ACP Internist

Tuesday, February 9, 2010

Vitamins in a Nutshell

This post by Davis Liu, MD, originally appeared at Better Health.

Some patients love their vitamins, spending hundreds to thousands of dollars annually. At times, they will even forgo proven medical therapy. As more Americans go without health insurance coverage while others face higher office visits and copays, increasing numbers of patients are seeking alternative, natural therapies instead of medical care. Are vitamins really the scientific breakthrough and secret that doctors refuse to recommend, or are they simply marketing hype? As any medical school student will tell you, the correct answer to any question is: it depends.

For certain groups, pregnant women, patients with macular degeneration and vegetarians, vitamins and minerals may be recommended as research finds them helpful. Prenatal vitamins have more folic acid, which has been found to decrease the risk of neural tube defects in the fetus. Vegetarians may need to supplement their diet with vitamin B12, iron, and vitamin D, which are absent in their food choices.

Patients with a history of gastric bypass should be on a multivitamin that contains iron and vitamin B12. The surgery, which is used to cause weight loss in morbidly obese patients, can bypass part of the digestive tract responsible for absorbing these nutrients.

Women of all ages should take calcium and vitamin D to improve bone density to decrease their future risk of osteoporosis. This means at least 1,000 mg of calcium daily and vitamin D 800 to 1,000 international units (IU) per day. Women over 50 should be taking 1,500 mg of calcium/day. A common misconception is that a multivitamin has enough calcium. It doesn't! A typical multivitamin has about 45 mg of calcium (a glass of milk is about 300 mg).

Aside from these individuals, the result of us with a balanced diet should get the right amount of vitamins and minerals. You don't need the large mega-dose vitamin packs found at your local warehouse store or nutritional shop. Not only are they expensive, but also unproven.

If you still feel like you can't get through life without taking vitamins, then at least be aware of the following:

Limit the amount of fat soluable vitamins that you ingest, specifically vitamins A, D, E and K. Unlike water soluable vitamins, of which excess amounts are excreted by the kidneys, fat soluable vitamins can build up levels in the body.

For vitamin A, toxic levels begin after ingesting more than 50,000 IU daily. Upper limit of tolerable intake (what is considered the upper limit of normal but still safe) is 10,000 IU. Recommended daily allowance is 3,000 IU.

For vitamin D, the upper limit is 2,000 IU. The current daily allowance is 600 IU. A new recommendation is expected in May 2010 by the Food and Nutrition Board. Vitamin D is obtained by the skin via sunlight exposure. With people indoors more often than generations ago and possibly the increased use of sunscreen, doctors are seeing more cases of vitamin D deficiency. Your doctor may prescribe a weekly dosage of 50,000 IU weekly for three months to replace. Low levels of vitamin D can cause muscle pains, so if a constant problem, ask your doctor to check your levels. (Cod liver oil, incidentally, is rich in vitamin D and is probably why growing up in Canada I had a lot of it during the winter. Ick.)

For vitamin E, the recommended dosage is 22.4 IU with the upper limit of tolerable intake no more than 1,500 IU. Some research suggested that there was increased mortality for those individuals taking more than 400 IU per day. Because of its antioxidant properties, researchers thought taking more was better. It wasn't.

For vitamin K, found in green leafy vegetables, it is the only fat soluable vitamin where there is no defined upper limit for toxicity. Overdose of vitamin K is rare.

Am I against vitamins? Of course not. For some patients, in fact, they are recommended. What I am against is, however, having individuals spend their hard-earned money for therapies that aren't proven. Note that the FDA, under current legislation since 1994, has no oversight over nutritional supplements.

This is why all vitamin package inserts have the following statement:
* These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

Want to live well? A better insurance policy than vitamins is to not smoke, perform regular physical activity, take in five servings of fruits and vegetables, and possibly drinking alcohol in moderation (as a doctor I can't recommend that, but if you drink already, it might be ok). Researchers found individuals who did all four behaviors added 14 years to their lives. Why don't more of us these activities? They all take some effort. Swallowing vitamins are quicker and easier.

If I still haven't convinced you not to take unnecessary vitamins, then at least check with your doctor before stopping your medical therapies or adding supplements that can interfere with your treatment.

Finally, please avoid colon or total body cleanses. Sounds natural and healthy, but again aren't required. A product found at a large nutritional chain's special "anti-oxidant" formulation basically consists of fruits, vegetables and fiber. You can do that yourself for a lot less, and it probably tastes better too.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: alternative medicine, drug interactions, vitamins, women's health

You can date your patients after all.

What with all those pesky ethics rules, it's not often that the line between romance and medicine gets blurred. But a new article (in the business section of AMedNews, of all places) brings the topics closer together than usual.

The story even begins like a romance novel. "The young woman wondered: Could Dr. Emmet be the right physician to perform her first pelvic exam?" Thankfully, before the situation deteriorated into any heaving bosoms, the article explains the woman and the doctor were participating in a physician-patient speed date. That's right, speed dating, an activity formerly confined to dark singles bars, could be headed to a hospital cafeteria near you.

At this Texan event, a group of physicians in need of patients and patients in need of physicians met and chatted to see if they were compatible. If they hit off, the pairs made appointments rather than second dates. But it's amusing to consider what kinds of icebreaker questions would have worked in both types of speed dating: "Are you looking to have children soon?" is probably OK, but "When was your last full-body exam?" might take some daters aback.

Labels: patient information

QD: News Every Day--Obama calls for a health reform summit

Health care reform
In a bid of showmanship, President Barack Obama invited Republicans to the White House for a televised half-day summit to lay out ideas for health care reform. During the president's State of the Union address, he asked if anyone had better ideas to bring to the table, and a chippy House Minority Leader, John Boehner, raised his hand. Here's his chance to speak. (Wall Street Journal, TIME)

H1N1 influenza
The H1N1 epidemic has "one foot in the grave," William Schaffner, MACP, told TIME magazine. Anne Schuchat, FACP, updated reporters about the issue last week. (transcript and audio)

With that good news, the Roman Catholic Archdiocese of Boston plans to restart offering the Communion cup and sharing the Sign of Peace, which were stopped because of its spread. Meanwhile, professional hockey's New York Islanders will host free flu shots to all fans at tomorrow's game. (Leave your own punch line in the comments field.) (WHDH-TV, NHL.com)

In case you missed it ...
A Dallas-Fort Worth area hospital used the speed-dating model to match patients to primary care physicians. In case you're not familiar with the concept, speed dating involves quickly rotating people for chats of a few minutes at a time. At the end of the event, people decide who they'd like to see again. (American Medical News)

Labels: H1N1, health care reform, QD

Medical News of the Obvious

Again this week, the mainstream reporters are doing our job for us. Newswise brings us reports of "an unmet need to study what might seem obvious: Gay kids will be pushed around." Researchers, published in the Journal of Adolescent Health, attempted to fill that need by surveying thousands of kids to learn that the very few who identified themselves as homosexual (less than 2%) or bisexual (0.5%) were also more likely to be bullied than the blend-in-with-the-crowd heteros.

In other news of those mysterious little miniature humans, it turns out that kids don't take themselves to the dentist. "About 86 percent of children whose parents had a dental visit during the preceding year had a dental exam, compared to about 63 percent of the children whose parents hadn't," HealthDay reports. What, that other 23% couldn't get it together to call a cab or hitchike to the dentist's office?

Labels: medical news of the obvious

Airplane Medicine: What Happens When You Answer The Flight Attendant's Call For A Doctor

This post by Liam Yore, MD, originally appeared at Better Health.

Rounding at 37,000 Feet

Anyone who has flown long-distance flights has heard the call: "If there is a doctor on board, please identify yourself to a flight attendant." But it's impossible to understand how that call induces the urge to flee to the lavatory and hide unless you are one of those unfortunate few who are on the hook, which is to say that you are qualified to respond, but you really really don't want to.

But gee, I can hear you think, Aren't you an ER doctor? Isn't this sort of thing second nature to you? Don't you revel in the adrenaline and glory? Well, yes. But, first of all, there is the performance anxiety thing. I'm used to working with a very small audience. In economy class, there may be 300 people watching me try to do my thing, and I'm just not used to that many people being in the exam room--and I know they are very interested in what's going on.

Also, being an ER doc, I am terminally paranoid, and over the Atlantic Ocean there's just no easy way to differentiate the Very Bad Things[tm] from the more common complaints which occasionally represent Very Bad Things[tm]. So that also is anxiety-provoking. And then there's the potential that things might turn bad, and then it's a flog to run a code in the limited space available.

Click on the "More" link to read the full post.

So, on Olympic Air, somewhere over the mid-Atlantic, the dreaded call goes out. I cringe and try to sink deeper into my seat, hiding my face behind my magazine. Finally, seeing that nobody else responded, I gave a deep sigh and pushed the call light. It was a 60-70ish guy in First Class with abdominal pain which radiated through to his back.

Great, I thought to myself, It's an aortic aneurysm. (See? I told you I was paranoid.) But his belly was soft with no pulsatile mass, good femoral pulses, and clinically, I thought the pain was much more suggestive of a kidney stone. I gave him some ibuprofen and said I'd check on him later.

I tried to sleep, but maybe an hour later, the attendant approached me again ... there's another patient for you. Sheesh. This is an older fellow with a history of heart disease who has epigastric pain and nausea. How the hell am I supposed to tell heartburn from angina over the Atlantic? I asked the attendant if there was a defibrillator on board, thinking maybe I could at least look at the ST segments, but the Greek-speaking attendant seemed to not understand the question. I mimed shocking someone with paddles, and his eyes got very big, but then said, no, they didn't have anything like that.

The patient said he has had typical chest pain with his heart attacks and this felt much more like his stomach. Then he threw up and felt a little better. I rooted through the medical kit and found something which looked like Greek meclizine and gave it to him. I checked on the first guy and he said he felt a lot better.

A couple of hours later, they roused me from a deep sleep (this was an overnight flight), to apologetically tell me that there was a third passenger in need of attention. Oh. My. God. This elderly lady was having trouble breathing and they had gotten an oxygen mask on her. Well, her lungs were clear and her pulse was normal and she seemed really panicky and her traveling companion said she had been under a lot of stress and hated to fly. So probably a panic attack. I told the flight attendant to keep her on oxygen for another half an hour (purely for placebo value) and told the patient in my most authoritatively reassuring tone that she would be feeling better by then. I then checked on the kidney stone (sleeping) and the nauseated fellow (much better, thank you). I went back to the galley and hung out with the crew, drinking coffee for half an hour, then went back to the panicky lady who had in fact experienced a miraculous recovery.

The flight crew was very nice and gave me a free bottle of champagne as a gift. And I swore I would never again admit that I was a doctor on an airplane flight.

The time in Greece was lovely. We started off on the island of Kos, Hippocrates' birthplace, and I got a cool T-shirt with the Hippocratic Oath on it, in Greek. As it happened, that was the only clean garment I had for the flight home (this time on Delta). This time we made it most of the way across the Atlantic before the call came for a doctor. I waited and waited and nobody else responded. Finally I decided that I couldn't very well walk around with the fricking Hippocratic Oath on my chest and not help out, so I gave in and rang the bell. As I stood up, I saw an elderly man about 10 rows in front of me, standing in the aisle in the tripod position, labored breathing, gray and sweating. That must be my patient, I thought. He doesn't look good. He couldn't tell me anything (too short of breath), but his traveling companion cheerfully informed me that he had had a heart attack only two weeks ago, and just got out of the hospital with congestive heart failure and had a pacemaker put in.

Oh, is that all? His pulse was about 150, way too fast, and his blood pressure was also very high. When I asked, he nodded "yes" that he was having chest pain. I figured that most likely he had gone into an irregular heart rhythm as a consequence of his heart failure and the low oxygen pressure in the cabin. I got out the defibrillator and moved him to an empty seat in business class because I figured that if he was going to code, I wanted room to work it. He looked that bad. I rooted through his med bag (a cornucopia of heart meds) and gave him aspirin, nitro, lasix, and metoprolol. And oxygen, of course. Then I went to talk to the pilot. We were two hours out from JFK, he said, but we could get down just a bit sooner by landing at Halifax, Nova Scotia. I tried really hard not to let the knowledge that I had a connecting flight affect my decision-making. Tough decision. Finally, I said that I thought he could make JFK but we should expedite it. I heard the engines spool up as the pilot accelerated the plane. So I sat up in first class with him to keep an eye on him (The wife eventually joined me when I didn't return to our seats in coach), and he progressively improved. His pulse came back towards normal with a second dose of metoprolol, and by the time we landed (almost 40 minutes early) his color was much better and his breathing was a lot easier. I wrote up a little report for the paramedics/ER, and after the fastest landing and shortest taxi I have ever had, the medics bustled him off the plane.

Again, the flight crew was really nice (and almost pathetically grateful, which was appropriate, since an unscheduled landing would be just about the end of the world to them). They took my business card and promised me a "nice little something." Lord knows what that'll be--probably a fruit basket. It was rather a pain in the butt, but at least the guy really needed me, and it was gratifying to see him get so much better. And I have resolved that from now on, I will fly with an iPod in my ears, cranked up so loud I cannot hear a single overhead announcement ever again.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: humor, travel medicine

QD: News Every Day--The government's rising stake in health care costs

The federal government may be stalled on health care reform legislation, but the executive branch has been expanding its stake in paying for care.

Yesterday, QD reported that federal and state governments will pay for more than half of the health care purchased in the U.S. by 2012, and likely even sooner. Today, Medicare's actuaries announced that growth in national health expenditures (NHE) outpaced growth in the Gross Domestic Product (GDP) last year. The recession, H1N1 programs and federal subsidies for COBRA benefits all contributed to the largest one-year increase in history, from 16.2% of GDP in 2008 to 17.3% of GDP last year.

In 2010, NHE growth will decelerate to 3.9% while GDP is anticipated to rebound to 4% growth. But, and this is a big caveat, much of the projected slowdown in NHE growth is attributed to the 21.3% slashing of Medicare physician payment rates called for under current law’s Sustainable Growth Rate provisions.

We here at QD love a good chart to explain all this, and there's plenty to peruse.

Also released today is a report that, one year after expanding Children’s Health Insurance Programs, 2.6 million more children gained Medicaid or CHIP coverage. As a result of the extra federal spending, all but two states cover children in families earning at least 200% of the federal poverty level, ($48,100 for a family of four in 2009.)

Health care reform
Speaking to a friendly audience, President Barack Obama broadly outlined his goals for moving forward on health care reform. He called for a "methodical, open process" and a public airing of ideas from partisan legislators and non-partisan experts. Vice President Joe Biden backed up those statements, but U.S. House leaders dodged the topic following a meeting with the President. (New York Times, The Hill, Politico)

Labels: H1N1, health care cost, health care reform, Medicaid, QD

Invest in Primary Care to Bring Costs Under Control

I went to my physical therapist yesterday for knee treatment and we talked about the fact that Blue Cross is cutting their reimbursement to the point that the cost of providing care will not even be covered. All I could do was lament with him and listen. One insurer even told him (the owner of the business) to just "make the sessions shorter and don't give as much care." As if that is how it works: "You get little money, so just do a little".

Clearly the insurance intermediaries, who never actually see a patient or deliver any care, haven't got a clue how this whole health thing works. They are happy with mediocre doctors that cut time and care. Those doctors (and physical therapists) run mills, but the insurance companies are happy with them. Quality and quantity of time are not rewarded, and in fact are punished in the health care environment we have.

He asked me if primary care had any problems like that. (I felt like screaming "Aren't you reading my blog?") More the point, why doesn't the entire population know that access to a primary care physician will become as rare as swimming with dolphins? It will depend upon how much money you have to buy concierge/retainer medicine. Where you live will play a role. If your community has a large multispecialty clinic, like Kaiser or Sutter Palo Alto Medical Group, you may have access.

Doctors in training are flooding away from general internal medicine, pediatrics and family medicine in droves. Only 2% of medical students plan to go into primary care. It used to be over 50%. A recent Jim Lerher report discussed the reasons. We've been talking, talking, talking about it for years but things have only gotten worse, not better.

The whole premise of health care reform ensures that everyone has access to good quality care. Every nation that provides good, quality access has a strong primary care base that is the foundation--primary care that is valued by the government, the payers, the population and even by the physicians.

We have it all backward. It is time to revamp the system from the bottom up. Frankly, I don't care if we get one more multimillion dollar robot to assist in a rare surgical procedure or one more new " next generation" imaging scanner until we can rationalize how we pay for care.

We have not yet begun the hard work to bring costs under control because there are too many pigs at the trough. One of my favorite teachers (you know who you are, Ed) said "You can't clear the swamp until you get the pigs out of the way."

We have a lot of pigs to move aside so more people can get to the water.

Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Labels: health care cost, health care delivery, primary care, primary care shortage

ACP Internist hosted Grand Rounds on June 16, wrapping up the best of the medical blogosphere. Click here for the complete wrap-up.

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Blog log

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

db's Medical Rants
Robert M. Centor, FACP, contributes short essays contemplating medicine and the health care system.

Everything Health
EverythingHealth is designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Getting Better with Dr. Val
Getting Better is the continuation of Dr. Val Jones' previous blog at Revolution Health. It is devoted to helping people understand health issues from a balanced, scientifically sound perspective.

HealthHombre
A roundup of health policy news drawn from a database of hundreds of Web sites.

Interact MD
Michael Benjamin, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

Kevin, MD
The alter ego of Kevin Pho, ACP Member, is the closest thing to royalty in the medical blog world.

LSUHSC-S Medical Library Evidence Alert
Major guidelines, systematic reviews, meta-analyses and/or major reviews by national and international organizations.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by a doctor.

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