Saturday, June 30, 2012

Government in Control of Your Health Care

Government in Control of Your Health Care

            Last week’s JAMA powerfully and beautifully expressed one consequence of current government intrusion into the doctor patient relationship. I have written about this before.

            Sadly, so many, including physicians, are well intentioned yet misguided or uninformed. Most of the problems with health care and health insurance in the U.S. are due to government meddling and government regulations.  A complete government take over is the worst possible response.
            The road to hell is paved with good intentions.   
            All of us deserve better.

            If you wish to read more, with an open mind, visit the following websites:

                 Cato Institute

                 Docs 4 Patient Care

                 National Center for Policy Analysis

                 American Association of Physicians and Surgeons

                 National Federation of Independent Business

                 Canadian Fraser Institute

Sunday, June 24, 2012

Weight and Topamax

Weight and Topamax

We may soon see new drugs approved by the FDA to help with weight loss. 
One of these contains Topamax. The generic name for Topamax is topiramate. 
Topamax has been known for almost 10 years to promote weight loss.
Of course, Topamax is not approved by the FDA for weight loss.

Topamax is approved by the FDA for prevention of seizures and prevention of migraines. 
But when Topamax was tested for seizures, studies showed that it tended to cause weight loss. Since then multiple studies have confirmed that Topamax even in low doses tends to cause weight loss.

These early studies have been confirmed with further randomized controlled clinical trials in those with diabetes on metformin or diabetes on no other medication, those with binge eating disorder,  those with migraines and others. A controlled release form of Topamax has also  proven effective.

There does not appear to be much benefit of Topamax on weight above 200 milligrams per day and 100 milligrams works well in many studies.

As with other medications for weight loss, individual responses can vary considerably. But in most studies about 5-6% of baseline weight was lost with Topamax as compared to about 1.5% with placebo treatment. And improvement in blood pressure and blood glucose control has been seen.

Topamax can produce plenty of side effects. Most of these are related to brain function. These include problems with memory, concentration, attention, alertness, sleepiness, changes in taste and tingling feelings. These neurologic side effects depend on the dosage, the higher the Topamax dosage, the more likely the side effects. Dosage no higher than 100 milligrams seems to be tolerated best. And most patients do best with slow upward increases in dosage, starting with dosing at bedtime. Any side effects promptly go away when the Topamax is discontinued.

Topamax  also increases the risk of calcium phosphate kidney stones by reducing the ability of the kidney to excrete acid and reabsorb alkali. The urine becomes more alkaline and the blood becomes more acidic. Technically this means that Topamax produces a renal tubular acidosis. Increasing fluid intake may reduce the risk of kidney stones in those taking Topamax.

No drug for weight loss should be used during pregnancy. And topiramate can cause birth defects if  taken during pregnancy. The likelihood of cleft lip and cleft palate are increased at least two-fold if topiramate is used during pregnancy.

The combination drug Qsymia may be approved soon for weight loss. It contains both Topamax and phentermine in an extended release formulation. 

Topamax itself has beneficial weight loss effects. But as with all other conditions, there is no perfect drug.

Modifying behavior with dietary effort and exercise continues to be very important. And Topamax may help.

Saturday, June 16, 2012

Facts on Fish Oil: what is fish oil really good for?

What are the facts on fish oil? 
What is fish oil really good for?

In a previous post I described the results of randomized trials with fish oil to answer the question: what is fish oil good for?
Those who read that post will know that there are select groups of people that seem to benefit from fish oil supplements.

Now we have more facts on fish oil. The results of a large randomized controlled clinical trial were presented at the American Diabetes Association meeting this week. This study called ORIGIN randomly assigned over 12500 persons. All had elevations in blood glucose and 82% had  diabetes at the start of the study.  Treatment was given with insulin glargine (Lantus Insulin) to one half of the participants and usual care of the blood glucose to the other half.  I will discuss the results of the Lantus treatment in an upcoming post.

Half the ORIGIN group were given prescription fish oil in the form of Lovaza 1 gram per day and the other half received an identical appearing placebo pill. The average age of the participants was 63 years and about 60% had previous cardiovascular disease. They were followed closely for an average of more than 6 years.

So what did the ORIGIN investigators find were the effects of the fish oil supplement?  First we know that Lovaza and fish oil in general lowers triglycerides if you take enough. Even at this low dose of fish oil, the triglycerides were about 10% lower than in those who were given placebo. And the ORIGIN group as a whole did not have high triglycerides to start with; the median level was 140 mg/dl.

Fish oil had absolutely no effect on the occurrence of cardiovascular death, or heart attack (medically known as myocardial infarction)or on stroke.  Keep in mind that about half the patients were on statin therapy at the start of the study and statins are proven to reduce cardiovascular events. And two thirds were on the proven-to-benefit ACE inhibitors or ARBs.

So in this population of people with no recent myocardial infarction or heart failure, a fish oil supplement at this quite low amount was not helpful beyond the other treatments these people were getting. Would a higher dosage, say 4 grams per day have been effective? Many experts think so.

Keep in mind these facts on fish oil when you read all the hype. You can the read the published paper here.

Fish oil contains omega 3 fatty acids which lower triglycerides and may be helpful for people with:
  •       high triglycerides or
  •       heart failure or 
  •       people who have had a myocardial infarction in the previous 3 months.

Those are the main persons for whom there is fairly good evidence of benefit from fish oil omega 3 fatty acids. More details can be found in my previous post.

Watch for claims on omega 7 fatty acids. There are even less data to support their use. And a common omega 7 fatty acid,  palmitoleic acid, appears to raise LDL cholesterol, the “bad cholesterol”.

Maybe you should reconsider that fish oil supplement. 
Most people would be pleased to be taking fewer pills and saving some money too.

Tuesday, June 12, 2012

Insights from the American Diabetes Association

 I am a few days late for my weekly posting. I was really busy attending the 72nd Scientific Sessions of the American Diabetes Association (ADA). This year the meetings were held in  Philadelphia. I know Philadelphia is not exactly a top destination spot.

But regardless of the city where the ADA is held, I find these meetings to always be intellectually exciting and engaging. Enthusiastic attendees share a passion for preventing and treating diabetes. Attendees spend most of their waking hours during these meetings sitting down in air-conditioned rooms listening to presentations on the latest research. There are opportunities to network and discuss.  There is a substantial international attendance. And over 17,000 people attend. But unfortunately, relatively few endocrinologists that I know attend. That's a shame because there is much to learn here.

But every year I attend the ADA I have to deal with two challenges. One is avoiding a sore bottom from sitting so much. I am not used to sitting for hours at a time. This year taking the stairs and a short run at the end of each day helped me deal with this prolonged inactivity.

The other challenge is deciding which sessions to attend. There are multiple presentations held at the same time. It is often very difficult to decide which one to go to. This year I focused on nutrition, weight, behavioral issues and medications. I still missed out on a lot. Sure you can buy a recording of the entire meeting which is said to include all presentations but when I've done that in the past I never seem to find the time to view it.

I do find it helpful to write down key points from the meetings. 
And here are a just few insights from the ADA:

Any physical activity is better than none. Walking for 5 minutes every hour that you are sitting can significantly help in managing your blood glucose. The risk of diabetes does increase as we get older but that is because we become more inactive. Those who remain physically active as they age will reduce their risk of diabetes.

All exercise is helpful: muscle toning, so called resistance exercise, as well as aerobic exercise is important. And don't forget flexibility or stretching and balance training. Wow, balance training.

It's common for patients to not take medication as prescribed. This is called non-adherence. There are two types of non-adherence: intentional and non-intentional. We have better tools to detect non-adherence but we all need to understand more about non-adherence. It's no surprise that those who have higher non-adherence do worse. If you do not take your medication for diabetes your sugars run higher. If you miss your blood pressure pills, your blood pressure is not well controlled.

Most studies show that a higher protein intake reduces appetite. But that's when the protein is in solid form. Liquid protein as in protein shakes have less satiating effect. Some studies support a “protein leverage hypothesis”: we eat more until we get enough protein. And in the U.S., as most Americans have gained weight, over a 40 year period ending in 2000, there was an increase in average carbohydrate and fat intake per person but no increase in protein. Interesting!

But there is a lot more to food intake than just appetite.
Often we eat when we’re not hungry. We are fortunate though to have better medications for diabetes that reduce appetite and that do not cause low blood sugar. See my recent post.

I will share more insights from the ADA soon.
Tomorrow it’s back to work to implement some of what I’ve  learned.

Sunday, June 3, 2012

Alternative thyroid treatments are junk and a waste of money

Alternative thyroid treatments are junk and a waste of money.

Alternative thyroid treatments are sold under such names as Iodine Plus 2, Thyroid Assist, Thyroid Support, Thyroid Energy and other similarly misleading names.

Some medical doctors (M.D. or D.O) even promote alternative thyroid treatments. But most who say they’re doctors and tout these alternative thyroid treatments are either chiropractors (D.C.) or naturopathic doctors (N.D.).

By the way, some people think that the N.D. stands for “not a doctor”.
I would not disagree.

If you have hypothyroidism, that’s the medical term for an under-active thyroid, then you need thyroid hormone. 
For hypothyroidism you should take levothyroxine also known as L-thyroxine.

Most endocrinologists recommend brand name levothyroxine. Those brands that all contain levothyroxine and tend to be the most reliable are: Levoxyl, Synthroid, and Tirosint.

See my previous post if you have questions about so called natural thyroid hormones.

Now how about alternative thyroid treatments?
There is no doubt that alternative thyroid treatments are junk and a waste of money.

What is typically found in these alternative thyroid treatments?

Iodine, tyrosine, selenium and B vitamins are the key and most common ingredients in alternative thyroid treatments.  Some of these supplements claim to have “Raw Thyroid” but those do not have any significant amount of thyroid hormone.
Supplements that are called Raw Thyroid cannot contain any meaningful amount of thyroid hormone because of laws that do not allow it.

Some supplements also throw in a host of other vitamins and minerals. And those vitamins and minerals you could get in any cheap one a day vitamin and mineral supplement. 

But all these alternative thyroid treatments are simply junk and a waste of money. There is no scientific evidence that giving these pills to someone who cannot make thyroid hormone can bring their thyroid levels miraculously back to normal.

The most common causes of hypothyroidism in the United States are Hashimoto’s disease, radioactive iodide treatment to destroy the thyroid or surgery to remove the thyroid.

The thyroid needs iodine to make thyroid hormone. See my recent post.
But in the U.S., and Canada, iodide deficiency almost never is the cause hypothyroidism.
Iodide has been added to salt since the mid 1920s.

Taking too much iodide can actually make it harder for your thyroid gland to work if you have hypothyroidism. Thyroid experts have known that fact for many years

Most multivitamin and mineral supplements will provide the 150 micrograms recommended dietary allowance for iodine. Getting this amount of iodide is important for all women during pregnancy.

Some supplements provide the iodide as bladder wrack or kelp. Bladder wrack and kelp are types of seaweed that contain lots of iodine.

But the ingredient in these alternative thyroid treatments that is really a joke is tyrosine. Sometimes tyrosine, also called l-tyrosine is sold separately as alternative thyroid treatment.

Tyrosine is an amino acid your body can make. Tyrosine is a building block of proteins and part of the thyroid hormone molecule. See below and see if you can find the structure of tyrosine in levothyroxine. 



But people do not get hypothyroidism because of a shortage of tyrosine.
Giving someone tyrosine when they have Hashimoto’s disease or another cause of hypothyroidism is laughable.
That’s like putting gas in your gas tank when the car has no engine!

And supplemental B vitamins do not help thyroid function in those with hypothyroidism.

But how about selenium? Selenium is a trace mineral in selenocysteine that is a required part of the enzyme that converts levothyroxine to triiodothyronine, T4 to T3.

Well it turns out that supplemental selenium might be helpful but so far this has been shown only in a single study during pregnancy
So selenium is not recommended during pregnancy

And selenium does not seem to lower the levels of anti-thyroid antibodies found in Hashimoto’s disease. 

Selenium may help some patients with eye disease associated with the overactive thyroid condition called Graves’ disease. But too much selenium can cause serious problems. For those interested in reading more about selenium, a good recent review was published.

So to summarize, if you have hypothyroidism, read the labels of any supplements you might be considering.

It is best to simply stay on your levothyroxine and follow up closely with your doctor.
Those alternative thyroid treatments are just not worth it.