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Whoa!  Lay Off the Vitamins!
Posted: 12 October 2014 08:22 AM   [ Ignore ]   [ # 436 ]
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johnw - 11 October 2014 08:43 PM

Many doctors are businessmen.
Most doctors are ethical.

How many doctors out there, that are businessmen and unethical? This is a rhetorical question.

We all have seen/read about doctors getting paid by pharma representatives in pretty much every country:
http://www.news.com.au/lifestyle/health/hundreds-of-doctors-paid-thousands-to-advise-drug-companies-on-their-products/story-fneuzlbd-1226673435918

John this makes great headlines but its grossly misleading. “Hundreds of doctors paid thousands” sounds awful until you realize a few things.

Yes there are a few hundred doctors who received large payments but that’s a few hundred out of nearly 900,000 doctors actively practicing in the U.S. (http://kff.org/other/state-indicator/total-active-physicians/)

The small number of doctors who are being paid to do this are not being paid to prescribe the drug. They are being paid to give talks to other physicians about the drugs. Some physicians are researchers so that the money they receive may be simply the salary they are earning from their employer (pharma). There is nothing ethically wrong with a physician doing that especially since physicians are far more qualified to do these jobs than non-physicians who don’t understand the biology and pharmacology.  If that doctor then preferentially prescribes that drug to his patients without informing the patient of the potential conflict of interest then that would indeed be unethical.

The implication of these stories is that doctors in large numbers are taking money from pharma as a payoff for prescribing their drugs but the numbers do not support that headline. The numbers only show a small percentage of doctors taking significant amounts of money from pharma and its unclear to what extent this has affected the prescribing patterns of those few physicians.

If you are really worried check your own physician at http://projects.propublica.org/docdollars/. When you do keep in mind that amounts of $300-400 may represent 2 or 3 lunches brought to the office for staff by reps during the year. While I don’t agree with this practice I seriously doubt most physicians are going to change theri prescribing habits because their staff got a couple of sandwiches.

[ Edited: 12 October 2014 08:31 AM by macgyver ]
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Posted: 28 October 2014 09:57 PM   [ Ignore ]   [ # 437 ]
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TimB - 14 April 2014 06:13 AM
Lois - 14 April 2014 04:54 AM

My own doctor said there is no effective substitute for statins, but if you can get your cholesterol levels down with vitamins, I might try it myself because my body does not tolerate statins.

Lois

I’ll let you know what happens with my cholesterol levels. I am not overly optimistic. But even if my levels turn out to look better, it doesn’t necessarily follow that it would work for you.  I could just be an outlier.


Lois, as I said I would let you know:

For 7 months I took high doses of fish oil.  I attribute the changes in my cholesterol levels to this, as I made no significant changes to diet or activity level or lifestyle.

My total cholesterol increased from 227 to 242. 

My triglycerides went from 217 (high risk for heart disease) to 181 (borderline risk for heart disease.

My Total Cholesterol to HDL ratio went from 5.28 (low moderate risk) to 4.6 (low risk). 

My LDL/HDL went from 3.28 (low average risk) to 3.5 (high average risk).

So the results were a mixed bag, but in terms of cholesterol, I think my risk for heart disease, overall, went down slightly.  I am a big guy, and I was taking at least 4000 mg of fish oil a day for part of the 7 months, and as much as 7200 mg for some of the time.  Generally, my understanding is that a dosage of greater than 4000 mg a day of fish oil may be associated with a greater risk of stroke.  So I am now taking only 4000 mg.  per day.

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Posted: 29 October 2014 05:43 PM   [ Ignore ]   [ # 438 ]
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Tim,

Unfortunately, this sort of personal experiment isn’t as helpful as you might think. For one thing, the magnitude of the changes you report is of questionable clinical significance. Also, since there is normally quite a bit of random variation in these values from one measurement to another, it would take a lot more data to see if this truly represents a consistent trend. Finally, these are proxy markers, useful only to the extent that they correlate with clinical disease. We don’t, ultimately, care what our lipid values are but what our chances of developing cardiovascular disease are, and the lipid values are only useful if they help us predict this. So to know whether or not the supplement is “working,” we would have to establish that these changes are real and sufficient to affect your risk of clinical disease.

It is, of course, impossible to know this from any study of one individual, which is why we do large-scale clinical trials. Ultimately, whether these numbers mean anything will be determined by what such trials say about the effect of fish oils on actual disease in the population, and whether there is net benefit or harm or no net effect at all. All of this doesn’t mean you are wrong to take them, only that it would be wrong to draw any conclusions about their effects from a couple of lipid panels like this.

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Posted: 29 October 2014 07:47 PM   [ Ignore ]   [ # 439 ]
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Adding to McKenzie’s comments on the variability found in routine cholesterol testing. Many people don;t realize that no measurement is ever perfectly precise. Such precision is technically impossible to achieve. There is always some degree of imprecision. IN the case of blood tests if we were to take your sample and put it in three different tubes and send all of them to the same lab we would not get the same results on each one. The margin of error for these tests can vary depending on the method used and the substance being measured. Precision can also be affected by the absolute number. Values that are at the extremes tend to have higher levels of imprecision.

Its difficult to find good information on the precision of cholesterol measurements because there are a number of different techniques that are used but I have seen levels of imprecision of about +/- 3-5% quoted for a number of cholesterol testing methods. That means that an LDL of 130 isn’t really 130. What it really means is that there is 95% chance that your LDL is between 123.5 and 136.5.

In addition to lab precision some of these values fluctuate significantly from one day to the next. The best example is the Triglyceride number. I have seen Triglycerides change by 300 points in the course of a few days. Unlike other cholesterol numbers triglyceride levels are affected far more by carbohydrate intake than fat intake. After a carbohydrate rich meal there can be a rapid and dramatic increase in the triglyceride levels in the blood but even fasting triglyceride levels can change dramatically form one day to the next.

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Posted: 29 October 2014 08:51 PM   [ Ignore ]   [ # 440 ]
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Well thanks, guys, for the info about the variability of cholesterol readings.  And I agree that, even if testing were completely reliable and valid, and even if the magnitude of differences were greater, a single data point cannot represent clear clinical significance that one could properly use to generalize to a larger population. 

I only reported my results as I told Lois that I would. (And note that I issued a disclaimer to her, in advance, that the info would not necessarily be pertinent to her.)

However, for me and my physician, personally, it is some information, rather than none.

It seems to me that a physician is perpetually conducting a kind of single subject research design (although typically rather haphazard) with each client with whom he prescribes a treatment.  These treatment prescriptions are most often based on results of rigorous studies of broad populations, but one never knows for sure how an individual will respond to a particular treatment.  And subsequent treatment decisions for the individual, are based in great part on the individual’s response.

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Posted: 30 October 2014 03:32 PM   [ Ignore ]   [ # 441 ]
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Tim you are correct. Studies can only tell us about general trends and patterns. They do not have the resolution to tell us how each individual will respond to treatment although we can sometimes refine our recommendations to certain subgroups by gender, age,or race. We can also sometimes tailor our recommendations based on coexisting medical conditions.

In the end its all about probability though and blood tests and other measurements need to be looked at from a step back. In other words important decisions should never be made based on a single measurement. Ideally multiple measurements should be done over time with an eye towards any patterns that emerge. If for example a patients BP goes from 130/80 on one visit to 145/94 on the next I would not usually change medications but instead have the patient get some readings at home and return for a repeat visit a few weeks later to see if the increase is confirmed on repeat measrments.

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Posted: 24 November 2014 07:37 PM   [ Ignore ]   [ # 442 ]
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Just an update on Vitamin D. The US Preventative Services Task Force has issued a recommendation against screening for vitamin D deficiency in healthy adults.

Based on its review of the evidence, the task force notes:
There’s no consensus on the definition of vitamin D deficiency, nor is there agreement on the optimal blood level of 25-hydroxyvitamin D.

No studies have assessed the direct benefits or harms of screening for vitamin D deficiency.

Adequate evidence suggests that treating asymptomatic adults with vitamin D deficiency offers no benefit in terms of cancer, diabetes, or mortality outcomes.

Treatment also does not affect fracture outcomes in those not at high fracture risk.

[ Edited: 26 November 2014 01:57 PM by mckenzievmd ]
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Posted: 25 November 2014 12:55 PM   [ Ignore ]   [ # 443 ]
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mckenzievmd - 24 November 2014 07:37 PM

Just an update on Vitamin D. The US Preventative Services Task Force has issued a recommendation against screening for vitamin D deficiency in health adults.

Based on its review of the evidence, the task force notes:
There’s no consensus on the definition of vitamin D deficiency, nor is there agreement on the optimal blood level of 25-hydroxyvitamin D.

No studies have assessed the direct benefits or harms of screening for vitamin D deficiency.

Adequate evidence suggests that treating asymptomatic adults with vitamin D deficiency offers no benefit in terms of cancer, diabetes, or mortality outcomes.

Treatment also does not affect fracture outcomes in those not at high fracture risk.

I was really glad to see this when it came out recently. I was beginning to feel like I was swimming upstream against the rest of the medical community when it came to vit D testing and some of my patients were to wondering why my recommendation was exactly the opposite of what all of their friend’s doctors were telling them. The day this came out I printed it up and posted it in my exam rooms.

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Posted: 25 November 2014 06:54 PM   [ Ignore ]   [ # 444 ]
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Good to know.  I can stop wasting money on Vit. D.

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Posted: 29 November 2014 01:45 AM   [ Ignore ]   [ # 445 ]
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TimB - 28 October 2014 09:57 PM
TimB - 14 April 2014 06:13 AM
Lois - 14 April 2014 04:54 AM

My own doctor said there is no effective substitute for statins, but if you can get your cholesterol levels down with vitamins, I might try it myself because my body does not tolerate statins.

Lois

I’ll let you know what happens with my cholesterol levels. I am not overly optimistic. But even if my levels turn out to look better, it doesn’t necessarily follow that it would work for you.  I could just be an outlier.


Lois, as I said I would let you know:

For 7 months I took high doses of fish oil.  I attribute the changes in my cholesterol levels to this, as I made no significant changes to diet or activity level or lifestyle.

My total cholesterol increased from 227 to 242. 

My triglycerides went from 217 (high risk for heart disease) to 181 (borderline risk for heart disease.

My Total Cholesterol to HDL ratio went from 5.28 (low moderate risk) to 4.6 (low risk). 

My LDL/HDL went from 3.28 (low average risk) to 3.5 (high average risk).

So the results were a mixed bag, but in terms of cholesterol, I think my risk for heart disease, overall, went down slightly.  I am a big guy, and I was taking at least 4000 mg of fish oil a day for part of the 7 months, and as much as 7200 mg for some of the time.  Generally, my understanding is that a dosage of greater than 4000 mg a day of fish oil may be associated with a greater risk of stroke.  So I am now taking only 4000 mg.  per day.


Thanks for the information, Tim. I appreciate it.

Lois

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