Saturday, December 31, 2011

Enjoy Grapefruit with Your Statin

Do you worry about grapefruit? This is not a strange question if you take a statin. 
I say: enjoy grapefruit with your statin.

Do you take a statin? Do you like grapefruit or grapefruit juice? Then read on.

There are 7 statins on the market. They all lower the LDL cholesterol and are prescribed to reduce the risk of cardiovascular disease. These statins are listed below with the brand name in the U.S. given in parentheses:
·      atorvastatin (Lipitor)
·      fluvastatin (Lescol),
·      lovastatin (Mevacor)
·      pitavastatin (Livalo)
·      pravastatin (Pravachol)
·      rosuvastatin (Crestor)
·      simvastatin (Zocor)

If you take a statin, you may have seen warnings or alerts about eating grapefruit or drinking grapefruit juice. Those warnings imply that drinking grapefruit juice anytime during the day even hours apart from when you take your statin may be deadly.

These alerts are almost everywhere. And I believe they are way overblown and not based upon sufficient scientific or clinical evidence.

Only three of the above statins have warnings regarding eating grapefruit or drinking grapefruit juice while taking the statin. Those 3 statins are: atorvastatin (Lipitor), lovastatin, and simvastatin.

The official prescribing information for these 3 statins cautions about drinking more than a quart a day of the grapefruit juice. 
Wow that’s  a lot! There are not going to be too many people doing that.

But what if you’re a little weird and do drink more than a quart a day of grapefruit juice and  also take atorvastatin which is now available as a generic? Or, what if you love grapefruit and eat 3 a day and also take simvastatin?

How risky is this?

Well it turns out that this whole issue might be important but it is probably very much exaggerated.
Or to put it another way it is likely clinically insignificant.

The chemical components in many foods affect how our body handles or processes the chemical molecules in drugs. Grapefruit is one of those foods that contain substances that affect how are body processes some of the statins.

The liver and kidneys are the main organs that metabolize, breakdown, process or eliminate the chemicals in drugs and the many chemicals that make up our foods. Remember food is composed of chemical molecules too.

Food is digested in our small intestines. And substances that make up our food get into the bloodstream from our intestines.

Well, it turns out that besides the kidneys and liver, our intestines also change and process chemical substances from our medications. The intestines are not just for digestion. They also process chemical molecules.

Grapefruit juice has substances that affect how the intestines process many drugs. 
Those effects vary between people.
And these effects of grapefruit are also difficult to predict and very complicated.

It appears that some substances, called furanocoumarins, in grapefruit juice may reduce intestinal CYP3A4 an enzyme that breaks down many drugs.
Grapefruit may also reduce uptake into the bloodstream of substances by acting on OATP1A2, a transporter protein.

And last, grapefruit may affect blood levels of drugs by affecting a substance called P-glycoprotein. P-glycoprotein helps the body eliminate drugs from cells.

Most of the scary alerts about grapefruit and statins arose because of a study done out of one center in Finland. That study used a 60 milligram dose of simvastatin which is now above the recommended maximal dose of 40 milligrams. In addition, that study had the 10 volunteers drink 200 milliliters of double strength grapefruit juice three times a day. That amount of grapefruit juice is equivalent to about 40 ounces or 1 and ¼ quarts of single strength grapefruit juice daily!

In this study there was an increase in the blood level of simvastatin. The study was conducted over only 2 days.

Another, more recent study conducted by these same researchers also showed an increase in blood levels of simvastatin but the volunteers in this 3 day study drank only only 200 milliliter (about 7 ounces). The amount (expressed as area under the curve and peak concentration) of the simvastatin was increased on average about 3-4 times above the usual.

And when the simvastatin is taken24 hours after high dose grapefruit juice, no meaningful increase in simvastatin levels were seen.

The concern is that there may be an increased risk of muscle damage with the high blood levels of the statin. Muscle damage or myopathy is the only real risk of statin use.

Rhabdomyolysis is a severe form of muscle damage. Rhabdomyolysis is rare.
Rhabdomyolysis occurs in less than 2 persons out of 100,000 who take statins for a year.
Doctors can reduce the chances of a patient getting rhabdomyolysis by understanding  factors that increase risk.

 No clinical reports of problems have been described in humans when grapefruit juice is taken with statins.

And remember, this is primarily a possible issue with simvastatin and lovastatin
In a recent study, daily drinking of grapefruit juice did not have a significant effect on drug levels of atorvastatin despite the official prescribing information

Grapefruit juice should be an important concern in those people on immuno-suppressants, those on chemotherapy and those on drugs for HIV infection.

There are also certain medications that you might be taking that could increase your risk of statin myopathy whether you drink grapefruit juice or not.
Your doctor should know about those and take one of three steps:
reduce your statin dose or change you to a safer statin or change the other medication.

For most people,  you can enjoy grapefruit with your statin.
Check with your doctor if you have questions. And direct him to this post if he is not sure.

Sunday, December 18, 2011

No Flush Niacin is No Good

No Flush Niacin is no good
No good for improving your cholesterol or triglycerides. 
And no flush niacin is no good for raising your HDL cholesterol. 
The HDL cholesterol is the so-called “good” cholesterol.

You may know that niacin is one of the B vitamins. The Recommended Daily Intake for niacin is 20 milligrams. You may see this as Daily Value on the label of the vitamin supplement you may be taking. 
Niacin can be taken as nicotinic acid or nicotinamide.

By the way, nicotinic acid has nothing to do with nicotine.
Nicotine is a very different chemical.
Nicotine is the addictive substance found in tobacco. Niacin is not nicotine.

High doses of niacin as nicotinic acid but not nicotinamide can lower cholesterol and triglycerides. Those fats in the blood are called lipids.

But, in general, you need at least 500 milligrams of niacin to see an effect on lipids. This benefit of niacin on lipids has been known since 1955. 
It is nicotinic acid that is the active substance that lowers the lipids. If there is not enough nicotinic acid produced from the pill, the lipids don't improve.

The problem is that niacin in a dose as low as 100 milligrams can cause unpleasant skin redness, itching, and burning. These symptoms are the niacin flush. The niacin flush may last about an hour or more and starts shortly after you take the pill.

And there are other possible side effects of niacin. But the flush is the main challenge.

Most people get flushing from niacin when they take immediate release niacin to lower their lipids. Prescription niacin that is extended release and marketed as Niaspan is safe and less likely to cause this flushing.

The good news is that the flushing goes away over time and there are several tips that we give our patients to keep the flushing to a minimum. Most patients who stick it out and continue on niacin therapy are not troubled by the niacin flush.

But there are two things we do not advise. 
First don't use the non-prescription slow release niacin. These supplements might work for the lipids but slow release niacin supplements appear more likely to cause liver damage.

Number two. No flush niacin is no good. The usual no flush niacin that is sold is inositol hexanicotinate. This stuff appears to deliver very little nicotinic acid. Remember nicotinic acid is the chemical that lowers the lipids.

Based upon the best evidence, inositol hexanicotinate sold as no flush niacin simply does not work. Save your money!

And check your labels. I do not recommend non-prescription niacin. Before Niaspan was available, I advised my patients to use immediate release niacin. Now, if I  tell people to take niacin I prescribe Niaspan.

But keep in mind, in terms of reducing heart attacks and strokes, niacin has far less evidence of benefit that do the statins. An old study before statins were available that was done in men who had had a heart attack showed a slightly lower chance of having a second heart attack. 
A more recent trial  in people already on statin therapy showed no benefit of Niaspan in reducing cardiovascular events.

Still niacin can still be very helpful in selected people like those with high triglycerides.
But the niacin flush must be worked through.

Sunday, December 11, 2011

How Not to Treat Obese Children

You may have heard of the obese 8 year old in Cleveland Ohio who was taken from his home because the governmental Child and Family Services agency felt the mother was neglectful. After all, he was failing to lose weight as the doctor was advising.

Sure she was not beating him. But he stayed fat.  In the government's view this constituted neglect.

Wow! Does that ever happen to adults that physicians advise to lose weight? And adults have more coping skills and understanding than an 8 year old. Maybe we should we take obese adults out of their homes too?

After all if they get Medicare or Medicaid this costs the taxpayers money. Maybe we should we arrest anyone who is getting government healthcare who is seen leaving McDonalds with a large fries.

And do you think it is easier for obese children to slim down than it is adults?

This child was doing well in school. He was likely getting food from someone other than his mother. That's why her efforts were not successful in getting him to lose weight. But the state agency took him out of his home and put him into a foster home.

There is no evidence that this intervention would help a child lose weight. 

And don't you think he might do a little more eating now in response to stress?

I could not restrain my outrage. I wrote a letter to the Cleveland Plain Dealer.

This incident made the national news.

You can  read the news release on November 30 2011 from the Obesity Action Coalition here.
They were equally incensed.

The American Society of Bariatric Physicians was also extremely critical of this crass government intrusion. 

We have a lot more to learn about treating obesity.
We don't need government bullies to help us.

Your Diabetes Endocrine Nutrition Group

Sunday, December 4, 2011

Does good sugar control help healing?

If you have diabetes, there are many good reasons to control your blood sugar.   
And what about healing?

Does good sugar control help healing?
How about vice versa?
If you heal well, does that mean your sugar is under good control?

Let’s tackle the first question, first. Does good sugar control help healing?
Is there good evidence that better blood glucose control means a better chance of healing of wounds, skin sores or infections?

Many doctors believe that skin wounds or soft tissue ulcers on the arms, legs or feet might heal better with better blood sugar control. But it may surprise you to learn that there is no solid evidence that better sugar control translates into a better chance of healing. Getting blood glucose close to normal might help healing and certainly shouldn’t hurt healing but there just are no high quality studies that I could find to prove the benefits of blood sugar control on healing.

It is clear that certain infections are much more likely to occur when blood sugars are uncontrolled. For example, vaginal yeast infections, called vaginal candidiasis are much more likely when blood sugars are high. In fact, some women discover they have diabetes when they just can’t seem to get rid of their vaginal yeast infection and their doctor thinks to check the urine for sugar or to check the blood sugar level.

And men can get yeast infections on their penis when their sugars are running especially high.

But when it comes to skin cuts, wounds or ulcers on the feet, legs and arms, blood sugar control has not yet been proven to be important for healing.  
On the other hand, some doctors who run wound care centers think blood sugar control really makes a difference. They see non-healing foot ulcers suddenly heal when the blood sugar is controlled. 
Despite these doctor's stories, that we call anecdotes, the proof is not there that good sugar control helps healing.

So now I bet you can answer the other question I asked.
If my cuts and sores heal quickly, does that mean my sugar is well controlled?

The answer is absolutely not!

You can have poor control of your diabetes and still heal okay.
I have certainly seen this among my patients.

You need to test your sugar and have testing of Hemoglobin A1c (abbreviated HgbA1c) in order to tell if your diabetes is under good control.

Remember, there are many reasons to keep those sugars controlled. Like protecting your eyes, kidneys and nerves from damage. And when there’s nerve damage, over time, there’s an increased risk of foot problems, even amputations.

Until further studies are done, prevention is key. 
Keep your glucose well controlled and take good care of your feet.

Saturday, November 26, 2011

Is CoQ10 worth taking?

Is CoQ10 worth taking? After all, CoQ10 is a fairly expensive supplement.
Is CoQ10 worth the cost?

And what is CoQ10? 

CoQ10 is also called ubiquinone or Coenzyme Q10. Although CoQ10 has been called a vitamin by some promoters,  CoQ10  is not.

Our body makes CoQ10 so that means it is not a vitamin. Vitamins are certain substances required by the body for normal function. Vitamins cannot be made by our body and must be taken in the diet.

CoQ10 has an important role in the function of our mitochondria. Mitochondria are found in most of the cells of our body. Mitochondria are involved in a multitude of cell functions. Mitochondria are the center for energy production in the cell but mitochondria do much more than that. And CoQ10 is important for normal mitochondrial function.

CoQ10 also can serve as an antioxidant. CoQ10 is also found in other parts of our cells besides mitochondria.

So what is the evidence for taking CoQ10? Is CoQ10 worth taking?

The most recent and best evidence come from randomized controlled clinical trials. In these randomized controlled clinical trials, the participating person gets either CoQ10 or placebo. See my post on clinical trials.

Because statin therapy may lower blood levels of CoQ10, studies have looked at whether supplementing with CoQ10 might be beneficial in those people who get muscle problems while on statins. The results are not convincing of benefit. 

There have been two published randomized controlled trials that explore CoQ10 treatment in people with muscle symptoms while taking statins.

The larger study  that lasted longer and used a higher dose of CoQ10 showed no benefit but the patients in that study may not have had such severe muscle symptoms. The other smaller study that lasted only 1 month suggested some benefit, less muscle pain, with 100 milligrams of CoQ10 daily.

Other studies suggest possible benefit for heart failure, muscular dystrophy, high blood pressure , migraine prevention, dry mouth and sperm function.These studies are small and all require confirmation.

If you have muscle aching while on a statin you might try a CoQ10 supplement. 
If you notice no benefit after about a month, stop it. 

We all await the results of more studies on CoQ10
In the meantime, I would suggest that most of us should just save our money. 
CoQ10 is not worth taking.

Saturday, November 19, 2011

Cycloset benefits

Have you heard of Cycloset?
Cycloset was approved by the U.S. Food and Drug Administration (FDA) in May 2009 to treat Type 2 Diabetes.  
That’s over 2 years ago. But I suspect you have not heard of Cycloset.

Yet Cycloset benefits are many. These include lowering blood glucose without causing hypoglycemia (too low blood glucose) and reducing serum triglycerides. And Cycloset does not cause weight gain.
But most important are Cycloset benefits to the heart.

But what is Cycloset? Cycloset is a special quick release formulation of bromocriptine. Bromocriptine has been on the market for over 35 years. Bromocriptine has been used to treat elevated prolactin levels and to treat Parkinson’s disease. So we have a thorough understanding about the safety of bromocriptine. After all, it has been well studied over the past few decades.

Side effects of Cycloset are mostly nausea, dizziness and headache. These tend to be mild and go away over time. And slowly increasing the dose over several weeks and taking the pills with food helps. For most people, these side effects are no big deal.

Cycloset lowers blood glucose modestly.  Fasting glucose drops around 20 mg/dl and after meal glucose drops around 35-50 mg/dl. The Hemoglobin A1c (Hgb A1c) drops around 0.5 to 0.9 %.

These effects on glucose are about as much as you get with the DPP4 inhibitors.
That class of drugs for Type 2 Diabetes includes Januvia, Onglyza and Tradjenta.  
I bet you’ve heard of at least one of those DPP4 inhibitors. They are prescribed fairly often. Especially Januvia; it’s been out the longest.

But I think doctors should be thinking of Cycloset before a DDP4 inhibitor.

Why? Here’s the story.

The FDA requires that all new drugs for diabetes have to be tested for heart safety. That means usually that a clinical trial has to be performed in which the drug is tested versus placebo and the number and type of cardiovascular events is carefully evaluated.

The idea is that any drug used to control the blood sugar for people with Type 2 Diabetes should not increase the risk of heart attack, heart failure or stroke.
Of course, it would be great to reduce those risks but at a minimum the drug should not increase cardiovascular risk. This recent FDA requirement for drugs for Type 2 Diabetes came about after the uncertainty about the heart safety of Avandia.

All new drugs for Type 2 Diabetes are being studied for their cardiovascular safety. 
The study with Cycloset has already been completed.

Cycloset or identically appearing placebo was given to about 3000 adults with Type 2 Diabetes. The average age was 60 years and 31 % already had a history of coronary artery disease and about 5 % had a previous stroke.

Only 12% of the group were using just diet for control of their blood glucose.
The others were on pills or insulin. The study participants were followed closely over 52 weeks. The main result planned was the combined rate of several cardiovascular events. These events included heart attack, need for bypass surgery, hospitalization for heart failure or angina and stroke.

The risk of a cardiovascular event with Cycloset was 42% less! There were 3.2% events in those on placebo but only 1.8% in those on Cycloset.

And many of the patients in the study were already on the usual drugs shown to reduce cardiovascular risk, like aspirin, statins and ACE inhibitors.

How might Cycloset reduce cardiovascular risk? The answer is not known.
There are many possible mechanisms.

 But the clinical results are clear. This is the first medication for Type 2 Diabetes that appears in a randomized placebo controlled clinical trial to reduce the risk of cardiovascular events.

I think Cycloset should be considered more often for people with Type 2 Diabetes. 
And now you know why.

Saturday, November 12, 2011

Prevent Kidney Stones

Did you know that you can prevent kidney stones?

Several weeks ago a patient brought in two kidneys stones she recently passed.

How miserable and painful is passing a kidney stone? Extremely!

Many say it’s the worst pain they have ever had. Women who have experienced both labor and passing a kidney stone say that a kidney stone is far worse than labor.
So wouldn't you think that people who have had a kidney stone would want to do all they could to prevent kidney stones from forming in the first place?    I think so. 

And half the people who have had one stone will have another over the next few years. Some people have many stones in their kidney just waiting to pass at some later date.

Those people who have more than one stone we call recurrent stone formers.
Yet it's amazing that so few stone formers are doing anything to prevent kidney stones from forming.

Maybe that's because they just don't know any better.

Most people have been told that drinking more fluids can help prevent kidney stone formation. That’s true but there is a lot more that can be done.

Sadly, few doctors seem to take an interest in or have knowledge of how to prevent kidney stones. Urologists are surgical sub-specialists.

Urologists usually focus on treating the stone once it’s there causing problems.
I often wonder whether urologists would take more interest in how to prevent kidney stones if they themselves had had a stone.

Two Kidney Stones

But besides knowing what to do, it takes a lot of physician time and energy and working closely with each patient in order to prevent kidney stones.
Just what steps to take to prevent kidney stones depends on the stone composition.

For example, is the stone made up mostly of calcium oxalate or uric acid or something else? The chemical makeup of the stone former’s urine is the other key factor to understand in order to prevent kidney stones.

Detailed analysis of the urine can allow us to design treatment to reduce the chance of another stone. Treatment for each person is often different. No one size fits all.

Sometimes treatment to prevent kidney stones involves modest changes in diet. But that does not mean eating a low calcium diet like avoiding such dairy products as milk, cheese or yogurt.

Did you know that low calcium diets actually may make matters worse for stone formers? Experts do not recommend reducing dietary calcium in those with calcium containing kidney stones.

Often safe, cheap medication is needed to help prevent kidney stones. There is fairly good scientific evidence for kidney stone prevention.

Not everyone’s kidney stones can be prevented but specific treatment can reduce chances of another stone by up to 80%. 
I offer kidney stone prevention to all my patients who have had one or more kidney stones.
I would want that for myself.

Have you suffered from one or more kidney stones?
Maybe we can help prevent your next stone from forming.

Saturday, November 5, 2011

Saving Lives: A Forgotten Study?

It’s almost 12 years since a major clinical trial showed a shockingly simple way to reduce death, strokes, heart attacks and heart failure.
Saving lives: simply and safely.
Saving lives with 1 capsule once a day.

The medication used in that study is often forgotten now because it is off of patent. That means the pharmaceutical companies do not promote it.
And many doctors seem to have forgotten or do not know about this important study.

The study was called HOPE an acronym for Heart Outcomes Prevention Evaluation.

The medication is ramipril. 10 milligrams of ramipril daily was the dose that worked. 
A lower dose has not been shown to provide the same results.
Too often, I see lower doses prescribed.

Ramipril is one of 10 drugs in the U.S. classified as angiotensin converting enzyme inhibitors, or ACE inhibitors, for short. But ramipril is the only one proven to have shown this benefit in saving lives. Perindopril proved beneficial in a large study but all those patients had coronary artery disease.

The HOPE study included over 9200 people aged 55 and older.  80% had cardiovascular disease such as a previous heart attack, coronary artery bypass surgery or other evidence of coronary artery disease. About 11% of the 9200 had suffered a previous stroke. 38% of the whole group had diabetes.

And about 12 percent of the group had diabetes but no previous stroke or known heart disease. These participants with diabetes had other conditions that increased their cardiovascular risk such as high blood cholesterol or protein in their urine or tobacco use.
The people with diabetes in the HOPE trial are like many of the patients with Type 2 Diabetes doctors see in their office.

Half of the 9200 people in the HOPE trial received ramipril and the other half were given an identical appearing placebo. So this was a randomized placebo controlled clinical trial. Patients were followed for an average of 5 years.

Now you should know that ramipril is a blood pressure medication, like the other ACE inhibitors. But blood pressure was fine at the start of the study. It averaged 139/79. That level would be considered normal or acceptable control.

For those who received ramipril, the overall drop in blood pressure was very small at the office measurements: on average 3/2 mm Hg.

Despite this small change in office blood pressure, those participants receiving ramipril had dramatically better outcomes:

22% lower risk of death from cardiovascular causes
20% lower risk of heart attacks
23% less heart failure
32% lower risk of stroke
16% lower chance of dying from any cause

So why this striking reduction in bad outcomes?
How is it that ramipril led to saving of lives when the reduction in office blood pressure was rather trivial?

Well, it turns out that ramipril was given at bedtime. Ambulatory blood pressure monitoring revealed why this might have been important.

A select group of 38 participants in the HOPE trial underwent evaluation with ambulatory blood pressure monitoring. They had on average an office blood pressure of 152/83.

They wore a blood pressure cuff that gave readings over a 24 hour period while doing their usual activities during the day and night; that includes sleeping.
They used this 24 ambulatory blood pressure monitoring before starting on ramipril or placebo and then again 1 year later while in the study.

There was no difference in the office or daytime blood pressures but those on ramipril had 17/8 reduction in nighttime pressure as compared to the group receiving placebo. This meant over the 24-hour period that those on ramipril had 10/4 lower pressure than the placebo group. That’s a lot lower than what was measured in the office.

This significantly lower blood pressure at night could have explained the striking reduction in cardiovascular events in the ramipril group. Lowering blood pressure significantly in those with increased risk means saving lives. 

There may be other mechanisms by which ACE inhibitors may reduce cardiovascular risk in patients such as those in the HOPE trial. This is an area of controversy. Many experts think the results seen were simply due to blood pressure reduction.

Some patients cannot take an ACE inhibitor. The most common side effect is a tickle-in-the-throat type dry cough. This cough occurs in about 5-10 % of people. The cough is more common in women.

Those who cannot take an ACE inhibitor can take a medication called an angiotensin receptor blocker, or ARB for short. An ARB is no more likely to cause cough than is a placebo.

Telmisartan, currently marketed as Micardis, was studied in a very large trial and compared to ramipril. It was as effective as ramipril in reducing cardiovascular events. It is not known if other ARBs are as effective as telmisartan. At the time of this post, there is only one generic ARB, losartan.

The results of ramipril therapy in the HOPE trial again point to the benefit of bedtime dosing of medication for high blood pressure and the potential use of ambulatory blood pressure monitoring to guide therapy as discussed in a previous post

In any case, if you think you are like the people included in the HOPE trial ask your doctor if an ACE inhibitor like ramipril is right for you. Perhaps you're already taking one.

Saturday, October 29, 2011

Take Vitamin D Year Round

Most of you have heard that lots of people are low in vitamin D. 
But many people who take vitamin D stop their vitamin D supplement during the summer.
They think they don't need it then.
I recommend that you take vitamin D year round.

Sure you make some vitamin D when you expose your skin to the sun’s rays. But sunscreen reduces vitamin D production in the skin. And those with darker skin need 3-5 times the amount of time in the sun to make vitamin D compared to a person with light skin.

Worried about getting too much vitamin D? Well you can’t get too much vitamin D from sun exposure. 

Even people who live in sunny regions like Arizona  and Hawaii commonly have low levels of vitamin D in their blood. 

And very few foods contain much vitamin D. Even foods fortified with vitamin D do not provide enough vitamin D for most people.

You may know that Vitamin D year round is important for bone strength and bone health. Vitamin D is also important to maintain normal levels of calcium and phosphorus levels in the blood. And adequate levels of vitamin D help prevent falls and improve balance.

But did you know that vitamin D may also be important for cancer prevention and optimal function of the immune system? Vitamin D acts more like a hormone than a vitamin D. It has multiple effects on tissues throughout the body.

People with vitamin D deficiency may have muscle achiness that gets better with vitamin D supplementation. A recent study showed improvement in insulin secretion with vitamin D.

There is  need for more randomized controlled clinical trials with vitamin D.
A large NIH trial is being conducted to examine the effects of 2000 units of vitamin D daily on cancer and heart disease risk. Prescription fish oil is also being studied in this trial.

The test used to measure vitamin D levels is the serum 25 hydroxy-vitamin D.  I usually aim for a level of at least 35 but below 60 ng/ml. This is consistent with the recent Endocrine Society guidelines.

The Endocrine Society recommends measuring vitamin D levels in those at increased risk of vitamin D deficiency. Those at increased risk for vitamin D deficiency include people who are overweight, or above 50 years of age or those who get little sun exposure. 
I have found that about 80% of adults I test are either low or borderline low in vitamin D.
This includes those not considered to be at increased risk.

Of course, our practice is in northern Ohio! Not too often sunny here and recently very rainy.

A standard multivitamin supplement only contains 400 units of vitamin D3. For those with a low vitamin D level, supplementation with 4000 to 6000 units daily of dietary supplement vitamin D is usually needed. Some doctors prescribe a supplement of 50,000 units weekly of vitamin D2. All supplements obtained without a prescription contain vitamin D3.

It is important to continue to supplement with vitamin D once the blood level is normal. If the vitamin D supplement is stopped, the level will drop again. Your body needs a continuous supply of this vitamin.

2000 units of vitamin D daily are needed by most people to maintain an adequate level. A higher daily dose of Vitamin D year round may be needed in those who are overweight or obese.

For those with vitamin D deficiency, I periodically check blood levels. 
Yes it is possible to get too much vitamin D. For most people, 10,000 units a day is the upper safe limit.  
But remember that dietary supplements like vitamin D are not regulated like prescription drugs. 
You may be getting more or less than you think in each supplement. There have been reports of vitamin D overdose  with dietary supplements. So you should be monitored if you are taking more than 2000 units a day.

And don't think you’ll be fine in the summer months without a supplement.
Most people need to take vitamin D year round.


Saturday, October 22, 2011

Does Eating More Frequently Help You Lose Weight?

Often patients tell me that they're eating more times each day in order to lose weight. Some dietitian (certainly not the one in our practice) or some friend told them that they needed to eat 3 times or maybe 6 times a day to lose weight.

Other people try to eat by the clock, every 4 hours, at least while awake, even if  they’re not hungry. They think that by eating more frequently they will lose weight.

So what about it? Does eating more frequently help you lose weight?

Surprisingly little research has been done on meal frequency. But from the evidence there is, in answer to the question “does eating more frequently help you lose weight?” I can state emphatically NO!

It is total calorie intake that is key. Clinical trials in children and adults show that if anything eating more frequently, say 6 times versus 3 times a day, leads to increased calorie intake, weight and appetite.

Higher protein intake does appear to improve satiety or, stated another way, more protein in the diet appears to reduce appetite. I discussed this a little in an earlier post.

So if you feel best eating 2 meals a day, say a late breakfast and a supper, that’s fine. 
You should not need to work in snacks or extra meals in order to lose weight.
There are also no good studies that demonstrate that eating 3 meals a day is superior to two meals a day for weight loss. 

In my experience, those patients who tend to not feel hungry in the morning and skip breakfast are those who tend to eat from supper to bedtime.                They eat so much late at night that it is not surprising that they are not hungry in the morning.
When they eat nothing after supper, they usually wake up hungry.

So, I have 3 take away principles below. And these hold for people with diabetes too. If you have to eat more than you prefer to because of your diabetes medications, that means you need your medications changed.

1. Eat when you’re hungry.
2. Don't eat when you’re not hungry.
3. Don't eat more frequently each day with the hope that this will help you lose weight. The evidence indicates it will not.