Red Yeast Rice

I was very grateful that i didn't have to be put on Lipitor. I just took one every evening after dinner, that was it, That easy!
--A happy Red Rice Yeast consumer on Amazon.com

Interesting stuff, this red yeast rice (RYR).* Used for over 1,000 years in Chinese medicine to promote circulation, this medicinal food is made by fermenting rice with red yeast or monascus purpureus. One of its active constituents --monacolin K-- is also known as lovastatin. Monacolins inhibit hydroxymethylglutaryl-CoA reductase (HMG-CoA reductase) which is an enzyme essential to the body's production of cholesterol. In fact, lovastatin was the first statin drug marketed in the U.S. years ago under the trade name Mevacor.

So is RYR an effective, natural, and SAFE way to lower your cholesterol? Even though the Chinese have a century+ of casual, everyday, human trials, the first formal study of the substance was conducted there in 2002. The results confirmed its efficacy: total cholesterol, LDL cholesterol, and triglycerides dropped by 23, 31, and 34 percent, respectively and HDL levels increased by 20 percent. In other words, RYR did all the good things that statins do because RYR is basically a statin or rather a statin is basically RYR. Other studies, one of which was conducted by the American Heart Association, confirmed the general findings although the benefits weren't quite as robust.

The doses used in these studies were 1.2-2.4 gms/day; some Asian diets include up to 55 gms of RYR per day. Because agents such as RYR and statins decrease the production of coenzyme Q10 which is important to energy production in muscles, supplementation of CoQ10 is recommended with either the nutraceutical or the pharmaceutical approach. The standard dose of lovastatin, however, is 20-40 mg/day whereas the daily amount present in most RYR preparations varies between 5-15 mg.

ConsumerLab.com is an independent testing laboratory that evaluates the quality and contents of nutritional supplements. In a recent investigation, they looked at different RYR products both for the amount of active ingredient (lovastatin) and for the presence of citrinin, a renal toxin that may be produced by yeast grown on cereal grains such as rice. Nature's Plus® Herbal Actives Red Yeast Rice contained very high levels of lovastatin whereas Walgreen's brand contained very little of the active monacolin. Four products had citrinin contamination.

What's in it for your brain? Recent Taiwanese studies of RYR compared its protective effects on cells under ambush from beta-amyloid (the sticky protein that gums up the brain in Alzheimer's disease) with those of lovastatin. The RYR won hands down in not only protecting against cell death from beta-amyloid but also in decreasing inflammation and oxidative stress. This same research group found that rats infused with beta-amyloid learned more, had better memories, and accumulated less beta-amyloid when they signed up for RYR supplements with their kibble.
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*Red mold rice (RMR) if you're a Taiwanese biotech sort, and red mould rice if you're British.

Making scents of the gene pool

Is this your man?

Here's an interesting theory on how we choose our mates, and how birth control pills may be messing with our offspring's chances of survival. Well, obviously, if we don't have children at all based on the use of BCPs, this is a moot point. Assuming, however, that we choose the father of our future kids during a phase in our life when we're not quite ready to make them, here's the scoop.

Scientists believe there are advantages to dipping into a gene pool far different from our own when constructing the DNA of the next generation. Not only will this strategy decrease the likelihood of passing along two copies of a gene mutation for an inherited disorder, research suggests that the children produced from a thoroughly mixed-up match of chromosomes will also be resistant to a wider range of diseases. Those genes in charge of the composition of a person's immune system are called the major histocompatibility complex (MHC), and MHC heterozygosity (meaning mom's MHC contribution is quite a bit different than dad's) gives the kids a survival advantage in future battles against a wider array of disease-causing pathogens.

Interestingly, MHC is a major determinant of body odor in mice and men and women too. The olfactory neurons of mice in charge of odor recognition respond to fragments of MHC molecules even when these peptide pieces are present in extremely small quantities. Many rodent studies confirm that mice prefer nonself MHC-types as mates.

So what's this got to do with BCPs? A 1997 study found that all male subjects and those female participants not taking contraceptives preferred the smell of used T-shirts from persons with MHCs different than their own. The more the subject liked a T-shirt's odor, the less similar their MHC profile to that of the T-shirt's owner. No such correlation was found between Pill-users and their favorite unwashed T-shirt smells.

So if you want to party hearty with respect to producing hardy children with top-notch immune systems, sniff out potential mates in a Pill-free mode before you mate.

How a Corvette smashed my nail

My patient arrived at his physical with a blackened fingernail. When I asked him how he damaged his finger, he replied "I passed a Corvette on the highway, and that's bad luck." I replied that mostly Corvettes are going too fast to pass, bad luck or not, but what did that have to do with his nail. Here's the scoop.

For reasons unknown, he'd always believed that overtaking these sports cars was an invitation to disaster. Recently, however, he decided to defy his magical thinking and left a 'vette in the dust. Within 15 seconds of completing the deed, he got a flat tire. While changing the tire, 1) his girlfriend's nose got smashed by the car trunk as it swung open, and 2) he smashed his finger with the tire iron.

Never a dull moment at these physicals!

Hepatitis A vaccine for post-exposure prevention

(In case you're wondering what all this vaccine information is about, I am preparing a workshop on immunizations, so my brain's shot full of shots.)

In a recent post, I mentioned that hepatitis A immune globulin (IG) is the preferred approach for the prevention of infection in folks who've been exposed to the disease through household contacts or 'fecal fingers'. My information, I discover, is running about 10 months behind the times.

Last October, researchers published a study in the NEJM (1) comparing the use of HAV vaccine with IG in persons ages 1-40 exposed to hepatitis A. The two groups were randomized to receive one therapy or the other within 2 weeks of viral exposure. Few subjects developed hep A no matter which shot they received, and the CDC concluded that the two strategies were equally efficacious.

As a result, they now officially recommend the HAV vaccine for postexposure (less than 2 weeks) prophylaxis in this age range as 1) it's less painful, 2) it's more widely available, and 3) the shot provides longterm immunity. Older persons or people with chronic liver disease tend to be sicker with hepatitis A, so the CDC continues to recommend IG for them. What they really recommend, however, is that all children get this shot after age 1, and most adults should consider receiving a shot as well so they can eat unwashed lettuce with impunity and immunity.
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(1)Victor JC et al. Hepatitis A vaccine versus immune globulin for postexposure prophylaxis. N Engl J Med 2007 Oct 25; 357:1685.

Gardasil vaccine

It's important that women understand if they're sexually active, there's a chance they won't receive full benefit from the vaccine.
--Dr. Laura Koutsky, epidemiologist at the University of Washington

I get asked this question a lot by women who are already sexually active including some who have had abnormal Pap smears as a result of infections by the human papillomavirus (HPV). HPV infections cause virtually all cervical cancer, and bad actor HPV types 16 and 18 are responsible for 70% of these malignancies. The Gardasil vaccine (and the not yet approved Cervarix vaccine) is highly effective at inducing immunity against these carcinogenic viruses; in fact, this vaccine is the first one to specifically designed to prevent cancer caused by a virus.

Dr. Koutsky and company (an enormous panel of clinical investigators) published the results of their FUTURE II trial, aka Females United to Unilaterally Reduce Endo/Ectocervical Disease, in a May, 2007 edition of the NEJM(1). While the vaccine prevented 98% of cervical lesions--precancerous and malignant--in subjects who tested negative for exposure to HPV types 16 and 18 at the time of entry into the study, it was only 44% protective in women previously infected with these cancer-causing viruses.

The ideal population, therefore, that will benefit from this vaccine is those girls/women not yet exposed to the virus. The CDC's Advisory Committee on Immunization Practices has recommended without reservation that girls 11 and 12 years of age receive this shot.
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(1)The FUTURE II Study Group. Quadrivalent Vaccine against Human Papillomavirus to Prevent High-Grade Cervical Lesions. NEJM,Volume 356:1915-1927, May 10 2007.

B.Y.O.P.

Looks like I'll not only be buying my own pens in 2009, but will need my own darn sticky notes and mugs as well. New guidelines for pharmaceutical companies will end this mini-fountain of free office supplies, and physicians will have to make their own judgments about the drugs they prescribe free of that subliminal influence from their writing utensils and coffee cups.

Now I do agree that this is a silly use of funds that could (but won't be) diverted to more productive ends by the companies who distribute these freebies by the gross. I am a bit miffed by the implication that a free roller-ball pen (and they are a godsend for those of us who spend our days scratching our way through handwritten charts) would change my decision-making process. I do rely on post-it notes to remember the next step in patient care ('Call Dr. M,' 'pre-authorize MRI,' 'check on last week's labs,' etc.). On the downside, I sometimes find to my horror that I've given a post-it note to a patient that incidentally advertises vaginal cream or a drug for erectile dysfunction. But I swear that I've never noted the note, then changed my therapeutic plan based on its message.

Oh well, I'll buy my own pens, apply my own message-free sticky notes, and drink my morning coffee from a mug that declares I'm "over 50 but not over the hill". But I'll hold out hope that the new conduct code won't cut off those drug money cookies.

Who needs a shingles shot? Part II

I wrote some time ago about who needs a shingles shot. Here is a summary of the last 4 people I've seen in the office, all in the past 2 weeks, who wished they'd had the shingles shot before their leftover chickenpox (herpes zoster virus) staged a comeback.

The first patient was down on my schedule as 'bug bite.' I'm always suspicious, even in summer, that a 'bug bite' appointment will actually be shingles. Indeed, this 38 year old man's painful 'bite' was, in fact, a cluster of herpetic blisters on his left shoulder. He is too young to have been offered a shingles shot as they are approved for persons sixty and over. The shot would doubtless work on younger patients, but they are quite expensive, and insurance companies would be disinclined to pay for the vaccine in this low risk population.

The second patient complained of a 'bee sting.' This theoretical bee had gotten her on her left buttocks, an area not commonly at risk for a bee attack. At 62, she could've had a shingles shot instead of this stinging red circle of blisters.

The third patient, only 52, is undergoing chemotherapy for cancer. Her shingles were extensive, painfully covering most of her buttocks. She is at risk for a recurrence of herpes zoster as her treatment has compromised her immune system.

The fourth patient--age 49 and therefore too young for the shot-- came in with back pain which she described as a strip both numb and painful from her lower back around to the middle of her front at the level of her lowest rib. She had no rash...yet. I don't know for sure, but her presentation was typical of the pain that precedes a shingles outbreak.

I actually saw one other person this week who could've used a shingles shot, but he needed it 12 years ago when he was 81. Now at 93, he continues to have a painful itch over his left eye up onto his forehead from his remote encounter with his resident zoster virus. He really should re-up his immunity now against another potential attack, but he's not fond of shots.

Who is?

Face it, not in the exam room!

We always ask our patients to bring in a list of their current meds. As I perused my patient's list this afternoon, I noticed that he had written 'face' by one of his prescription drugs given to him by another MD.

I asked him what that meant. He said that when he told me on his last visit that he was on that medication, I'd made a face. He wondered what the face meant.

While I couldn't recall making a face nor any reason why that particular medication should make me grimace or roll my eyes, I did think that I should keep my future opinions off my mug.

Who needs a Hepatitis A Vaccine?

Fecal fingers.

Yucko. But that's what they're called, the 'fomites' (vectors or vehicles of infection) that bring you hepatitis A. That occasional, unclean digit of the unwell worker who forgot to read the sign you've seen posted in restaurant restrooms, namely "Employees are required by law to wash their hands before returning to work." I'm sure the majority of kitchen- and wait-staff are law-abiding citizens, but what if they're stomach's upset AND they're in a bit of a hurry.

There are worse things than having hepatitis A (like having hepatitis B or C). Unfortunately, however, this disease which was formerly known as infectious hepatitis can take a chunk of days from your life and a chunk of points from your sense of well-being. While children can contract the disease with few or no symptoms, adults are generally nauseated, yellowish, and too exhausted to care, and may remain thus for weeks. Fortunately, hepatitis A virus (HAV), unlike B or C, cannot set up permanent housekeeping in your liver in a chronic sort of way and only rarely causes liver failure.

We have shots, a series of two to be exact spaced at least 6 months apart, that can raise your immunity to fecal fingers at least in a HAV sort of way.* As you ponder whether or not this shot's for you, consider that 1) I haven't seen a case of hep A for years (and I do check liver functions in persons with persistent nausea and GI upset), and 2) If you happen to have eaten in an establishment subsequently found to be the source of a HAV outbreak, we can administer hepatitis A immune globulin (IG) to you. This drug contains preformed antibodies to HAV and is 85% effective in preventing a hep A infection in persons exposed to the disease. Protection from an IG shot lasts for 3 months. It is made from blood products from paid donors, and while there are no reported cases of hepatitis B or AIDS from hep A immune globulin, this blood products from paid donors thing may seem a little unsavory.

The vaccination is made from HAV raised in cultures, then inactivated with formalin. You can't get hep A from the shot. Several different brands are available, and none are preserved with the controversial, mercury-based preservative thiomerisol. The shot is highly immunogenic meaning that nearly everyone who gets it quickly develops protective levels of antibodies within one month of the first dose. So if you've put off getting the hep A vaccine,and you are planning travel to a country known to be high-risk for HAV infection, chances are good that even a last-minute shot will afford you some protection. The shot is considered very safe.

Many school systems require the two-dose hep A series for children entering school. Remember that 85% of children do not develop symptoms of hep A, so an unvaccinated child who contracts the infection while traveling out of the country can bring the disease back to more vulnerable personal contacts at home. The incubation period for the disease is 2-6 weeks. Adults in high-risk groups for infections (say those who are in institutions or immuno-suppressed) or persons who work with high-risk groups, and anyone traveling to a high-risk country should consider receiving vaccination against HAV.
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*There are other infections leaping from the fecal fomites such as salmonella and shigella.

How much sleep do we need?

or how do I get my teenager up for work on a summer morn'?

Generally he gets his own darn self up, but this a.m. was an early start, and early start and summer and teenager are not necessarily part of the same sentence. When I first woke him up, it was clear that no one was home behind his eyes. After I poured water on his head, it was clear that an angry but wakeful human had taken charge.

Here are some observations from a recent article in ScienceNOW Daily News(1) about how much sleep animals need in the wild and why that may or may not apply to humans and the subset of humans known as teenagers:

1. "Animals sleep less if they need to graze extensively--as with herds of horses." This is a tough one, he already grazes extensively. The problem must be, however, that if all the grass...er food...is right there in the 'frig, he doesn't need to spend much time doing so. Note to self: Empty out 'frig.


2. "Animals that sleep in groups, such as herds of grazing animals, get less sleep than species that live alone." Scientists theorize that this is based more in eating habits of herd animals rather than the herdiness of it all. M. certainly has quite a sociable herd to graze with, but, again, the good grazing is apparently too close at hand.

Perhaps when he moseys back down the road to school, no more 'summertime, and the grazing is easy. This kid has a 9 a.m. class this fall; I hope the living is lean and dangerous at school. Or maybe not...
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(1)http://sciencenow.sciencemag.org/cgi/content/full/2008/722/2?etoc

Deplin testimonial

I posted some time ago about Deplin, a glorified B vitamin (methylated folate to be exact) that may supplement antidepressants by promoting the production of neurotransmitters in the brain. I've prescribed it to some people not on antidepressants and found that many of them have a positive response with respect to energy and focus. Check out this e-mail from a patient with MS who struggles with low energy and lack of focus:

This new addition to my Rx. closet has made an incredible difference. I feel human, actually went for a walk with my dog last night (1st time in 10 years), feel more alert, have terrific energy and life is suddenly colorful.

Who's the pain in the butt here?

My patient has a pain in the butt. Not 'is a' mind you, but 'has a'. I've never seen anything like it. Her sit bones (ischial tuberosities) are painful to sit upon. She's o.k. with standing or lying, but her sitting hours are intolerably painful so, therefore, seriously curtailed.

I didn't know what to do with her (my father's advice from my childhood regarding things medical that were problematic --"Don't look at it for three days and it will go away"-- didn't work). Ibuprofen and such made no difference. I had to send her to a specialist, and believe me, it was hard to know just what specialist to use.

The orthopedist ordered an MRI of her butt. It showed minimal inflammation of the spot where the hamstrings insert onto the butt bones, but treatment for tendonitis, including cortisone injections, was useless. The neurologist was clueless, the physical therapist energetic but likewise without results.

We finally sent her to a pain management specialist. If you can't beat it, treat it. She was frantic to travel (out of the question) or simply to read a book in the seated position (if you're like her, reading while lying down is a recipe for sleep).

He listened to her story. Don't know if he examined her butt. He suggested Tylenol (heavens, Doc, been there/tried that already!). When she asked him what else could she do to once again achieve comfort in her life, he answered "Just stand up!"

I kid you not, that's what our pain specialist recommended.

The ups and downs of being a doc

Life and a road trip recently took me through Rawlins, Wyoming. Hours of driving through the monotony of southwest Wyoming dictated the need for a pit stop; time to eat and rest glare-weary eyes.

We found a little restaurant, actually the only diner on Main St. that teemed with life and advertised breakfast served all day. Several stuffed animals graced the entryway, real stuffed animals including a bobcat caught for all eternity mid-leap as he brought down a fleeing pheasant. The women's room sported, of course, the title 'Cowbelles' and the men's merely 'Cowboys.'

The meal was so-so, they were out of blueberry muffins and I passed on the alternative biscuits and gravy. As we finished our meal, a tall and sunburned man strode by, balding head shaved close, a slight potbelly protruding over his turquoise studded belt buckle and a beeper hanging off the belt. Most heads turned as he passed, a wide variety of townfolk waved and called "Hi Doc."

Ah, a diner in a town where everybody knows your name. I longed to jump up too and yell "I'm a Doc" and have them all laugh with delight that this dusty aging hippie in coffee-spotted capris and a t-shirt was a colleague to their own dear Doc.

Anyway, Doc Rawlins got to the counter to pay his bill, and I waited to see if they would offer him a bag of blueberry muffins to add to the bag already on his waistline. But instead, the older woman at the register started in on a long story about her bowels and her trip to the regional hospital. Not that I was eavesdropping, but shoot, we were sitting nearby, and I was hoping, at least, for some wonderful tale about how the Doc had saved her aging aunt.

Then I remembered that I live in a neighborhood and shop at a grocery store where many know my name. Why one patient one day described her vaginal woes to me in produce, and another pulled down her lower eyelid in paper goods to ask me whether or not her bloodshot, oozing eye was conjunctivitis. It was. I called in a prescription right then and there to the pharmacy located just east of aisle 18.

On my second day back to work after our Wyoming tour, the nurse practitioner asked me to look at a cat bite, or rather a young woman's hand with four cat bites on it one of which had penetrated her thumbnail. In the day since the feline's attack, the hand had swelled some, the thumb turning pink and puffy. Cat bites are nasty affairs; think for a moment what sorts of fishy things go in that mouth. I told the NP to call a hand surgeon and confirm that oral antibiotics would suffice for a now.

Several minutes later, she returned, sadly shaking her head. "No go, Chief," she reported, "I couldn't get past the front desk with my question. They offered me an appointment for next Tuesday."

What sort of nonsense was that? I strode to the phone and pulled the officious "This is Dr. P, I need to talk to your on-call physician now about a patient."

"Just a moment, I'll get Dr. W," the receptionist said. A moment later she returned to ask "Would this be about a cat bite perhaps? We just had a patient call here for advice a moment ago."

The hand surgeon came on the line shortly thereafter and confirmed the NP's plan as a good one. I realized then, once again, the value of the title and the ease with which it takes me right to the top. Maybe someday it will get me blueberry muffins as well.

Payback time for moms

The female brain is a dynamic structure, which expresses its plasticity most readily following reproductive experience.
---from the Department of Psychology-Neuroscience, University of Richmond

According to research out of the University of Virginia(1), there may be psychological compensation for all those sleepless nights, saggy breasts, and stretch marks that accompany motherhood. Those tedious months of pregnancy, suckling, and pup-rearing...oh right, we're talking rats here.

Neuroscientist Dr. Craig Kinsley and colleagues proved that mother rats adapted better to the stress of confinement in a Plexiglas restraint tube than their female colleagues who'd not yet coped with the demands of ungrateful offspring. Did they consider that lady rats--married, with children--may have just been grateful for the relative peace and quiet afforded by those Plexiglas walls? Speaking from my current perspective of mom to one teenager on site for summer, I would easily adapt, right here, right now, to voluntary confinement at an air-conditioned hotel.

The researchers conclude: "The data suggest that reproductive (hormonal) and/or maternal (pup exposure) experience may inure a female and her brain to stress, rendering her less susceptible to the behavioral-or other-disruptions that stress sensitivity can produce."
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(1)Wartella, J et al. Single or multiple reproductive experiences attenuate neurobehavioral stress and fear responses in the female rat.Physiol Behav 2003 Aug;79(3):373-81.

Lab test for ovarian cancer

A friend/patient of mine was recently diagnosed with Stage IV ovarian cancer. That, of course, is one of the most difficult aspects of ovarian cancer, namely that it is relatively symptom-free until it reaches an advanced stage.

In retrospect, she identified certain vague abdominal symptoms in the months prior to diagnosis (constipation, bloating, the development of a small 'middle-aged' pouch in the midriff), most notable and puzzling to her through the winter and spring was the increasing agitation of her devoted dog. The dear but scruffy mutt would scarcely leave her side, and no sooner did my friend lie down, but the dog would lay paw or muzzle on her abdomen. Most dramatically, the dog would eye her directly with long and beseeching looks.

An article in the June, 2008 edition of Integrative Cancer Therapies(1) may explain her canine's consternation. Swedish researchers in collaboration with members of the Working Dog Clubs of Sweden and Hungary theorized that dogs could be trained to recognize the characteristic odor of ovarian cancer. They not only found that the scent of an ovarian tumor in a doggy sense is different from that of other gynecological cancers (e.g. cervical or uterine) but that these cancer-screening pooches correctly sniffed out early-stage and borderline tumors as well as big, advanced ones.

The authors wrote: "Our study strongly suggests that the most common ovarian carcinomas are characterized by a single specific odor detectable by trained dogs, and while we do not believe that dogs should be used in clinical practice, because they may be influenced during their work [now what, really, could distract a dog?]... still, under controlled circumstances, they may be used in experiments to further explore this very interesting new property of malignancies."
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(1)Horvath, Gyorgy, et al. Human Ovarian Carcinomas Detected by Specific Odors. Integrative Cancer Therapies Vol 7 Number 2 June, 2008.

It took all my education...

A man came in today worried about a red area on his arm. The spot was about the size of a quarter and had two raised bumps within its circumference. He told me that he'd had two similar areas recently, one on the other arm and one on his back, both now resolved. All of them itched.

And they pay me for this?

Tumor necrosis factor

This sounds like a good thing, right? Produced by cells of the immune system, this protein's name implies that it is a sort of cellular "ace-in-the-hole," inducing death in wayward cells and their mutant offspring before a cancerous tumor is formed.

When first discovered in 1975, tumor necrosis factor (TNF) was noted to induce death in malignant cells in laboratory studies. Unfortunately, it is most complex in its actions, proving toxic to healthy cells and actually promoting the growth of certain kinds of cancer. TNF in the wrong place at the wrong time causes unwanted inflammation. This little troublemaker is a destructive party crasher in the joints of persons with rheumatoid arthritis, It also has destructive, pro-inflammatory effects in Crohn's colitis, smoking-related lung disease, atherosclerosis, Alzheimer's disease, and doubtless much more of that which ails us. It contributes to the profound wasting of AIDS and induces fever and shock in the face of overwhelming bacterial infections.

TNF is a good thing if you happen to do battle with a saber-toothed tiger, accidentally drive a Folsom point into your leg, or fall off your bicycle and scrape your knee. TNF is known as an 'acute phase reactant'; as the body's own EMT, it is one of the first responders at the scene of injury or infection. Produced by activated white cells and the endothelial cells that line blood vessels, TNF attracts bacteria-killing white cells known as neutrophils, promotes the passage of these cells through the blood vessel lining into damaged tissues, alerts the liver to produce pro-inflammatory molecules such as c-reactive protein or CRP, suppresses appetite, and promotes fever.

If TNF and company are activated, however, by cigarette smoke, doughnuts, McDonald's french fries, or too much waisted fat, this same immune response sets off a world of trouble in our arteries. Likewise, auto-immune diseases such as lupus or rheumatoid arthritis cause TNF inflammatory responses in joint spaces and other body tissues.

Body balance or homeostasis depends on equilibrium between troubleshooters such as TNF and peacemakers such TNF inhibitors. Therapies directed against TNF have changed the long-term outlook for patients with rheumatoid arthritis. These new drugs include TNF antibodies such as Remicade and Humira, and proteins that fuse with TNF such as Embrel. Early suppression of the joint-destroying inflammation associated with RA can prevent skeletal deformities and pain, markedly improving a patient's quality of life. Unfortunately, blocking a bad actor such as TNF which also has essential immune functions is not without problems. For one thing, TNF has an active role in the body's response to mycobacterial infections. As a result, cases of active tuberculosis have been reported with the use of anti-TNF agents.

Optimal vitamin D doses

I thought everyone had heard the news about the widespread deficiencies in vitamin D, yet the majority of people whose D levels I check measure way, way low in this essential vitamin. Even those who take a daily multi-vitamin with 400 units of D per tablet (the current RDA) are failing to top 30 ng/ml, the lower end of the desirable range.

Doctors in Beirut studied two groups of adolescents over 16 weeks. Half took 1400 units of D3 per week (the RDA for this age group is 200 units) and the other half took 14000 units per week. By study's end, the high dose group had a significant upward change in their serum D levels, but, better yet, demonstrated "substantial increments in lean mass, bone area, and bone mass."(1)

Many of my patients take 400 units of D3 per day, the amount present in most multi-vitamin pills. Per Toronto's Dr. Reinhold Vieth and colleagues "Supplemental intake of 400 IU vitamin D/d has only a modest effect on blood concentrations of [vitamin D], raising them by 7–12 nmol/L [2.8-4.8 ng/ml], depending on the starting point."(2) So if you're skidding along in a pasty white fashion, no sun plus one multivitamin pill/day, and your vitamin D level is around 11 (like so many of my patients), adding one more 400 unit D tablet per day will only get you up to 15, still terribly deficient.

Experts recommend supplementation in the neighborhood of 2000 units per day. Studies suggest that fracture risk falls with D levels of 30 ng/ml, and the improved outcomes not only result from stronger bones but also from greater muscle strength.
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(1)Maalouf J, et al "Short term and long term safety of weekly high dose vitamin D3 supplementation in school children" J Clin Endocrinol Metab 2008; DOI: 10.1210/jc.2007-2530.

(2)Vieth, R et al. "The urgent need to recommend an intake of vitamin D that is effective" American Journal of Clinical Nutrition, Vol. 85, No. 3, 649-650, March 2007

Dr. Ed Hepworth, Denver, CO

Credit where credit's due. I know that people search for patient reviews of physicians, so here's one from a woman who had complicated sinus surgery with Dr. Ed Hepworth here in Denver:

This guy's incredible. Man, he's good!

Lipotoxicity

Here's the new lipocentric news! What is not news, of course, is how lipocentric we're all getting, our fat or lipid-filled midriffs featured front and center in a pregnant abdomen sort of way. Researchers now, however, are theorizing that the fat load we carry as a result of overeating and undermoving is the primary metabolic driver behind the current epidemic of type 2 diabetes. Dr. Roger Unger of the Touchstone Center for Diabetes Research concludes in a recent JAMA editorial that "If this is in fact the case, [high blood sugar] should be corrected by eliminating the lipid overload."(1)

Want the skinny on fat overload? Check out: Lipotoxicity for the details.
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(1) Unger, RH. Reinventing Type 2 Diabetes. JAMA, March 12, 2008, Vol 299, No 10.