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.

Monday, October 17, 2011

Antioxidant Nonsense

These days, it seems that everyone is touting their products as powerful antioxidants. From pomegranates to acai berries to dietary supplements like alpha lipoic acid and CoQ10 and vitamins E and C.

All those antioxidant must be great for you! Right? Is all this antioxidant nonsense?

Well maybe. And maybe not. The truth may surprise you.

Some knowledge of chemistry is required to really understand what an antioxidant is. More specifically, you should know biochemistry since we are dealing with biological systems, like your body.

Let me simplify. But first some background.

All animals need oxygen for life. When oxygen combines with molecules in our body all is not perfect. Some undesirable processes including oxidation occur in the body. Oxidation involves oxygen, Electrons are transferred between molecules. With oxidation, molecules called free radicals and reactive oxygen species are produced.

Examples of reactive oxygen species include: superoxide, hydrogen peroxide, nitric oxide, peroxynitrite, hypochlorous acid, singlet oxygen, and the hydroxyl radical. Reactive oxygen species can cause harmful chemical reactions damaging or killing cells.  This is called oxidative damage.

Antioxidants tend to stop those reactions. On the other hand, pro-oxidants tend to increase those reactions and increase reactive oxygen species. And iron tends to promote oxidative damage. Zinc tends to prevent oxidative damage.

But reactive oxygen species are not all bad. Reactive oxygen species are essential for our immune system. Reactive oxygen species are used to kill bacteria and viruses. And one of these molecules, nitric oxide is required for a multitude of body functions. We would die without nitric oxide.

In our body there is a very complex balance between antioxidants and pro-oxidants, between oxidation and, its opposite, reduction.

You can’t just easily change that balance by taking pills or foods that contain supposed antioxidants. One recent study showed that in people with chronic kidney disease.

And something that is an antioxidant in the usual laboratory test may not act like an antioxidant in your body.

For example, Vitamin C can serve as a pro-oxidant. Flavonoids like those in red wine can also act like pro-oxidants.

And if it’s an antioxidant in the laboratory that does not mean it’s safe. Diethylstilbestrol (DES) is a good antioxidant in the lab. It is also well known as a substance that causes birth defects and cancer.

We also have better ways now to test for antioxidants and oxidative damage in the lab.  One of the best methods measures F2-isoprostane production. This test gives information on oxidation of fats. Older methods like total oxidant capacity are probably worthless.

So don’t think you’re smarter than your body with it’s amazing array of complex mechanisms working to balance pro-oxidants and antioxidants, oxidation and reduction.

And what if you succeed in disrupting this fine balance? Maybe you’ll mess things up and cause more problems.

Now you might better understand the results of recent large randomized, controlled clinical trials with vitamin and mineral supplements. 

So all this stuff about antioxidants is more antioxidant nonsense and marketing hype than it is sound science. 

Eat a variety of foods including plenty of fruits and vegetables but don't take pills or eat foods just because you think they are antioxidants.

That's antioxidant nonsense.

Sunday, October 9, 2011

Taking Blood Pressure Medications at Bedtime

Controlling blood pressure is important to prevent strokes, heart and kidney damage. 
A recent study in people with diabetes showed that taking blood pressure medications at bedtime rather than in the morning might be best.

Control of blood pressure during sleep and throughout the day may be more important than just the daytime blood pressure measured at your doctor’s office. Ambulatory blood pressure monitoring with devices that measure blood pressure automatically every 15-30 minutes over a 24-48 hour period have been used in recent studies.

This recent trial followed 448 adults with Type 2 Diabetes on high blood pressure medications. The researchers randomly assigned each person to take their blood pressure medication either in the morning or at bedtime. They followed the patients for up to 8 years (median follow up of 5.4 years).

The researchers used ambulatory blood pressure monitoring at least every year during the study. Office blood pressure measurements and measurements found on the ambulatory blood pressure monitoring were used to adjust blood pressure medications.

So what did these researchers find? First they found better control of blood pressure during sleep in those taking blood pressure medications at bedtime. That's not too surprising.

But their other findings were really striking!

The risk of suffering a cardiovascular event such as a stroke or heart attack or heart failure was 67% less in the group taking blood pressure medications at bedtime. Every 5 mm Hg (that’s millimeters of mercury, the units we measure the blood pressure) decrease in systolic blood pressure during sleep corresponded to a 12% reduction in cardiovascular risk.

Keep in mind that this study used ambulatory blood pressure monitoring to guide treatment of people with Type 2 Diabetes and high blood pressure.
Unfortunately, ambulatory blood pressure monitoring is seldom used in the U.S..

Why’s that?  Largely because ambulatory blood pressure monitoring is not usually reimbursed by Medicare or other insurances.
If you have been diagnosed with high blood pressure, Medicare will not cover ambulatory blood pressure monitoring.

The impressive results of this study need to be confirmed in a larger trial.  
But at a minimum it seems to support taking blood pressure medications at bedtime.

This study and others also support the use of ambulatory blood pressure monitoring to diagnose and manage high blood pressure.

 We plan to start using ambulatory blood pressure monitoring in our office soon, despite the reimbursement challenges.

Your Diabetes Endocrine Nutrition Group

Monday, October 3, 2011

CKD Stage 4 Study

Our site is now participating in an important clinical study for persons with Type 2 Diabetes and Stage 4 chronic kidney disease (CKD).
This study called BEACON is being conducted around the world at multiple research sites.

At this time our site is the only active site in northern Ohio conducting this study for people with Type 2 Diabetes and Stage 4 CKD.

Stage 4 CKD is defined as a severe decrease in kidney function with 
an estimated glomerular filtration rate  (GFR)  
                                           between 15-29 (mL/min/1.73 m2).
A GFR below 15 generally requires dialysis to treat the kidney failure.
GFR declines with age but a normal value in a young adult is above 90.

In the U.S., diabetes is the most common cause of chronic kidney disease requiring dialysis. Despite our best efforts, most people with Stage 4 CKD have a worsening in their kidney function and will need dialysis or kidney transplant.

Bardoxolone methyl is an oral agent being investigated for treatment of CKD in diabetes. Results from a recent clinical study have shown encouraging results. 
Bardoxolone methyl is being studied in BEACON.

Interested persons can call our office at 440-266-5005 or 440-266-5000  to see if they qualify or simply to learn more.
You can also visit this link  to read more about this study.

Sunday, October 2, 2011

Statins and Sex Hormones

Last week, a concerned patient brought in a newspaper clipping. She was worried that her statin might be lowering her sex hormones and reducing her libido.
The authors of that newspaper column wrote that statins could lower sex hormones. 
And those lower sex hormones would mean reduced libido.

That column and many others written by those authors is one example of sloppy scientific analysis in the media.
Such poorly researched columns do a lot more harm than good. 
And these people have a radio show too!

So what about statins and sex hormones?

Testosterone is the sex hormone that tends to increase sexual desire.
But many factors affect sexual desire or libido.
And most women with reduced sexual desire have normal testosterone levels.

But do statins lower levels of testosterone?

The best evidence from randomized placebo-controlled double-blind clinical trials is that in women and men statins cause no significant effects on testosterone. These studies were published in 1994, 1995, 2000, 2003, 2004, 2009, and this year.

But as always, the story is more complicated than you’d think. So in women who have polycystic ovary syndrome (abbreviated PCOS) and excess testosterone, statins actually may lower their elevated levels. These women with PCOS often are troubled by excess facial hair. So women with PCOS don't want to have those high levels of testosterone.

But for all of those others who are on statins, rest assured that your testosterone level is not likely to be affected by the statin you are taking.

And lots of other factors, besides testosterone, impact your sex drive. 
Like worrying about your job, money, the kids.

And how well do you two communicate?
Did you come to an improved understanding after your last argument?

I hope so. 

Saturday, October 1, 2011

Is Saw Palmetto Worthless?

Are you thinking of using saw palmetto for an enlarged prostate?   
As many as 5% of men may take saw palmetto.
Does saw palmetto really reduce lower urinary tract symptoms from an enlarged prostate?  Or is saw palmetto worthless?

A previous well-designed randomized,placebo-controlled, double-blind clinical trial had shown no benefit with saw palmetto extract for men with lower urinary tract symptoms.

Now a just published clinical trial tested up to 960 milligrams of saw palmetto extract. This is 3 times the standard dose of 320 milligrams.

This most recent trial of saw palmetto extract showed no benefit for men with lower urinary tract symptoms. Treatment with each dose of saw palmetto extract lasted up to 24 weeks. 369 men participated in the trial.

No significant safety issues or adverse effects have been seen so far with saw palmetto extract. Blood tests were done to monitor the men during this recent study.

Both this study and the earlier trial were double-blind and placebo-controlled. Placebo-controlled means, in this case, that those participating received either placebo or the saw palmetto extract. Double-blind means, in this case, that neither the men participating in the study nor the investigators taking care of them knew whether saw palmetto extract or an identical appearing placebo was being taken by any particular man. The code to identify the pills was revealed at the end of the study when all data were to be analyzed.

A randomized, double-blind, placebo-controlled clinical trial is the best way to answer an important clinical question. It appears that these two trials have shown no benefit of saw palmetto extract for men with lower urinary tract symptoms related to their prostate.

Devotees of saw palmetto extract might argue that a different saw palmetto extract made by another company might really work. That may be.

We’ll have to wait for the randomized, double-blind, placebo-controlled clinical trial with that formulation. If  that study is ever done.

Until then, is saw palmetto worthless?
I would answer, yes.