Amazing Vitamin K

The Amazing Vitamin K Story

by JP Saleeby, MD

In very recent years, the medical and scientific communities have begun to focus their attention on the benefits of Vitamin K.  While not as popular as its big brother, Vitamin D, Vitamin K will no doubt come to the attention of mainstream media as soon as its many benefits are realized by the public.   In the last five years, primary care physicians and specialists are testing Vitamin D levels on almost every patient.  As research has poured in on the many health benefits in multiple arenas, from bone health to immune function, Vitamin D therapy is now considered standard of care.  Likewise, Vitamin K is slowly gaining momentum in the public eye and in doctor’s offices. 

Of historical interest, Vitamin K was first discovered as a compound in the 1930's.  It was reported in a German science journal as koagulationvitamin for its control over coagulation, hence the letter designation “K” for koagulation.  Newsworthy in the mid-20^th century, Vitamin K made headlines when the 1943 Nobel Prize in Medicine was shared by American Dr. Edward A. Doisy and German Dr. Henrik Dam for their work with this vitamin.  As early as 1938, the first report of using Vitamin K to treat a life threatening case of hemorrhage due to liver disease was documented.  Its use as a therapeutic saved the patient from certain death.

Vitamin K is a lipophilic vitamin (meaning it is fat soluble) and is required chiefly for blood coagulation and metabolism of bone and other tissues.  There are two natural forms of this vitamin and several synthetic versions.  Vitamin K1, also known as phytomenadione, and Vitamin K2, menaquinone, are the two natural forms.  Vitamin K2 is produced chiefly by bacteria in our large intestines. Vitamin K1 is found in green leafy vegetables such as spinach, turnip greens, Swiss chard, and the brassica vegetables like cabbage, broccoli, Brussels sprouts, and kale.  Fruits like kiwifruit and avocado, as well as soybean oil are other food sources of Vitamin K.

The chief utilization of Vitamin K in medicine as a "therapeutic" is in its role with the coagulation of blood.  It plays a key role in factors II, VII, IX and X as well as in protein-C and protein-S.  All of these blood factors and proteins are linked to the clotting cascade that prevents us from hemorrhaging in the event of a severe traumatic injury.  Additionally, Vitamin K has a significant role in bone metabolism with a relation to osteocalcin.  It acts as a bone building hormone in a way, much like Vitamin D.    Osteocalcin is synthesized by Vitamin K and is the "matrix" in bone that holds the calcium molecules together.  Without Vitamin K, hip bone fracture rates increase despite adequate Vitamin D and calcium intake.  In the 1998 Nurse’s Health Study, oral administrations of 110 micrograms per day of Vitamin K proved to decrease hip fractures when compared to control subjects. 

Vitamin K is important in vascular biology as well, especially in the realm of artery plaque formation (calcification).  There are Vitamin K dependent proteins involved in atherosclerosis or hardening of the arteries.   The process of calcium plaque formation is hindered with adequate Vitamin K levels in circulation.  Warfarin (Coumadin ®) is a drug often used to treat folks with coronary artery disease (CAD) and to prevent blood from clotting in heart chambers and deep veins where severe compilations may arise.  However, while treating certain medical conditions with these blood thinners, which inactivate Vitamin K, we create other problems.  Chief among these problems are an increase in our risk for developing arterial plaques, the possibility of affecting our immune system, and the likely impediment of bone mineralization.

Vitamin K's effect on coronary arteries goes like this.  With low levels of circulating Vitamin K in the serum, there is an impact on the function of a protein within the endothelial lining of the arteries called the Matrix Gla protein (MGP).  The effect of low Vitamin K on this protein is that it allows for an increase deposition of calcium in arteries.  Drugs that lower Vitamin K's effect in a sense raise the risk for coronary artery disease.  Vitamin K facilitates our immune system with positive links to phagocytosis and chemotaxis (the process by which “microorganism attacking cells" in our body find and eliminate infectious organisms).  Furthermore, Vitamin K appears to have a role in apoptosis, the process of natural and desirable cell death.  Apoptosis is the process by which our bodies can eliminate damaged, old or mutated cells thus reducing many forms of cancers.

Because Vitamin K2 is produced by bacteria in the human alimentary tract, the overuse of broad-spectrum antibiotics can wipe out this good type of bacteria in our intestines and may cause a relative deficiency.  Poor nutrition with inadequate consumption of greens and fruit is another way to attain deficiency.  Both means of deficiency can lead to clotting dysfunction, immune disruption, bone loss, and coronary disease.  With a look at the latest research, it appears that Vitamin K2 is longer acting, has better bioavailability, and provides better bone strength when compared to Vitamin K1 supplementation.  A subset of Vitamin K2 known as menaquinone–7, or MK–7 shows promise in current research as even a more potent form of Vitamin K.  In the future, we may learn the better Vitamin K supplement to take is in fact MK-7.

There is no known upper limit or toxic level of the natural Vitamin K1 & K2, however, scientists show toxicity with the synthetic forms and that they should be avoided as a source of supplementation.  This fact was demonstrated in a recent ban on synthetic Vitamin K3 due to the occurrence of hemolytic anemia and cytotoxicity.  This is yet another example of how natural compounds often trump synthetics in nutritional medicine.  It appears Mother Nature can rarely be outperformed in the lab.

How to get the most Vitamin K out of your veggies?  Well, cooking them in water will yield less concentration due to the hydrophobic properties of this vitamin.  You will probably throw out much of the Vitamin K in your vegetables when you pour off the cooking water.  Cooking them in oil (sautéing in olive oil, for example) will retain the bioavailability of this vitamin three-fold.  Eating meat, eggs, and dairy is another source of providing Vitamin K2 in addition to that produced by E. coli in our gut.  But it is with a healthy gut microflora that we acquire most of our Vitamin K2.

Deficiencies can occur with Inflammatory Bowel Syndrome (IBS), cystic fibrosis, alcoholism, liver disease, in bulimics, and those taking chronic anticoagulants, antibiotic therapy, and salicylates.  Bleeding and bruising disorders are signs of deficiency; osteoporosis and coronary artery disease (CAD) are also associated, but realized over the course of many years.  Unlike many other vitamins, Vitamin K is recycled in our bodies, thus reducing the threat of deficiency, provided both enzymes responsible for this process in our bodies are working well.  Warfarin (Coumadin ®) blocks Vitamin K epoxide reductase (VKOR), one of the two enzymes responsible for Vitamin K recycling and maintaining healthy levels.  Interesting to note, long term use of aspirin (ASA) and cephalosporins (an antibiotic class) can lead to K1 deficiencies by interference with enzyme function.  Furthermore, the drugs cholestyramine, cholestipol, orlistat, and the fat substitute, olestra, have been noted to decrease Vitamin K absorption, in all probability leading to a drop in serum Vitamin K levels that can affect health. 

Because newborns are susceptible to clotting abnormalities, due to immature livers and sterile guts (inability to have E. coli produce Vitamin K2), they are usually born deficient in varying degrees.  There is a 1.5% incidence of unexpected bleeding in newborns due to low levels of Vitamin K.  Mothers on anticonvulsants, rifampin and isoniazid (both antibiotics) while pregnant tend to have offspring with sterile guts and an even higher incidence of Vitamin K deficiency.  Therefore, the American Academy of Pediatrics recommends about 1.0 milligram of Vitamin K1 be administered to each newborn. 

There is a connection in theory with Alzheimer’s disease.  The APOE4 gene that has been implicated in Alzheimer's disease seems to be responsible for low Vitamin K levels in this subset of patients.  It is surmised that supplementation with Vitamin K may reduce the occurrence of Alzheimer's disease, but more research is needed.  There also appears to be a connection with some types of cancers.  Interestingly, there are two Japanese studies showing females with liver disease with a high risk for liver cancer, having a 90% reduction in development of liver malignancy if they were supplemented with Vitamin K.  In a 2008 published German study of male subjects, there was a drop in prostate cancer risk with Vitamin K supplementation.

Vitamin K must be rather important to our body as there are at least three ways in which it is maintained; by diet (eating greens), by production in our gut (bacterial), and by enzymatic recycling.  Sometimes the importance of a particular substance can be found in the redundancies our body creates to conserve it, such is the case with Vitamin K.

Pearls from Dr. Saleeby:

• Vitamin D dependent osteoblasts effect production of osteocalcin, a Vitamin K dependent protein, leading to good bone health, as long as both vitamins are in adequate and balanced supply.
• Growth arrest specific gene 6 protein (Gas6) a Vitamin K dependent protein is responsible for cellular growth regulation factor found in nerve tissue, heart, lung, kidney and cartilage.
• Good idea to supplement with between 10 - 120 mcg/d of Vitamin K2 (providing Coumadin users are monitored closely under physician supervision).
• Large Vitamin A doses have been noted to affect absorption of Vitamin K, while large doses of Vitamin E can affect and antagonize Vitamin K enzymatic activity.  We see a rise in bleeding risk with large doses of Vitamin E intake.  There is a balance between the fat soluble vitamins that needs to be adhered to.  It is unwise to guess and gamble with what you take and supplement.

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JP Saleeby, MD is an integrative and nutritional medicine practitioner.  He has been the chief formulator for a number of independent nutraceutical companies.  He is a medical writer / blogger and offers telemedicine consultations to his patients.

(c) 2011

References:

Berkner, K. L. and Runge, K. W. (2004), “The physiology of vitamin K nutriture and vitamin K-dependent protein function in atherosclerosis”. Journal of Thrombosis and Haemostasis, 2: 2118–2132.

Neil C Binkley, Diane C Krueger, Tisha N Kawahara, Jean A Engelke, Richard J Chappell and John W Suttie. (2002) "A high phylloquinone intake is required to achieve maximal osteocalcin {gamma}-carboxylation". American Journal of Clinical Nutrition 76 (5).

Higdon (2008). "Vitamin K". Linus Pauling Institute, Oregon State University. http://lpi.oregonstate.edu/infocenter/vitamins/vitaminK/. Retrieved 01-10-2011.

Warner, E.D.; Brinkhous, K. M.; Smith, H. P. (1938). Proceedings of the Society of Experimental Biology and Medicine 37: 628.

Stafford, D.W. (2005), “The vitamin K cycle.”. Journal of Thrombosis and Haemostasis, 3: 1873–1878.

Saxena S.P.; Israels, E.D.; Israels L.G. (2001). "Novel vitamin K-dependent pathways regulating cell survival.". Apoptosis 6 (1-2): 57–68.

Nimptsch K, Rohrmann S, Linseisen J (2008). "Dietary intake of vitamin K and risk of prostate cancer in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition. (EPIC-Heidelberg)". Am. J. Clin. Nutr. 87 (4): 985–92.

Brown, S.E., "Key vitamins for bone health — vitamins K1 and K2". www.womentowomen.com. http://www.womentowomen.com/bonehealth/keynutrients-vitamink.aspx. Retrieved Jan., 10 2011.

Nimptsch K, Rohrmann S, Linseisen J (2008). "Dietary intake of vitamin K and risk of prostate cancer in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition. (EPIC-Heidelberg)". Am. J. Clin. Nutr. 87 (4): 985–92.

Allison (2001). "The possible role of vitamin K deficiency in the pathogenesis of Alzheimer's disease and in augmenting brain damage associated with cardiovascular disease.". Medical hypotheses  57 (2): 151–5.

Habu, D., (2004) "Role of Vitamin K₂ in the Development of Hepatocellular Carcinoma in Women With Viral Cirrhosis of the Liver.". JAMA, 292 (3): 358-361.

Bellido-Martin, L. (2008) "Vitamin K-dependent actions of Gas6.". Vitam. Horm. 78:185-209.

Hendler S.S., Rorvik D.R., eds. (2001) “PDR for Nutritional Supplements.”. Montvale: Medical Economics Company.

Shakeology Lecture by Dr. Saleeby

https://docs.google.com/present/edit?id=0Af1JpAZlkE5rZGQ0a3pyOHdfMTg0ZnQ4amJrY3g&hl=en

Click on this for a PowerPoint Lecture on Shakeology (given 3/2009)

New Online Laboratory launch

AtroGene is soon to launch an online Direct Access Testing (DAT) web site for lab testing.  Keep your eye out for www.eStatLabs.com as it will be up and running in a month.

Osteoporosis Lecture by Dr. Saleeby

Happy New Year - Important new info from Dr. Saleeby

HAPPY NEW YEAR!

My main practice web site has changed... have a look at the new pages of http://www.carolinamobilemd.com/  The practice name and location has changed.  New space is shared in a finer, more upscale property downtown Conway.  The name AtroGene will represent the practice as it moves more into the 21st Century reliance on the Internet & Tele-medicine.  Will also be offering best-in-the-industry Online Labs at great cost savings to the consumer.  Access to my active patients to the full line of Xymogen nutraceuticals will be offered to my patients, via the web (http://www.xymogen.com/) email me for more information.

Today I want to feature a very well written article by Dr. Klein on the relationship between Diabetes and select supplements to deminish the coronary artery disease properties.

JP Saleeby, MD
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Diabetes and Atherosclerotic Vascular Disease- Nutraceutical Intervention Update


David S. Klein, MD, FACA, FACPM

Alpha Lipoic Acid: The incidence of type 2 diabetes mellitus (DM) in the U.S.
is already high, and the rate is climbing rapidly. Medical complications seen in
DM patients include coronary heart disease, peripheral vascular disease,
nephropathy, neuropathy and retinopathy. While control of blood sugar levels is
of paramount importance, attention to the sequelae may reduce morbidity and help
reduce healthcare costs.

Pivotal in the development of diabetic complications is dysfunction of vascular
endothelia. Inflammation of the inner lining of the blood vessels results in
platelet aggregation and deposition of cholesterol resulting in atherosclerotic
plaque development. The formation of atherosclerotic plaque is results directly
from endothelial inflammation, often monitored by serum CRP levels.


Recently, it was observed that intravenous alpha lipoic acid (ALA), was found to
be beneficial in patients with DM who suffer from endothelial dysfunction.(1)
Forearm blood flow was measured before and after 21 days of either IV treatment
of 600mg ALA or placebo. Intravenous ALA treatment improves endothelium-dependent
vasodilatation. The investigators also observed that LDL-cholesterol was
reduced in the ALA treatment group.

It was postulated that ALA might improve endothelial function through inhibition
of NF-kappa B and metalloproteinase-9 and upregulation of intracellular adhesion
molecule-1 (ICAM-1).

Alpha Lipoic Acid may also be useful in the treatment of obesity, which is
itself a risk factor for the development of DM. At this time, 34 percent of
adults aged 20 and older are obese; 34 percent are ‘overweight.’
In a recent study, ALA was studied for weight loss in ‘pre-obese’ and obese
adults. Findings of a recent study observing 1,127 men and women between the
ages of 18 and 60 years, observations after measuring the BMI of all
participants, 53 percent were found to be obese and 43 percent were pre-obese.
Study participants were given ALA for 4 months at a dosage of 800mg per day.


The participants experienced After supplementation, investigators found that
participants experienced an 8-9 percent reduction in body weight, a reduction in
BMI by 2-4 points, and a reduction in waist size by 2.5-4 inches.(3)


Resveratrol: Resveratrol is a naturally occurring polyphenol found in the
skin of red grapes and is found in red wine. Thought to offer a range of
beneficial medical effects, Resveratrol is being studied for anti-cancer effects
and for cardiovascular benefits.


Recently, Resveratrol was studied (2) in patients given Resveratrol 40 mg, or
placebo, for six weeks. In the Resveratrol group, there was a significant
reduction in the generation of reactive oxygen species, binding of NF-κB (a
major regulatory component of pro-inflammatory cytokine production), and
expression of JNK-1 and Iκκβ (pro-inflammatory molecules). Study participants in
the Resveratrol group had decreased levels of CRP, TNF-alpha and IL-6 (two major
pro-inflammatory cytokines that are regulated by NF-κB.

According to the authors: “The extract induced a significant reduction in
reactive oxygen species generation, the expression of p47(phox), intranuclear
nuclear factor-kappaB binding, and the expression of jun-N-terminal kinase-1,
inhibitor of kappaB-kinase-beta, phosphotyrosine phosphatase-1B, and suppressor
of cytokine signaling-3 in mononuclear cells when compared with the baseline and
the placebo. PCE intake also suppressed plasma concentrations of TNF-alpha,
IL-6, and C-reactive protein.”

Whey Protein: In a recent study, (4) the effects of supplemental dietary whey
protein was observed in relation to body composition, lipids, insulin and
glucose in comparison to casein and glucose (control) supplementation. In this
12 week study, subjects were randomized to receive whey protein, casein or
glucose supplementation. Seventy men and women, mean ages of 48.4 (SEM 0.86)
years and a mean BMI of 31.3 (SEM 0.8) kg/m2 completed the study. Subjects
supplemented with whey protein had no significant change in body composition or
serum glucose at 12 weeks compared with the control or casein group. Fasting
glucose levels were significantly lowered in the whey group, as compared with
the control group at 6 weeks, and there was a significant decrease in total
cholesterol and LDL cholesterol at week 12 in the whey group as compared with
the casein receiving cadre. Fasting insulin levels were also significantly
decreased in the whey group compared with the control group. Demonstrating that
supplementation with whey proteins improves fasting lipids and insulin levels in
overweight and obese individuals.


Recommendation: Increasing scientific data support the use of Alpha Lipoic Acid
and Resveratrol in the treatment of patients with type II Diabetes. Available
at reasonable cost, these two nutraceuticals are useful in the treatment of a
variety of other conditions, as well, and afford the practitioner an additional
modality to offer patients.
These two nutraceuticals are widely available, but should be used in conjunction
with appropriate diet modification.

References:
1. Heinisch BB, Francesconi M, Mittermayer F, et al: Alpha-lipoic acid improves
vascular endothelial function in patients with type 2 diabetes: a
placebo-controlled randomized trial. Eur J Clin Invest 2010 Feb:40(2):148-54.
2. Ghanim H, Sia CL, Abuayseh S, et al: An antiinflammatory and reactive oxygen
species suppressive effects of an extract of Polygonum cuspidatum containing
Resveratrol. J Clin Endocrinol Metab 2010 Sept;95(9):E1-8. .
3. Carbonelli MG, Di Renzo L, Bigioni M, et al: Alpha-lipoic acid
supplementation: a tool for obesity therapy? Curr Pharm Des. 2010;16(7):840-4.
Pals S, Ellis V & Dhaliwal S: Effects of whey protein isolate on body
composition, lipids, insulin and glucose in overweight and obese individuals. Br
J Nutr. 2010 Sept; 104(5):716-23.


David S. Klein, MD has practiced pain medicine for the past 27 years and is the author of over 50 published articles and textbook chapters.  His writings have appeared in this blog previously.

Lecture on Osteoporosis

Dr. Saleeby to give Free Lecture at Pure Compounding Pharmacy on Osteoporosis.  For more information please call the pharmacy and secure a seat for this lecture. 

Date:  Jan. 6th, 2011 (First Thursday of the Month Free Lecture Series)
Time:  6:15 PM

Location:
Pure Compounding Pharmacy
3072 Dick Pond Road
Myrtle Beach, SC 29588
(843) 293-7979

Stem Cell Transplant Cures HIV In 'Berlin Patient'

The Huffington Post   |  Carly Schwartz First Posted: 12-14-10 01:04 PM   |   Updated: 12-16-10 12:25 

On the heels of World AIDS Day comes a stunning medical breakthrough: Doctors believe an HIV-positive man who underwent a stem cell transplant has been cured as a result of the procedure.
Timothy Ray Brown, also known as the "Berlin Patient," received the transplant in 2007 as part of a lengthy treatment course for leukemia. His doctors recently published a report in the journal Blood affirming that the results of extensive testing "strongly suggest that cure of HIV infection has been achieved."
Brown's case paves a path for constructing a permanent cure for HIV through genetically-engineered stem cells.
Last week, Time named another AIDS-related discovery to its list of the Top 10 Medical Breakthroughs of 2010. Recent studies show that healthy individuals who take antiretrovirals, medicine commonly prescribed for treating HIV, can reduce their risk of contracting the disease by up to 73 percent.
While these developments by no means prove a cure for the virus has been found, they can certainly provide hope for the more than 33 million people living with HIV worldwide. Alongside such findings, global efforts to combat the epidemic have accelerated as of late, with new initiatives emerging in the Philippines and South Africa this week.

Wiki-Medicine

Sep 26 2008  Wiki-Medicine. Scary.


Please convince me that I shouldn’t be bothered by this. The other day I was at the hospital paying a visit to a friend. As usual this trip to the hospital - like every other - involved a significant amount of waiting and doing nothing. I killed the time by doing some people watching, specifically doctor watching.

One doctor in particular did something that caught my attention.
Leaving a patient in their room the sat down at the computer and started typing away. However as I looked closer I noticed that this dcotor was looking something up [pause for dramatic effect] on Wikipedia. Now for those of you who don’t know, Wikipedia is an on-line encyclopedia of just about anything, from the truly important to the totally random. What makes Wikipedia unique is that the content is user-created. That is, any dude sitting in his mom’s basement can jump on and help write the definition regardless of whether or not they have an idea of what they’re talking about. And while these same people can help ensure the accuracy of the content it is nonetheless the equivalent of selling dictionaries with an eraser and pen attached.

Now, please understand. I like Wikipedia. I use Wikipedia. But I don’t wholeheartedly trust Wikipedia. And I don’t think I want my doctor coming to a diagnoses with the help of Wikipedia. Aren’t there large, dusty books that they are supposed to be pulling off shelves or top-secret doctor only web-sites that they are supposed to be accessing when they leave the examination room? Is a 100K education supposed to hinge on what one can “google?”
Granted, I’m making an assumption that this doctor was doing something associated with a patient when she surfed to, read through, and wrote down several things in her chart from the site. But it sure looked like it.
I just don’t what the day that a doctor looks up my illness to be the very same day that some over-zealous pharmacy rep listed their experimental drug (that just so happens to lower your sperm count and make your hair fall out) as the “proven” cure all. But hey, maybe I’m making a big deal out of nothing. I tend to do that. Besides my doctor is awesome.
6 Responses to “Wiki-Medicine. Scary.”

1.Chrissy Says:
September 27th, 2008 at 2:16 pm

Geez…someone needs to tell that Doc about WebMD! That I trust!



2.Carrie LaMay Burgan Says:


September 28th, 2008 at 1:10 pm

I admit to using Wikipedia to identify muscle groups when I’m studying anatomy, but I’m but a lowly massage therapy student. General Wiki research is fine, but I would be scared, too. Is the doc to cheap to subscribe to the online reference DBs for docs? They exist in spades. Or yeah, use WebMD? Sadly, Google, Dictionary.com and Wikipedia are the top three free web “research” vehicles out there. When I was pursuing my Master’s in Library Science, we were inundated with information about students using these (non-reliable) sources as all primary sources in their undergrad-to-DOCTORATE papers. *slaps forehead* Heaven forbid someone actually pick up a dusty “Journal of the American Medical Association” (”JAMA”) and look something up.


3.Jen Says:
October 8th, 2008 at 9:19 am

Wow, that is really scarey. I am constantly telling people the truth about that website. Hopefully whoever wrote the page she looked at was another doctor.



4.Sarah Says:
January 8th, 2009 at 9:57 pm

Wikipedia is said to be more accurate in a lot more subjects than the Encyclopedia Brittanica.
I find that much more terrifying than any point you made.
5.dr who dolls Says: (spam content)

6.JP Saleeby, MD Says:
December 18th, 2010 at 7:33 pm

Well in this era of evidenced based medicine, it is really much different subscribing to an opinion, fact or fiction on wikipedia versus our established peer-reviewed journals? How confusing is it when in JAMA one month’s article in support of a new treatment is to be summarily rejected by another article the following month in NEJM?

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http://www.poporthodoxy.com/2008/09/26/wiki-medicine-scary/#comment-597

Lower-income families in high-deductible plans more likely to forgo care

Dec 10, 2010 Medical Economics

Lower-income families in high-deductible health plans are more likely to delay or forgo care due to cost than higher-income families who have similar coverage, according to researchers from the Robert Wood Johnson Foundation Clinical Scholars program, Philadelphia Veterans Affairs Medical Center, and the University of Pennsylvania, Philadelphia.

Families who enrolled in these plans initially had higher incomes, but lower-income families are now equally likely to be enrolled in high-deductible plans. Overall, lower-income families were more likely to report that they had delayed or foregone care because of the cost, including care for an adult, care for a child, and operations or procedures.

In addition, lower-income families said they did not find their health plans difficult to understand, nor did they believe their families were not well protected from out-of-pocket healthcare costs. Regardless of income, most participants reported that they would talk with their clinicians about delaying or making different plans in 3 hypothetical situations: a $100 blood test during a check-up, a $1,000 colonoscopy, and a $2,000 magnetic resonance imaging scan for back pain.

The findings suggest that physicians play a central role in helping patients with decision-making in high-deductible health plans.

Antibiotic Stewardship

Antibiotic Stewardship 

by JP Saleeby, MD

http://cme.medscape.com/viewarticle/731689 John G. Bartlett, MD

To open up, I want to make it perfectly clear the intentions of this article by stating a few facts.  These are facts back up by loads of peer-reviewed publications.  These facts are likewise rational and logical.

• Fact:  Antibiotics save lives.
• Fact:  Antibiotics reduce morbidity and mortality in severe and life threatening infections.
• Fact:  Antibiotics have in the past 20-years been over-prescribed.
• Fact:  Antibiotics are necessary in the practice of good medicine and new guidelines need to be followed in light of present day resistance.

It is both intuitive and evidence based that appropriate use of antibiotics in modern medicine have saved thousands of lives.  Prior to the discovery of the antibiotics (antimicrobials) infection was a leading cause of death in humans.  Today, many life threatening illnesses such as pneumonia, sepsis, flesh-eating bacterial infections (necrotizing fasciitis), or meningitis are so dangerous, that delay in antibiotic therapy can cost a life.

For those pseudo-healthcare practitioners that are blinded by sheer bias and hatred toward contemporary western medicine (and suffer brain squeeze because their craniums are so far up their rectums), spouting the foolish notions that "you don't need antibiotics" or "antibiotics are never good for you", be warned.  Those reading this article that are experiencing a grave illness due to a microbe should be aware that those advocating the cockamamie notion that all things antibiotic are evil, should run as fast and far away from those practitioners.  Furthermore, they can and should be held culpable for the death of a patient should they intentionally delay people from getting life saving antibiotic therapy.  Intuitive practitioners, some chiropractors and those who favor wave eagle feathers and crystals over folks in an attempt to cure a complex septic patient should put their unsubstantiated opinions and bias' aside and refer their patients to a medical doctor for definitive care.  No need to stain you hands with blood over an idiotic notion unfounded by any empirical evidence.  Enough ranting about unfounded prejudice against antibiotics amongst healers.

While there is no question about the helpfulness of antibiotics, it is also true that since their inception they have been abuse and over prescribed.  Now we realize the ills of haphazard and unbridled use as we see resistant organisms appear more often and on the rise.

According to Dr. J. G Bartlett in a Medscape CME published in November of 2010 entitled "Addressing the Rising Tide of Antimicrobial Resistance" he spells out the rise of the top six microbes that are defying our current regiment of antibiotic therapy.  They are Enterobacter, Staph. aureus, Klebsiella, Acinetobacter, Pseudomonas aeruginosa and Enterococcus.  In the US methicillin-resistant Staphylococcus aureus (MRSA) is on the rise with some 94,360 cases a year and 18,650 deaths annually reported by Kelevens et. al., in JAMA in 2007.  Those are some fierce numbers for a bacterium that only 10 years ago was only seen in hospital ICUs and nursing homes.  Now greater than 60% of cultures of abscesses in my local region culture positive for MRSA.  The whole penicillin class of drugs (Amoxil, Keflex, etc.) is useless against MRSA.  Clostridium difficile infections are another example with diagnosed cases on the rise and antibiotic resistance mounting as well.  Death by C. difficile infection has taken an exponentially rise since 1999.

Furthering the crisis of antimicrobial resistance and of great concern is that in the last ten-years the development of new antibiotics and antibiotic classes has all but dried up.  A 2004 report by the Infectious Disease Society of America (IDSA) stated that there is“antibiotic discovery stagnation” were we are witnessing bad bugs with no new drugs to fight them.  An example of how slow we are to develop new antimicrobials is seen in a study published in 2009 in the Clinical Infectious Disease journal by Dr. H.W. Boucher reporting that between 1983 and 1887 sixteen new antibiotics were developed.  From 1993 - 97 ten antibiotics were developed and this dropped to only five from 2003 - 07 and from 2008 projected until 2012 only one new antibiotic coming to market.  From the 1930's through the 1970's there were eleven new classes of antimicrobials developed by pharmaceutical companies, with only four classes in the 1950, and during the 2000's only two new classes were developed.  The 1980s and 1990's saw a dry spell, with no new antibiotic-class development. These are scary numbers considering the rapid rise in microbial resistant organisms just in the past decade.

http://cme.medscape.com/viewarticle/731689 John G. Bartlett, MD

So while antibiotic use is necessary and critical in the very ill, judicious use is necessary to save our "big guns" for those really bad infections.  Most pharangitis infections are viral and despite this fact many GPs would prescribe antibiotics just to appease an anxious patient, and not treat the real root cause.  This practice has to stop.  No one will argue about utilizing a broad spectrum aggressive antibiotic regiment in a septic patient, but we need to look at the evidence of stopping drugs when cultures are negative and using effective shorter courses.  Evidence is mounting that a three day course of antibiotics for community acquired pneumonia (CAP) is as effective as a seven- or ten-day course.  On the other side of the continuum, those that don't advocate the use of antibiotics at all will harm the really sick.  We must reach a happy medium.

JP Saleeby, MD is an emergency room physician who practices integrative medicine in solo practice.  His weltanschauung is practical, pragmatic and not at all crunch or granola.  For more information visit www.saleeby.net

© 2010

Dr. Saleeby's new practice Ribbon Cutting

Dr. Saleeby and Sharon are pictured with Dr. Melody Iles and Conway Chamber of Commerce members for the official Ribbon Cutting and Open House for the new practice located at 927 Fourth Ave., Conway, SC.  The practice SCWellness (aka Carolina Wellness & Medical Associates) is an integrative and holistic center offering traditional western medical and well as complementary and alternative medical treatments.  Dr. Iles is a naturopath with a masters in western herbology.  Dr. Saleeby has background in emergency medicine, occupational medicine and subscribes to a holistic approach.  A focus on prevention, wellness and balanced hormones he is now accepting new patients.

SC Wellness Open House and Ribbon Cutting Nov 17th 2010

http://southcarolinawellness.blogspot.com/2010/11/sc-wellness-open-house-and-ribbon.html

CDC's Recommendations for Flu Vaccine

What’s New for the 2010-2011 Influenza Vaccine

FDA Patient Safety News: Show #104, November 2010

With the influenza season upon us, the CDC is recommending that everyone aged 6 months and older get vaccinated to protect themselves and others. During the last influenza season, people needed one vaccine to protect against seasonal influenza, and another one for the 2009 H1N1 influenza. But this season's vaccine contains the 2009 H1N1 strain, along with two other strains that are predicted to cause influenza, so there is no need to get two different vaccines. As in earlier years, both inactivated and live attenuated vaccines are available.


There is now a vaccine that is specifically indicated for people 65 and older, called Fluzone High-Dose. People in this age group have the highest risk for seasonal influenza complications because people's immune systems weaken as they grow older. The new vaccine contains a higher dose of influenza virus hemagglutinin, which is intended to induce a stronger immune response and better protect the elderly against seasonal influenza.

People who are hypersensitive to egg proteins or who have had life-threatening reactions after previous influenza vaccinations should not receive the vaccine.


Additional Information:

FDA Center for Biologics Evaluation and Research. Influenza Virus Vaccine for the 2010-2011 Season. Updated September 17, 2010.

http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm094045.htm


FDA Press Release: FDA Approves A High Dose Seasonal Influenza Vaccine Specifically Intended for People Ages 65 and Older. December 23, 2009.

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2009/ucm195483.htm

CDC MMWR. Prevention and Control of Influenza with Vaccines

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr59e0729a1.htm



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FDA Patient Safety News is available at www.fda.gov/psn

Brain Support

You know it's time to see Dr. Saleeby for some Brain Support when you start doing things like this.

Just in time for the Flu Season

Be Prepared for the upcoming Flu Season

By JP Saleeby, MD

As the Flu season approaches, we need to be prepared. The Flu, which is different from the common cold, inflicts significant morbidity and even mortality and should be taken seriously. The Flu is caused by the Influenza virus of which there are three types (A, B & C). Type A is the most common and it is the subtypes of A and B that cause the seasonal outbreaks. The constant mutations of these viruses make it necessary to vaccinate annually. Everyone is affected, from the very young to the older adult. Most outbreaks or epidemics occur in late fall and early winter. It has been reported that as many as 20,000 deaths and over 100,000 hospitalizations occur each year in the USA due to the flu. Those deaths are highest in the elderly (over 65), folks with diabetes, HIV, nursing home residents, pregnant women and those with chronic diseases of the lung, heart and kidneys.

A person is contagious for up to 5 days after onset with symptoms that include high fever, aches in joints, muscles and around the eyes, weakness, headache, dry cough, sore throat and watery discharge from nose and eyes. Annually, there are many that miss considerable time from work in the winter months due to infection with this virus.

You acquire the flu virus through contact with contaminated aerosols or droplets found on surfaces such as doorknobs and telephones. So prevention is crucial. Of course maintaining a health lifestyle (not smoking, eating right, plenty of exercise) is important as is taking care not to come in contact with potential contaminants (good hand washing, not sharing cups with others, etc.) And vaccinations are of critical importance especially to those high-risk individuals. They may even be lifesaving.

The flu vaccine (shot) is unique each year, being made up of inactivated A & B viruses. It is injected into the upper arm and should be taken in early fall (from October to mid-November) because it takes two weeks to confer immunity. But once protected (it is considered 70 – 90% effective), it can protect you from the symptoms of the flu, lost work, hospitalization and even death. Who should get the flu shot? Anyone over 50, those with chronic diseases, those with HIV/AIDS, women over 14 weeks pregnant, residents of nursing homes, health care workers, bank tellers, waitresses, students especially those living in dormitories, and those people interested in reducing risk for the flu. Side effects to the shot are rare but include soreness and mild muscle aches or low-grade fever for only a couple of days. These untoward effects are most often noticed in children. Life threatening allergic reaction and something called Guillain-Barre syndrome are extremely rare reactions to the vaccine. But those allergic to eggs should probably avoid the shot.

Myths about the flu shot such as getting the flu from it are unfounded. Since it contains the killed form of the virus, it is impossible to actually acquire the syndrome. Another myth is that one shot in you life will do, but since the virus mutates from season to season, revaccination with new strains must occur each season.

What happens should you get the flu? Well, there are standard medications that should be started within 24 hours of symptoms such as Amantadine, Rimantadine (Flumadine), Zanamivir (Relenza) and Oseltamivir (Tamiflu). The prescription usually lasts 5 to 7 days and it may cut short the course of infection and prevent serious complications such as pneumonia. Decongestants such as phenylephrin and pseudoephedrin are helpful with symptoms. Antibiotics are not indicated unless there is a secondary bacterial infection. Antibiotics are useless against the flu virus.

Nutritional medicine offers high doses of vitamin C, and Zinc. Herbal remedies include Echinacea (E. purpurea root extract) and Goldenseal (H. candadesis root extract). Other immune boosting compounds are extract of maitake and reishi mushrooms, garlic and transfer factor (an extract of colostrum). A very powerful tool in the early treatment of the flu is something called the Myers’ Cocktail. This is a rapid intravenous infusion of high dose vitamins and minerals given over 10 minutes. It has proven effects in reduction of symptoms, viral spread and getting you back on your feet quickly after being infected. Myers’ cocktails must be administered in the doctor’s office and depending on how severe the illness, one to three treatments during a course may be indicated. If caught early, a Myers’ Cocktail may be the most effective remedy in the treatment of the flu. The Myers’ Cocktail is also useful in many other maladies, but for acute respiratory and viral infections, it stands heads above other treatments.

Another more detailed Article on the Flu by Dr. Saleeby:  http://southcarolinawellness.blogspot.com/2010/10/just-in-time-for-flu-season.html

The Vitamin D Story

Vitamin D

by JP Saleeby, MD

**To be published in an upcoming issue of American Fitness magazine

In the past half-decade, the importance of Vitamin D in western medicine has reached a new found echelon.  Interest in this vitamin’s effects, not only on bone health, but on immune function and the neurological system have caused the assessment of serum levels to become a standard practice during annual physical exams.  It is now routine to have your Vitamin D (25-OH-Vitamin D) level checked by your primary care physician.  The interest is in part due to the large body of evidence in the last ten years showing that this once esoteric fat-soluble vitamin is in fact an important player in wellness.

Vitamin D is a group of fat soluble secosteroids of which there are five known forms.  A secosteroid is a molecule that is similar in structure to a steroid, except two of its four B-ring carbon atoms are open.  Cholesterol is a common example of a steroid molecule and happens to be the substrate of which Vitamin D is made.  Vitamin D1 through D5 are the designations of the known forms of Vitamin D, as they were the 4th group of "vitamins" discovered and named; hence the fourth letter in alphabet designation.  I need to point out that while not exactly a vitamin in the strictest sense, since humans do produce them endogenously and by definition a vitamin is a substance necessary for survival of an organism that is required to be consumed or ingested, it is still worthy of the categorization.  Nevertheless, Vitamin D is a constituent nutrient where deficiencies are known to lead to illness and disease and supplementation is known to reduce illness, extend and enhance quality of life.

Of the five secosteroids in the class, only two, Vitamin D2 and Vitamin D3 have physiologic properties and are important to human (and other organisms) health.  The D2 form is also referred to as ergocalciferol and is produced by plants, fungi and invertebrates.  Like all forms of Vitamin D, it is produced as a result of irradiation of those life forms by ultraviolet-B wavelength (UV-B) radiation from the sun.  Vitamin D3, also known as cholecalciferol, is produced by our bodies in the inner most layers of our epidermis (skin) again by direct contact with UV-B radiation.  Vertebrates are the only know producers of Vitamin D3.  The two skin layers, stratum granulosum and spinosum, contains the substrate 7-dehydrocholesterol and when irradiated by sunlight wavelengths between 270-300nm, an enzymatic conversion occurs changing it to the pre-active form of Vitamin D3.  Sunscreen and even glass will block the sun’s UV wavelength’s ability to make vitamin D naturally. Even the pigmentation of our skin plays a factor.  It should be noted that this may be the reason African-American men have a significantly higher risk for prostate cancer than do Caucasian men.  Fair skinned people produce more of this vitamin than those of darker complexions containing more melanin.  The angle and time under the sun is also a determinant; equatorial inhabitants fare better with vitamin D production than do those living in higher latitudes. 

In man, the newly produced pre-Vitamin D goes through some additional changes in the liver to produce calcidol and from there further metabolism to the bioactive calcitriol by the kidneys and immune system’s monocytes-macrophages.  Calcitriol is responsible for maintaining balanced concentrations of calcium and phosphorus in our serum as well as healthy growth and remodeling of bone.  On the immune side, calcitriol converted by the macrophage system acts as a cytokine (think chemical immune-messenger) to help modulate immune function against microbes like bacteria and viruses.  Having renal (kidney) disease or liver damage can greatly impair circulating vitamin D as conversion of the pro-Vitamin D to its active forms is limited.

Experiments show that Vitamin D2 absorbs UV-B radiation in fungi, plants and invertebrates and acts as a natural sunscreen against the damage sun’s rays can cause on DNA and cells.  While more easily available and less expensive to produce, Vitamin D2 is not as bioactive in humans as is D3.  Much of what has been used to fortify cow’s milk and other food products, however, has been Vitamin D2 prior to 2006.  As our knowledge of Vitamin D grows and with the current research trends, the food and supplement industry is pushing to utilize better preparations for supplements and fortifying foods.  Preparations utilizing the Vitamin D3 are becoming more common, as the use of D2 is falling by the wayside.

Common maladies from a deficiency in Vitamin D are Rickets, osteomalacia, and osteoporosis.  The recommended daily allowance (RDA) of Vitamin D will keep you out to trouble with Rickets, but supplementing with higher doses of Vitamin D3 has added health and wellness benefits.  Vitamin D3 has been shown to reduce inflammation, influence genes that regulate proliferation, differentiation and apoptosis in cells, thus playing a major role in cancer prevention.  There have been studies showing benefit not only in bone health, immune function and cancer prevention, but also the delaying of the onset of dementia, multiple sclerosis and even schizophrenia.  A recently published peer-reviewed report demonstrated a reduction by almost 50% in stroke when low Vitamin D levels were corrected in the study population.

Even in history Vitamin D plays a significant roll.  For example, Dr. Adolf Windaus won the 1928 Nobel Prize in chemistry for his work with Vitamin D.  Dr. Harry Steenbock discovered, in the 1920’s, that irradiated foods produced higher levels of Vitamin D and that fortifying foods in this way would reduce Rickets.  By 1945 with Dr. Steenbock’s work recognized, the fortifying of milk and some staple foods was common practice; Rickets was all but eradicated in America.

Along with producing Vitamin D naturally with sun exposure, dietary intake is the only other practical way of receiving this beneficial nutrient.  Intake can be measured in terms of micrograms (mcg) or International Units (IU), where 1 mcg of Vitamin D is equivalent to 40 IU.  More often times foods and supplements are labeled using IU.  The National Academy of Sciences (now know as the National Academies) recommends 200IU for those under the age of 50-years and 400IU for those 50 to 70-years, and 600IU for those over 70-years of age.  The typical American diet averages 100 IU/day, but this is not saying much, as the “typical” American diet is rather poor when considering the fast foods we generally eat on the run and the processed foods we buy at market.  The combination of this type of dietary intake and average sun exposure may allow us to reach these USDA RDA levels without supplementation.  However, longevity and nutritional medicine physicians and organizations recommend quite a higher daily dose for wellness and health.

Foods where higher levels of Vitamin D3 are achieved are found in fatty fish, eggs and lean meat.  For example, a 3.5 oz piece of salmon will give you 360 IU, tuna (3.5 oz) will give you 235 IU, catfish is a great source having 425 IU per 3 oz and it should be noted 15cc (a tablespoon) of cod liver oil is worth 1360 IU of Vitamin D3.  We witness again the intuitive wisdom of our grandparents as they made us choke down cod liver oil when we were sick.  A whole egg by the way gives us 20 IU of the vitamin.  Fortified milk (historically containing D2) will give on average only 98 IU per 8 oz glass.  Consuming milk as our only source of Vitamin D, a person would have to consume ten glasses of fortified milk daily to get minimum effective levels.  It is good to fortify foods do not get me wrong, but don’t believe all the advertising, that milk is the one.  The only vegan source; the mushroom will confer about 14 IU (un-irradiated) and 500 IU (irradiated) per 100 grams of edible fungi.

How much sun exposure is necessary to achieve levels of Vitamin D3?  Experiments range in levels depending on ethnic groups and level of sun exposure (altitude and latitude), but in general for whole body irradiation without sun blockers in a Caucasian person a dose of UV-B likely to just about induce a sunburn will yield a comparative dose equivalent to between 10,000 and 25,000 IU taken orally.  To put it more simply and practically, a fair skinned man wearing shorts and a t-shirt in mid-day sun at the equator for 10-minutes can produce 10,000 IU of Vitamin D3.  You cannot produce toxic doses of Vitamin D (hypervitaminosis) with sun exposure, as there is an equilibrium state that is reached in the skin.  As you reach this equilibrium point Vitamin D3 is degraded as quickly as it is produced, thus prohibiting overproduction and toxicity. 

Obviously, from a pedantic perspective, sun exposure trumps dietary supplements as an inexpensive and practical way of achieving levels in the health range, however, skin cancer and photo-aging issues arise.  Studies observing surfers in Hawaii noted quite a variance in Vitamin D production, so there is a good bit of variability with sun exposure, time of day, region, ethnicity and skin pigmentation.  This makes difficult giving standard recommendations for sun exposure.

Dosages of upward of 5000IU daily are recommended in certain instances.  For the most part a range between 1000 IU to 2000 IU is the general recommendation by the Linus Pauling Institute and other organizations with a focus on prevention and nutrition.  These quantities are best achieved by pharmaceutical grade dietary supplements or prescriptions.

As alluded to earlier, Vitamin D3 makes for better supplementation than D2, as D3 binds with greater affinity to the Vitamin D Binding Protein (VDBP) which is responsible for carrying Vitamin D in the blood stream without degradation.  This allows the metabolites of 25-OH-Vitamin D (inactive pro-vitamin), specifically 1,25-OH-Vitamin D, which is the bioactive form to attach to Vitamin D Receptors (VDR) on cells and at the nucleus, much more so than Vitamin D2 metabolites.  Vitamin D3 also has a longer shelf-life and is more stable than Vitamin D2 when placed in tablet or capsule form as a supplement or in fortified foods for that matter.  In recent years the supplementation and fortification industry is swinging over to Vitamin D3 more exclusively in higher-end products.

We can practically and efficiently measure our body’s stores of Vitamin D in the clinical setting, as mentioned earlier it is becoming a standard annual reimbursable test for many.  Measuring serum levels of 25-OH-Vitamin D is by convention the best way to assess levels, as this metabolite has a longer (15-day) half-life than other forms and assays serum and tissue levels quite well.  Levels of > 30 ng/ml are desirable while >200 ng/ml are nearing the toxic (hypercalcemia, hyperphosphatemia) range.  Levels below 30 are considered too low for optimum health.  While “normal” ranges vary rather considerably from one reference lab to another the widely accepted normal range for 25-OH-Vit. D is between 30.0 and 74.0 ng/ml. A person's fat content (obesity) is linked with lower Vitamin D levels, not that fat blocks UV-B rays from doing their thing, but rather adipose tissue can store Vitamin D and take it our of serum circulation. 

Children born to women with lower levels of Vitamin D while pregnant have been shown to be at higher risk for Multiple Sclerosis (MS) and psychiatric disorders.  Researchers have noticed that women with low Vitamin D tend to have children with twice the risk for schizophrenia.  Some studies have shown that Vitamin D supplementation can lower the doses of anti-psychotropic medication and have witnessed a drop in frequency of symptoms of schizophrenia in those patients.  

Low Vitamin D levels can cause a drop in hair follicle growth, increase risk for peripheral vascular disease, cancers (breast, colon, prostate) and neurological disorders.  Rheumatoid Arthritis (RA) and other immune disorders, juvenile Diabetes (DM), Parkinson’s and Alzheimer’s disease have also been implicated in low levels.  It is estimated that forty (40%) percent of the US population has a known Vitamin D deficiency.  In our nursing home patient population it has been demonstrated that some eighty (80%) percent have a deficiency.  It is an unfortunately statistic that some seventy-six (76%) percent of pregnant mothers show levels of deficiency, and the repercussions on their offspring are worrisome.  It should be noted that in the medical literature, all deaths (due to all causes) rise when Vitamin D levels are less than 18 ng/ml.  When correcting a long standing Vitamin D deficiency, one must be patient, as it can take months to correct low levels with proper supplementation.

How Vitamin D is important to our immune system is theorized as conversion occurs of pre- (inactive) Vitamin D to active 25-OH-Vitamin D metabolites.  The active metabolite will bind to Vitamin D Receptors (VDR) located on Natural Killer Cells (NKC), enhance phagocytosis in macrophages, increase T- and B- Cell function, and increase cathelicidine, a natural antimicrobial peptide (yet another downstream metabolite of Vitamin D).  All of these properties together have a pretty big impact on our immune system.

Researchers have found and published reports that doses of Vitamin D in the range of 1000 IU/d will reduce colon cancer risk by 50%, breast and ovarian cancer by 30% and as little as 400 IU/d has shown in at least one study to reduce pancreatic cancer by 43%.  Studies conducted on dementia, Alzheimer’s disease and Parkinson’s disease have shown some promise with regards to Vitamin D therapy.  Scientists have found that Vitamin D binds to receptors on the HLA-DRB1 gene and reduces MS expression in susceptible individuals.  The importance of Vitamin D in neuropsychiatric disorders continues to be realized as new research is published.

Every fall season we worry about the impact of Influenza on our lives.  What is Vitamin D’s link to the Flu?  It has been noted that with lower endogenous production due to decreased sun exposure in winter, in theory, a drop in Vitamin D affects immune system function to the point that we are more susceptible to Influenza.  There are other cofounding factors that may prove this theory incorrect with further research.  However, it is recommended that higher doses of daily Vitamin D be taken when exposed to the flu, or during the flu season.

Vitamin D has also been linked to lowering elevated blood pressure and cholesterol, as well as helping with Peripheral Vascular Disease (PVD).  VDRs in the renin system, which is integral in blood pressure control can regulate the ACE- Angiotensin II conversion process that affects blood pressure.  Low Vitamin D can cause Non-Insulin Dependent Diabetes Mellitus patients to produce less insulin secretion from the pancreas, thus worsening their serum glucose levels. 

With regard to drug interactions, there are some medications that block or interfere with production, others that interfere with the vitamin’s ability to bind with VDRs and block metabolism in the liver.  Steroids impair Vitamin D metabolism, Xenical® (Orlistat) and Cholestyramine reduce Vitamin D absorption in the gut.  And with lower Vitamin D levels, this affects the way calcium and magnesium is absorbed by the intestines.  Phenobarbital and Dilantin® (Phenytoin) (both seizure medications) reduce absorption and metabolize Vitamin D into less active compounds.

While Vitamin D is not the end all, be all of dietary supplements, it nonetheless holds a pretty lofty position.   Unrecognized and untreated low levels of this vitamin have pervasive effects on our health and morbidity.

---

JP Saleeby, MD is an integrative and nutritionally minded physician, for more information visit www.saleeby.net

References:

McGrath J. (1999) Hypothesis: Is low prenatal vitamin D a risk-modifying factor for schizophrenia?  

Schizophr Res.  Dec 21;40(3), 173-7.

Institute of Medicine, Food and Nutrition Board. (1997) Dietary Reference Intakes: Calcium, Phosphorus,

Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press.

Holick MF. (2003)  Evolution and function of vitamin D. Recent results. Cancer Res, 164, 3-28.

Wolpowitz D, Gilchrest BA. (2006) The Vitamin D Questions: How much do you need and how

should you get it? J Am Acad Dermatol  6;54, 301-17.

Need AG, Morris HA, Horowitz M, Nordin C. (1993) Effects of Skin Thickness, Age, Body Fat,

and Sunlight on Serum 25-hydroxyvitamin D. Am J Clin Nutr, 58, 882-5.

Cranney C, Horsely T, O'Donnell S, Weiler H, Ooi D, Atkinson S, et al. Effectiveness and safety of vitamin

D. Evidence Report/Technology Assessment No. 158 prepared by the University of Ottawa

Evidence-based Practice Center under Contract No. 290-02.0021.

AHRQ Publication No. 07-E013.

Sigmund CD. (2002) Regulation of Renin Expression and Blood Pressure by Vitamin D(3).

J Clin Invest. 110(2),155-156.

Zittermann A.  (2003) Vitamin D in Preventive Medicine: Are we ignoring the evidence?

Br J Nutr. 89(5), 552-572.

Vitamin D. Natural Medicines Comprehensive Database [Web site]. December 3, 2007.

Available at: www.naturaldatabase.com.  Accessed November, 21, 2010.

Houghton, LA, Vieth, R. (2006) The Case Against Ergocalciferol (vitamin D2) as a Vitamin Supplement.  

American Journal of Clinical Nutrition, Vol. 84, No. 4, 694-697.

Adams M. (2005) Fifteen facts you probably never knew about vitamin D and sunlight exposure. 

Based on an interview with Dr. Michael Holick, author, The UV Advantage, http://www.naturalnews.com/003069.html,  Accessed November 21, 2010.

© 2010

Question answered on Hypothyroidism

You answered this question on 10/22/10 on About.com

Questioner:	Mandy
Category:	Family, Internal Medicine, General Medical Questions
Private:	No
Subject:	low thyroid - natural things to do before replacement therapy
Question:	I was wondering if it's worth trying out some foods containing iodine or what other things you might recommend for a low thyroid? I am a healthy older woman who has never needed medication for anything and I would like to see if there is before I commit to a low dose synthroid the Doctor prescribed for me.He said he caught this early and that is good but I really would like to try anything before a medication. A friend that has it told me I should not take the soy nuts and soy milk that I had been having for a year or so for menopause. My low thyroid symptoms are only some hair breakage,occasional nail breakage and mild fatigue at times. Can you recommend any herbal or diet for me to atleast try for a couple of weeks first? Thankyou for any info Thankyou
Answer:	Carolina Mobile MD Mandy, Treating folks for subclinical or lab normal hypothyroidism is my forte.  A few things you should know you will find at the following links.  The powerpoint hits on a few things you can try prior to taking prescription whether it be synthetic or natural HRT. Soy and some other foods are goitrogenic.  I would avoid too much soy or for a time at least don't take any to see if that affects your numbers/levels.  Make sure free-T3 and free-T4 levels are checked along with hsTSH. Besides soy isoflavones, cruciferous vegetables (those containing isothiocyanates), such as cabbage, Brussels sprouts, broccoli, broccolini, cauliflower, mustard greens, kale, turnips, and collards are also goitrogenic and can reduce thyroid hormone levels, so watch out for over consumption.  Gluten sensitivity or intolerance may also contribute in some people.  So limit gluten intake and see if that has an effect.  If you enjoy soy and soy based foods, it has been established that cooked, fermented or aged soy products have a much reduced isoflavone effect on thyroid.  Cooking soy apparently "turns off" the goitrogenicity of soy.  Also paring up soy foods with those high in iodine content counteracts the effect.  Moderation in all things I say. If you desire a tele-medicine conference call with me regarding this issue and more details and better management I am at your service.  Visit www.saleeby.net for more information. The links are: http://docsaleeby.blogspot.com/2005/05/natural-thyroid-replacement-therapy.html   and http://www.wellsphere.com/general-medicine-article/subclinical-hypothyroidism-le Slide #7 gives you some "natural non-hormone" things to try. I also highly recommend the use of Armour or bioidentical HRT (natural T4/T3) for bHRT versus the synthetic levothyroxine compounds. In Good Health, JP Saleeby, MD (800) 656-2297 www.saleeby.net

Good Quote from Will

"We could certainly slow the aging process down if it had to work its way through Congress."
                                                - Will Rogers

Understanding Breast Cancer - October is Br. Cancer Awareness month

Breast Cancer

By JP Saleeby, MD & Sharon K. Saleeby, RRT

published in AFAA's American Fitness Magazine 2007 for CEUs

Breast cancer is by far the most feared disease occurring in women despite its occurrence being second to lung cancer.  It is estimated that just over 178,500 new cases of breast cancer will be diagnosed in the US in 2007.  It occurs in about 12% of women who will live to the age of 90.  The death rate due to this cancer has steadily declined since 1990 due to early detection. As October is National Breast Cancer Awareness month, the American Cancer Society has many activities during this time to bring breast cancer to the public attention.  As a fitness professional it is important to appreciate that exercise plays a positive role in reducing breast cancer risk.

Several well-established factors increase the risk of breast cancer. They include family history, nulliparity (not having had children), early menarche (starting menstrual cycles early), advanced age, excessive alcohol consumption, hormone therapy, a personal history of previous breast cancer, and exposure to environmental toxins such as tobacco smoke. 

The most common types of breast cancer originate in either the breast's milk ducts (ductal carcinoma) or lobules (lobular carcinoma). The point of origin is determined by pathological appearance on biopsy.  Cancers can be broken down into in situ and invasive.  In situ means the cancer remains in its place of origin and has not invaded surrounding tissue.

Ductal carcinoma in situ (DCIS) refers to abnormal cells in the lining of a milk duct without surrounding invasion. Experts consider DCIS a "pre-cancerous" condition. This cancer is treated rather successfully and does not affect a woman’s life span.  If left untreated however, it can become invasive.  Lobular carcinoma in situ (LCIS) indicates abnormal cells that are contained within a lobule of the breast, without invasion of surrounding tissue. Researchers state that if you have LCIS, you are at an increased risk of developing breast cancer in either breast in the future.

Invasive or infiltrating breast cancers are those that extend beyond their origin, invading the surrounding tissues that support the ducts and lobules of the breast. The cancer cells can also travel to other parts of your body, for example the lymph nodes.  When this process occurs it is called metastasis.  Invasive ductal carcinoma (IDC) accounts for the majority of invasive breast cancers. This cancer starts in the lining of the milk duct and spreads to surrounding tissues and can metastasize to other locations in the body.  Invasive lobular carcinoma (ILC) is not as common as IDC.  ILC starts in the milk-producing lobule and invades the surrounding breast tissue. This cancer can also metastasize. The detection of ILC is difficult.  Rather than detecting a “lump” one may perceive only a general thickening.  ILC happens to be more evasive on a mammogram as well.

There are other less common or rare forms of breast cancer not all originating from the duct or lobule.  They include: inflammatory breast cancer, medullary carcinoma, mucinous (colloid) carcinoma, Paget’s disease of the breast, tubular carcinoma, phylloides tumor, metaplastic carcinoma (less than 1% seen), sarcoma, micropapillary carcinoma (a very small but highly aggressive metastatic tumor) and adenoid cystic carcinoma (a large local tumor, yet slow growing).

Early education on self-breast exam and early screening is extremely important in achieving good outcomes.  Self-exam and physician examination will detect cancer at a rate between 70 – 80%.  Adding screening mammography (mammograms) will increase detection to 96 – 98%.  It has been shown that early detection through clinical exam and mammography can reduce breast carcinoma mortality by 20 to 30%.  Today’s gold standard for screening (mammograms) will still miss between 10 and 15% of these tumors (neoplasms). 

Medical tests and diagnostics span the continuum between the very basic and the highly technical.  The basic physical examination of the breast by the patient or physician is a starting point that may reveal a “lump”, odd texture of the skin, an enlarged lymphnode, or nipple discharge.  The mammogram or the newer full-field digital mammography (FFDM) is another rather reliable screening tool and most often used in the US.  Breast ultrasound is oftentimes used in conjunction with or after a mammogram to further evaluate an abnormality.  Other tools include ductograms/galactograms, computer-aided scans, scintimammography (using radioactive tracers), Magnetic Resonance Imagining (MRI) (a very sensitive screening test which may become the gold standard replacing mammograms), Positron Emission Tomography (PET) scans (especially if metastasis is suspected) and biopsies.

Screening should start with a baseline mammogram at age 35, or younger if there is a strong family history.  Annual examinations should be performed once a woman reached 40 years of age.  Self examination should be encouraged monthly starting at the age of twenty.  If a clinically noted mass is followed by a negative mammogram the work up should then include a breast ultrasound and/or fine-needle aspiration cytology and close interval examinations.  The newer modality of MRI is a method of examining the breasts that is far more sensitive in picking up smaller tumors than plain mammography.  MRI is widely used in Europe, but has not yet taken on in the US as a primary screening tool.  Even with open biopsies of suspicious masses the diagnosis of a malignancy is one in about five biopsies performed.  This may seem costly but the morbidity and mortality of missing a malignancy is even more so.

A positive family history alone doubles the incidence of cancer increasing lifetime risk to approximately 25%.  Recently the interest has focused on cancers associated with germ line (inherited) genetic mutations.  While only 5 – 10% of all breast cancer sufferers have a mutation in BRCA1 gene (located on chromosome 17) and BRCA2 gene (located on chromosome 13), screening should be limited.  Only when a patient’s first degree relative with known cancer and a positive mutation or a women falling into a certain ethnic group should testing be done.  Women who have inherited a BRCA1 or BRCA2 mutation have a relatively high lifetime risk of breast cancer (about 50-85%).  Risk for cancer in the opposite breast of a woman with a BRCA1 mutation is about 25%.

Once a tumor is detected important prognostic determiners such as stage of the disease, histology and nuclear grade, estrogen and progesterone receptor status and HER2/neu gene amplification tests are advisable.  Staging determines treatment and prognosis.  Staging is based on the T, N, & M nomenclature where T designates tumor size, N represents node involvement and M denotes any metastasis.  For example T1N0M0 is a tumor 2-cm or less in diameter and has not spread to lymph nodes or distant sites. Once a pathologist knows the TNM characteristics he can stage the cancer.  Staging ranges from 0 through IV (with III in subgroups of A & B).  So a Stage 0 is non invasive, I & II are early stages, II with lymph node involvement and III are later stages and Stage IV is considered advanced.

There are several treatment options for breast cancer.  Surgery to remove the tumor depends on the stage, but if caught early breast-conserving surgery (lumpectomy) is considered followed by radiation therapy.  More aggressive tumors with lymphnode involvement will generally require mastectomy.  Adjuncts to surgery include the use of hormone therapy, chemotherapy, and targeted or biological therapy.  Radiation therapy (using measured doses) is very often supplemental, but holds very obvious untoward effects to surrounding tissues.  It can be administered by external beam or by implanting radioactive seeds (brachytherapy).  Scaring of skin and of the lung tissue is of greatest concern.  Patient can develop a "radiation pneumonitis," which causes cough, shortness of breath and fevers three to nine months after completing treatment.  This is important to consider when physical activity is planned.

Hormone therapy with the use of aromatase inhibitors (that reduce estrogen) such as Arimidex or Femara are used with women having hormone-receptor-positive breast cancer.  Selective Estrogen Receptor Modulators (SERMs) like Tamoxifen or Raloxifene are also used to suppress future tumor growth.  Another agent, Faslodex is an estrogen-receptor downregulator and is used in receptor positive cancer patients.  Finally in the pre-menopausal woman with receptor positive cancer there are ways to shutdown ovarian function or remove the ovaries (oophorectomy).

Chemotherapy conjures up horrific images for women, with the loss of hair, the weakness and fatigue, anemia, and the intractable nausea and vomiting.  While chemotherapy is a tough treatment modality it does result in significant reductions in the recurrence of breast cancer.  Modern medicine offers women ways to combat the nausea and anemia with drugs like Zofran and Procrit & Epogen respectively.

There are many regiments of chemotherapy and is very physician dependent.  A process called dose dense where therapy is administered every two weeks (instead of the typical three) has shown a greater reduction in recurrence rates.  However, as you can imagine it is “harder” on the body.  Drugs used in various combinations are Adriamycin, Cytoxan, Taxol, Methotrexate, fluorouricil (5-FU), and Taxotere.

The targeted or biological therapies are those agents that target a particular tumor which has certain genetic markers called HER2 genes.  Drugs such as Herceptin, Tykerb and Xeloda are used in recurrent disease resistant to some of the anthracycline and taxane chemotherapeutic drugs.  The agent Avastin which targets new blood vessels that feed cancer cells is often used in advanced cases and in combination with Taxol to slow progression of advanced breast cancer.

Physical activity during and after breast cancer treatment is important to maintain health.  However limitations under the direction of the patient’s physician are important to heed.  Depending on the types of treatments and any breast reconstructive surgeries the type and intensity of the exercise is important.

Research has strongly suggested that exercise is not only safe but also helpful during cancer treatment.  It improves the physical functioning of the individual as well as enhances quality of life.  Exercise has been shown to improve fatigue, self-esteem, reduce anxiety and maintain heart fitness, muscle strength and body composition.  Those who have been exercising prior to chemo and radiation treatments may have to reduce the intensity and pace themselves a little slower while undergoing therapy.  During chemotherapy there is a greater chance for bone fractures due to weakness and the increased risk of fall.  Complicated routines and high impact exercise should be done with caution.  Reports show that there is a five-fold increase in bone fracture in post-chemo breast cancer survivors due to bone density loss.  So even after treatment is finished there is an increased risk for fractures.  Recurrence of the breast cancer with mets to the bone can also cause fractures and is often times an early sign that the cancer has returned.

Depending on the type of treatments received there may be limitations to the types of exercise.  For example those who are on chemotherapy and have become immunocompromised (thus susceptible to infection) should avoid the germs commonly encountered in public gyms until their white blood cells counts have returned to normal.  Those receiving radiation may find the chlorine in the swimming pools an irritant to their skin.  And those who suffer from severe anemia should delay any activity such as aggressive aerobic exercise or resistance training until their counts have normalized.  Those who have not exercised prior to treatment should be started out with a low-intensity regiment and advanced rather slowly and cautiously. For older clients precaution should be taken to avoid falls as they may suffer from osteoporosis and arthritis.  Those women who undergo breast reconstructive surgery may be limited in performing upper body resistance exercise until they are released to do so by their surgeon.

Recent reports in the medical literature show that exercising while young can reduce the incidence and/or delay occurrence of breast cancer.  It should also be noted that exercise has been shown to reduce recurrence of breast cancer in breast cancer survivors.

It is extremely important for women to maintain annual physical exams and aggressive cancer screening regiments.  There are means to help prevent cancer in high-risk women and exercise appears to be one modality.

A resource for more information on breast cancer is the American Cancer Society’s web site: http://www.cancer.org.

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JP Saleeby, MD  is a seasoned Emergency Room physician and integrative (holistic) doctor.  He sits on the advisory board of AFAA and specializes in longevity medicine.  His practice is in Conway, SC (scwellness.net)

Sharon K. Saleeby, RRT is a pediatric respiratory therapist and Graduate of MUSC in Charleston, SC.

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References:

MayoClinic.com.  http://www.mayoclinic.com  (24 April, 2007)

Imaginis Breast Cancer Resource. http://www.imaginis.com/breasthealth/statistics.asp#1  (24 April, 2007)

Omni Medical Search: Breast Cancer Medical Tests and Diagnosis.  http://www.omnimedicalsearch.com/conditions-diseases/breast-cancer-medical-tests.html   (24 April, 2007)

BreastCancer.org.  http://www.breastcancer.org/dia_pict_staging.html  (24 April, 2007)

BreastCancer.org.  http://www.breastcancer.org/treatment.html  (24 April, 2007)

WebMD.org  http://www.webmd.com/breast-cancer/guide/breast-cancer-treatment  (24 April, 2007)

RadiologyInfo. (RSNA).  http://www.radiologyinfo.org/  (24 April, 2007)

American Cancer Society.  http://www.cancer.org/docroot/mbc/content/MBC_6_2x_FAQ_Nutrition_and_Physical_Activity.asp?sitearea=MH  (24 April, 2007)

BreastCancer.org.  http://www.breastcancer.org/cmty_trans_2006_01.html  (24 April, 2007)

Doyle, C., et al., Nutrition and Physical Activity During and After Cancer Treatment: An American Cancer Society Guide for Informed Choices. CA Cancer J Clin,2006; 56:323-353

Holmes, M.D., et al, Exercise After Breast Cancer Treatment May Improve Survival and Reduce Recurrence. JAMA, 2005; 293:2479-2486