ovarian cancer it is hard to argue against working more robustly in the normal range.
One study out of Canada, a low vitamin D/Sun exposure area, stating that vitamin D deficient women were more likely to get breast cancer, that their cancers were more aggressive, and responded less well to treatment certainly begs the question of why to not treat this problem more rigorously.
Yet the degree of increase is not my biggest gripe with the recommendations. To date I have yet to see sufficient attention paid in the guidelines to customizing the RDA for latitude. Patients in Key West are given the same advice that patients in Bangor, Maine receive. It deserves mentioning that simply living in a latitude south of Atlanta doesn't mean one will have Sun exposure. I have seen patients from Miami who avoided the Sun who had undetectable levels of vitamin D. Colleagues from San Diego have told me that they have seen a progressive frequency of vitamin D deficiency as sunscreen use has escalated.
It is for all the above reasons that I believe vitamin D protocols are something useful for you to consider in your office. If you haven't been already, test at least the at risk patients including those with dark skin, those with low bone density, fibromyalgia, osteomalacia, multiple sclerosis, and those whom are heavy users of sunscreen or whom avoid the Sun by virtue of their jobs or schedules. As you get a sense of your own practice's frequency of deficiency you may wish to expand the circles of patients you test.
This testing will give you an idea of how much vitamin D supplementation is needed for your area. As you see patients who come back with very good levels and review how much they've been taking it may help guide you to preferred replacement levels at your latitude. Many of my patients are taking between 2000 and 5000 units of over the counter vitamin D a day. Some do better with the size of the prescription vitamin D and do better keeping up with one pill on a scheduled basis than daily vitamins. In either case it is important to continue to monitor their levels and response to therapy, especially if they are taking 4000IU a day or more, or prescription capsules. Once you get familiar with how vitamin D responds in your area you may be able to move the monitoring on this somewhat expensive blood test to a less frequent interval, every two years in some cases of maintenance therapy, for example.
It is important to build into your protocol exceptions of patients with whom you will wish to avoid vitamin D supplementation, or at least will proceed with more caution, and more intensive monitoring, such as patients with sarcoidosis and other granulomatous conditions, those with cancer or undiagnosed/uncorrected hypercalcemia.
It typically takes 10-12 weeks for patients to note symptomatic relief. Serum levels of vitamin D should be stable within 3-4 months from initiating therapy so this can be a good time frame in which to retest, at least as you get used to supplementing and in higher risk patients. As a goal target blood level, +/- 75nmol/L is appearing appropriate at the time of this writing. Targeting this range I have yet to make a patient vitamin D toxic. If you are using the prescription vitamin D it is helpful to ask patients when they took their last capsule prior to testing, because if you check the day or so after the last capsule you may not see a steady-state result. It is also helpful to build into your protocol monitoring of serum calcium, and at times PTH and ionized calcium levels.
Those hoping for a cookbook protocol to be laid out in this entry are surely disappointed. Unfortunately, this issue underscores the importance of using one's brain, training and observational skills in optimizing the delivery of healthcare. However, this issue equally underscores how using these skills can optimize and streamline management within your practice of health issues. Once you've worked out the details monitoring protocols, refills, and patient recalls can be customized and benefit your patients and your office flow.
Disclaimer: This article is general discussion of information and opinions on the part of one internist. Derivation of protocols or individual treatment decisions by health professionals who read this are their own choices from their own clinical judgment. Lay persons who read this should consult with their healthcare provider prior to embarking on, or adjusting their health approach. Nothing discussed should be considered a substitute for a personal interaction with your own physician or healthcare provider. Author accepts no risk or responsibility for decisions others make based upon the opinion(s) as stated above.
Dangers of a High Fructose Diet, University of California, Davis Professor Peter Havel, CBC News April 20, 2009 http://www.cbc.ca/health/story/2009/04/20/fructose-glucose-drinks.html All sugars are not created equal when it comes to how our bodies metabolize the sweeteners, a new study suggests. People who drank beverages sweetened with fructose, but not glucose, showed an increase in intra-abdominal fat and blood lipid levels and decreased sensitivity to the hormone insulin, researchers reported in this week's issue of the Journal of Clinical Investigation.
The findings suggest that fructose-sweetened beverages can interfere with how the body handles fat, leading to medical conditions that increase susceptibility to heart attacks and strokes.
The results could be important given that in 2005, the average American consumed 64 kilograms (140.8 LBS) of added sugar, a sizeable proportion of which came through drinking soft drinks, said study author Peter Havel of the University of California at Davis and his colleagues.
Consumption of sugars and sweeteners in the U.S. went up by 19 per cent between 1970 and 2005, according to a commentary accompanying the study.
Increased use of high-fructose corn syrup as a sweetener in pop in the last few decades has been proposed as one dietary change fueling obesity in developed countries, Matthias Tschöp and Susanna Hofmann of the University of Cincinnati-College of Medicine noted in their commentary.
The most common form of the syrup contains five per cent more fructose than glucose and is perceived as sweeter, according to food and drink manufacturers.
In the 10-week study, 17 subjects consumed a quarter of their calories from fructose-sweetened beverages and another 15 subjects drank the equivalent amount in glucose-sweetened beverages. Participants had an average age of 50 and a body mass index of 29, which is considered overweight.
Both groups put on the same amount of weight, but only the fructose group showed the other differences.
People drinking the equivalent of about six cans of soft drinks a day in fructose became less sensitive to insulin, which helps control glucose levels in the blood, and showed signs of dyslipidemia such as high cholesterol.
Fructose is no worse than glucose if taken in moderation, said Dr. David Jenkins, who holds the Canada Research Chair in nutrition and metabolism at the University of Toronto.
"We're talking about excess in people who are gaining weight, people who are overweight to begin with and people who are not exercising to begin with," Jenkins said.
The long-term effects of fructose remain unknown, but it's clear that chronic overconsumption of dietary sugars in general is harmful to health, the commentators said.
"For our part, we will continue to aim for moderation of balanced caloric ingestion without excluding the occasional sweet soda," they concluded.
Some manufacturers have released sugar-free versions of soft drinks, and the corn industry has responded with ads suggesting high-fructose corn sweeteners have "the same natural sweeteners as table sugar." Read more: http://www.cbc.ca/health/story/2009/04/20/fructose-glucose-drinks.html#ixzz1BQnJ97dy