Sunday, December 1, 2013

Stop Electronic Medical Record Implementation

Here is a recent, nicely written, article by one of many physicians who shares my views on electronic medical records (EMRs).

See my posts on this subject.

Some patients express appreciation for access to some of their data online. The avenues for such access are so called electronic patient portals. A recent analysis showed unclear benefits of these electronic patient portals.  The researchers found no evidence for better outcomes for those patients who have access to patient portals.

These two publications constitute further evidence that forced implementation of electronic medical records should be halted.

Federal funding for EMRs should stop.
Before EMRs are used, there should be evidence of clear benefit and proof that no patients are harmed.

Your Diabetes Endocrine Nutrition Group, Inc.

Sunday, August 25, 2013

National Health Service Failing in England

National Health Service Failing in England

All those enthusiasts of increasing government control of health care may not know that the British healthcare system has been failing for years. 

The British National Health Service (NHS) is the oldest single payer healthcare system in the world. It started in 1948.  Despite decades of experience, the future of the NHS is doubt.

The British Medical Journal, a vocal advocate of the NHS,  regularly reports on the ailing NHS.  Recently they described a NHS funding gap of 45 billion dollars expected by 2020. 

In response to these financial losses, NHS hospitals are trying to make money by offering "private treatment options" for patients. This means you can pay or "self fund"  for services at these hospitals and get those services much quicker than if you just used the NHS approach. 

Here in the US some of us call the single payer approach the "public option". 
In the United Kingdom (UK),  it's the NHS or government health plan. 
For years, in the UK those with money could go to private hospitals to get care quickly using their own money. 

Now, you can even go to an NHS facility.
You won't have to wait too long if you yourself pay for your MRI or chemotherapy or knee arthroscopy.
Otherwise, who knows how long it will take if you try to get this care using your "free" NHS plan. 

Waiting lists are a clear way to ration care and keep costs down. 

In Canada the Fraser Institute publishes the waiting times for surgeries and procedures in that country's various provinces. Waiting months for surgery or an MRI or CT scan is not unusual.

Those with money don't wait, they come to the U.S. to get care.

We definitely have health insurance problems in the U.S..
But looking toward the UK and Canada should inform our policy makers that single payer approaches are doomed to failure. 

Patients will all suffer. In general, most politicians, blind to all but power, do not care.

If you are willing to think and read about this, beyond the mainstream media,  you will find solutions that empower individuals and keep costs down. 
Take a look at Priceless by John Goodman.


Tuesday, June 11, 2013

Armour Thyroid Reconsidered

Armour Thyroid Reconsidered

Most endocrinologists prescribe brand name levothyroxine (T4) for their patients with underactive thyroid. An underactive thyroid is also known as hypothyroidism.

Levoxyl is a low cost brand which unfortunately is not now available because of some production problems. Other brands of T4 are Tirosint and Synthroid
Both of these brands are lower cost than generic T4 but generic T4 may be less reliable.

We generally frown upon the addition of T3 along with T4. 
Doctors who prescribe both do so go most evidence that shows no benefit in clinical trials.

Recall from my previous post that your body makes the T3 it needs when you give sufficient T4. Some researchershave suggested that some patients may have a reduced ability to convert T4 to T3  and this may affect their response to T4 treatment.

Armour Thyroid is a form of dessicated thyroid extract derived from the thyroid glands of pigs. As an extract it contains both T3 and T4. The chemical structure of the T4 in the Armour Thyroid is the same as that found in Synthroid.

Armour Thyroid is no more or less “natural” than Synthroid. And you know by now from my previous posts just how meaningless is the term “natural”.

The interesting news is that the first rigorous clinical trial comparing Armour Thyroid to Synthroid has just been published!

In this study the researchers gave 70 adults with hypothyroidism either Armour Thyroid or Synthroid for 16 weeks and then switched to the other treatment. That means that each patient was treated with each preparation. Patients and the doctors did not know what pill they were taking since each pill was in an identical appearing capsule. This study was a double blind randomized crossover trial.

After 6 weeks they adjusted the dose by measuring the TSH in the morning. One milligram of Armour Thyroid appeared to be roughly equivalent to 1.47 micrograms of levothyroxine. It is likely to be very important when that TSH is measured especially in those on thyroid extract which contains T3. In this study, the lab draw was done before the Armour Thyroid was taken that morning.

During treatment with the Armour Thyroid patients lost on average 2.8 pounds. And 49% of patients preferred Armour Thyroid whereas 19% preferred Synthroid and 33% had no preference.

Overall there was no difference in symptoms or in neuropsychological testing.

I think this trial, although fairly small,  is important and should make doctors reconsider the use of Armour Thyroid in selected patients. This study has already changed my practice.

 I look forward to seeing these results confirmed in another larger study. 



Saturday, June 1, 2013

Liver and statins; FDA and fish oil

Liver and statins; FDA and fish oil

Many doctors are still routinely testing for liver damage in patients taking statins. Why?

Two years ago I posted that statins do not cause liver damage. And last year the FDA finally got up to date and stated that liver damage from statins was rare (if it occurs at all) and there was no need for routine monitoring with liver tests. So why do so many doctors still do routine testing?

I have my ideas. What do you think?

And one more point to remind you about your LDL cholesterol, the "bad" cholesterol, the cholesterol that statins lower so well. Fish oil does not lower the LDL cholesterol. 

I have seen a rash of patients and doctors recently who seem to believe that the LDL cholesterol will drop with fish oil. 

In fact, if the triglycerides are high, fish oil will increase, not decrease, the LDL cholesterol as triglycerides come down.  

There is one exception:  if the fish oil is pure EPA such as found in the new prescription fish oil called Vascepa. Vascepa does not raise LDL cholesterol.

Another EPA only product will be out soon. We'll see if it's any better than Vascepa. 

Stay tuned. And with regard to your liver, watch those alcoholic beverages not the statins.


Saturday, March 30, 2013

Indulging in Eggs

Indulging in Eggs

It’s Easter and it's Passover. Eggs are everywhere. But should you be eating eggs?

I still see patients and doctors afraid to eat eggs. They worry that their blood cholesterol levels will go up. They may skip the egg yolk and only eat egg whites since egg whites contain virtually no cholesterol.

A typical chicken egg provides 70 calories and 6 grams of protein and virtually no carbohydrates. That egg contains about 5 grams of fat of which only 1.5 grams is saturated. Saturated fat is the type that tends to raise blood levels of the bad cholesterol.  LDL cholesterol is the “bad” cholesterol and is abbreviated LDL-C.

Eggs are an excellent source of protein. They contain all the essential amino acids, those amino acids that our body cannot make.
And about half of the protein in chicken eggs is in the yolk.
The yolk also contains many other nutrients.
In fact, all the vitamins in eggs are in the yolk.

So why be afraid to eat eggs including the yolk?
Well, eggs contain about 200 to 300 milligrams of cholesterol for each egg. And the concern is that eating all that cholesterol from eggs may increase the blood levels of that LDL cholesterol (LDL-C), the “bad” cholesterol.  

Now we all know that it’s not good to have a high level of LDL-C in the blood. 
In general, the higher the LDL-C, the greater the risk of coronary artery disease.
Drugs, known as statins, lower that LDL-C and reduce the risk of coronary artery disease. 

So how many eggs can you eat in a week or in a day without increasing your blood cholesterol much? That answer is not known.

Genetic factors are most important in determining our blood levels of cholesterol. Our genetic makeup determines how much cholesterol our liver makes. When it comes to the diet, it is clear that what is most important is the saturated fat in the diet not the amount of cholesterol in our diet.

A recent meta-analysis showed no compelling connection between egg consumption and heart disease or stroke. Another recent expert analysis questioned the previous concerns raised about dietary cholesterol, eggs and heart disease.

And it has been 8 years  since the American Heart Association published anything significant on diet and cholesterol. At that time they stated:

“The principal dietary strategy for lowering LDL-C is to replace cholesterol raising fatty acids (i.e. saturated and trans fatty acids) with dietary carbohydrate and/or unsaturated fatty acids”.

“On average, an increase of 100 mg/day of dietary cholesterol results in a 2 to 3 mg/dL increase in total serum cholesterol, of which about 70% is in the LDL fraction.

The authors state further that  “there is considerable inter-individual variation in response to these dietary interventions”.  
That is definitely true. In fact, the majority of people do not have a significant increase in the LDL-C with increases in dietary cholesterol.  

Some data show an increase in the HDL-C, the good cholesterol with egg consumption; one such study was published back in 1994.

Based upon feeding studies, the authors state that a  “3% to 5% reduction in LDL-C can be seen when dietary cholesterol is reduced to less than 200 milligrams per day."  That’s what I would call a trivial benefit in LDL-C for a drastic reduction in dietary cholesterol. 

And those cited studies were not studies done simply with eggs. It is possible that egg consumption does not lead to the same changes in blood lipids as do other sources of cholesterol in the diet. 

Heath Canada nutritional recommendations do not suggest an upper limit on dietary cholesterol.

And there are reports of people who eat lots of eggs each day and still have excellent levels of cholesterol in the blood. That fact points out the importance of genetics and other factors in the diet.

Updated American Heart Association guidelines on treating high blood cholesterol, the so-called Fourth Report of the Adult Treatment Panel, should be out this year.
It will be interesting to see how diet is addressed.

I am not convinced there should be any limit on egg consumption. 
I suggest you have your lipids monitored regularly by your doctor whether you are an egg eater or not.
You can make specific dietary changes and then get your levels rechecked to see how those changes impacted your LDL-C,  other lipid measurements and your weight.
And you should stay active, try to maintain a healthy weight, and otherwise eat a balanced diet.

Happy Easter. Happy Passover.

Sunday, February 10, 2013

Should I Eat If I Am Not Hungry?

Should I Eat If I Am Not Hungry?

There are many misconceptions about weight control and weight loss.
I addressed a few in recent posts such as one on “starvation mode” and one on how to lose a pound.

A recent publication by 20 weight control researchers pointed out other common misconceptions, myths and unproven beliefs.

One commonly held belief is that we must not skip meals and that skipping meals, like skipping breakfast, will make you fat.
That belief holds that if you want to lose weight, you should eat regularly and not skip meals. It turns out there is no good evidence to support these beliefs.

I have seen patients with Type 2 Diabetes who typically eat twice a day, forcing themselves to eat an extra meal. 
Why?  A dietitian told them they had to.
Of course, they all gain weight in the process.

Many people who skip breakfast do so because they eat late at night so they’re not hungry in the morning.
Others skip breakfast for other reasons.

But skipping meals does not translate into obesity and making an overweight person eat more frequently has not been proven to aid in weight loss.

One thing is clear, the more calories you take in, the harder it will be to take off weight. Eating based upon what time it is seems silly to me and is not supported by good evidence.

So don't eat if you’re not hungry. 
And most important: reduce those calories and get more physical.


Sunday, February 3, 2013

Making the World A Better Place: Sanitation

Making the World A Better Place: Sanitation

Several years ago I read a book by economist Bjorn Lomborg called “How to Spend $50 Billion to Make the World a Better Place”. The book describes the conclusions of 38 world-class economists who met to come up with the so-called Copenhagen Consensus. They answered the question: if you had 50 billion U.S. dollars how should it be spent to make the world a better place? These economists struggled to find the best return on this investment. They ranked many different proposals.

The best use of that money was for the control of communicable diseases such as HIV and malaria. In the top ten proposals were various approaches to improve sanitation and provide clean water. Among the worst proposals, the most wasteful, were the use of the funds to address “climate change”, previously known as global warming.

I thought of the extraordinary suffering caused by lack of sanitation when I read a recent article in the British Medical Journal called “More temples than toilets?”. India takes the lead when in comes to open defecation: India has 60% of those in the world who defecate in the open, 626 million people.
Open defecation leads to contamination of groundwater and agricultural produce and contributes to multiple parasitic illnesses. Worldwide, each year 2.2 million people die of diarrhea, 90% are children.These deaths are largely preventable.

In 2010, of 423 cities surveyed in India, none received a “healthy and clean” designation. But poverty is not the only reason for this sickening lack of adequate sanitation.
Watch this informative video, if you dare, to learn more.

And be thankful for our sanitation!


Sunday, January 20, 2013

Is Metanx worth it?

Many patients with diabetes have been told to take  Metanx by their podiatrist or other doctor?
Metanx is an expensive supplement. It is not a “drug”.
Technically, Metanx is called a “medical food” by the FDA.
But Metanx is only available by prescription.
Metanx is supposed to be used only under medical supervision.

Metanx contains a form of three different B vitamins: B12, B6 and the B vitamin called folic acid. Metanx is taken by mouth.

Metanx typically is prescribed to help patients who have nerve damage from diabetes. This is called diabetic neuropathy.  Many podiatrists are advising their patients to take Metanx to help reduce pain from diabetic neuropathy. There are several prescription medications available to relieve the pain from diabetic neuropathy.

A very effective and low cost medication for painful diabetic neuropathy is a tricyclic antidepressant. Tricyclic antidepressants or TCAs are available as low cost generics.

In low doses, I find that about 90% of my patients get relief from a TCA.
I usually prescribe 10-20 milligrams of imipramine at bedtime. The imipramine is taken every day not as needed. Reports describing the efficacy of imipramine date back to the 1980's. 
Many docs fail to think of TCAs for neuropathic pain. 
They are not promoted like the newer pricier brand name drugs are.

And many patients can stop the TCA after several months. The pain just seems to go away over time. But that does mean the nerves are healed.

Other drugs proven effective for painful diabetic neuropathy are far more costly but might work when imipramine does not.
Cymbalta is one of these. Cymbalta has many other proven benefits.

Neurontin also works and is available as a generic called gabapentin
A more expensive drug chemically related to gabapentin is Lyrica.
But there is no good evidence that Lyrica is worth the extra cost over gabapentin when used to reduce pain caused by diabetic neuropathy.

Okay let’s get back to Metanx. How effective is Metanx?
Well first, you should know that the FDA does not approve or regulate medical foods like Metanx. So Pamlab, the manufacturer, is free to make many claims for this product.

Do randomized controlled trials show benefit with Metanx?
Do these studies compare Metanx to a cheap dietary supplement of the vitamins that you can get without a prescription?

Well most of the studies done with Metanx had no control arm. That means they were not rigorous well done studies.
And many were done by a single podiatrist in St. Louis. 
That fact alone should make you a bit skeptical.

But just recently, a randomized controlled trial of Metanx was done that showed reduced pain in those given Metanx as compared to placebo. There appeared to be no improvement in nerve function in this study that only lasted 6 months. It is not known if Metanx is any better than just a cheap vitamin B12 supplement. 

And the long term safety of folate supplements is not clear. Remember folate and vitamin B6  are in Metanx.
One large trial found an increase in cardiovascular events when folate and vitamin B6 were given in combination after a previous myocardial infarction (heart attack).  Two other trials published in 2006 and 2008 with different types of patients did not show this. The forms of B6 and folate used in these studies are different from that in Metanx.

Some patients might benefit from Metanx because their vitamin B12 level improved and was actually slightly low to start with. B vitamins are important for nerve function and vitamin B12 deficiency is common, and much more common in those taking metformin, a drug commonly used for Type 2 Diabetes.

In fact, those who tended to feel better in this recent trial may have had larger drops in their level of a substance called methylmalonic acid or MMA for short. MMA tends to be high in those who lack Vitamin B12.  Vitamin B12 supplementation brings the MMA back down to normal. 
What this suggests is that just taking B12 might work just as well as Metanx.

A recent report found that some people may be B12 deficient even though the blood test suggests they are fine. This can be a challenging problem.
Recently I have been testing both MMA and vitamin B12 in my patients who have evidence of neuropathy.  B12 deficiency can be missed if you just check the B12 level. But a level above 400 pg/ml is probably normal. 

Of course, most neuropathy in people with diabetes is from the diabetes not from B12 deficiency but patients can have both.

To sum all this up, Metanx might be helpful to reduce pain from diabetic neuropathy but its long term safety is not clear and my guess is that it is no more effective than a cheap B12 supplement. Pain from diabetic neuropathy goes away over time in most patients and the pain improves with better glucose control. Low cost prescription medication often is very effective.

So, is Metanx worth it?  Probably not.


Sunday, January 13, 2013

Raspberry Ketone Rubbish

Does raspberry ketone help with weight loss?
Well, you may have heard that last year, on his TV show, Dr. Oz recommended raspberry ketone as a “miracle fat burner”.

And what is raspberry ketone?
Raspberry ketone, is a simple chemical found in a variety of fruits. 
Raspberry ketone is used in perfumes and has a fruity aroma.

So how about it? Is it any good?

There have been only two trials published that were conducted with raspberry ketone as a supplement. Both were done in rats. Neither trial was controlled.The best one was done 7 years ago.

There is no good evidence in rats of weight loss with raspberry ketone.

And humans are not rats.

There are absolutely no published data in humans with raspberry ketone. None.

And it is not known if raspberry ketone is safe when taken as a supplement.

To summarize, consider raspberry ketone rubbish.
Or just more garbage from Dr. Oz.
So I suggest you save your money,
          eat smaller food portions, and move more. 
And you can speak to your doctor about a new FDA approved prescription medication for weight management.
Weight loss is difficult. There are no simple quick fixes.
But these are some "sure fire" ways  to “burn fat.”


Friday, January 4, 2013

More harm to doctors and patients

More harm to doctors and patients

The federal government is tying hospital payments to the results of patient satisfaction surveys. This can actually be quite bad for patients.

It turns out that there is no evidence that patients actually do better in the long run if they answer a survey and state that they were happy with the care they received. Of course, most people don't complete such surveys, especially when they feel sick.

But the federal government can use these dubious survey data to justify paying hospitals less. And hospitals might even use the results to pay doctors who work at the hospital less money.

Read this excellent piece from Forbes magazine writer   
Kai Falkenberg.
Form your own opinion and leave a comment.

I think this is one more example of harm from Federal rules and regulations. 
The electronic medical record is one of many others. 
Consumers should be in charge of their healthcare decisions not the government.
Here are two websites to learn more: