Robinson Family Medicine Blog:

The most important question a doctor should ask is “why?” not “what?”

What is the #1 priority of a physician’s education? It is to become a good diagnostician. To answer the question “what is the diagnosis?” I challenge physicians to ask whether this is the most important question.

We are trained to take the presenting signs and symptoms then put it inside a box with a label. Then we treat all those patients with that label using “evidence based medicine” – algorithm X for everyone with diagnosis X. I used to love algorithms – not so much anymore. Labeling patients with diagnoses is contributing to escalating health care costs as well as the incidence of age-related disease. We are spending more on health care and ironically getting sicker at the same time (more on this later).

The #1 question we should be asking is not “what is the diagnosis?” but “why does the patient have the symptoms?” What body system or process is out of balance. Symptoms are nature’s way of saying that something is no longer working the way it should and it is usually because the owner of the body is not taking proper care of it.

I believe that this change in our approach will have the biggest impact in the health of our patients. So next time you evaluate a patient, first ask “why?” not “what?”

The top 6 supplements you should consider taking… #6 (drum roll please)

The #6 of the top 6 supplements you should be taking is… well, it depends. It depends on your family history, your symptoms, and other medical conditions. The following are some of my favorite supplements for those with specific problems. What makes these supplements favorites is that there is evidence that these supplements are beneficial for some people and I have seen improvement either in clinical symptoms and/or improvement in laboratory values or other testing.

Gastrointestinal problems: Much of our immune system is in our gastrointestinal tract and depends on a normal population of good bacteria. This bacteria requires fiber in order to thrive. Our typical American diet high in processed foods and low in fiber is a set up for poor gastointestinal immune function and subsequent problems. Patients who have irritable bowel syndrome, inflammatory bowel disease, lactose intolerance, allergies, inflammation, or allergies should consider taking a daily probiotic of lactobacillus and bifidobacteria (10-60 billion colonies). We can help support a healthy GI tract by eating at least 30 grams of fiber = 5 cups of fiber rich foods such as fruits, vegies, beans, nuts, oats, and whole grains.

Insomnia – Sleep is essential to life and chronic insomnia is linked to a wide array of medical problems including obesity, diabetes, cancer, heart disease, etc… Melatonin is a hormone produced by the pineal gland that regulates our sleep cycles. Many of my patients have been able to stop taking chronic prescription sleep medications, which are addictive and dangerous, by supplementing with Melatonin. Our bodies produce 0.3mg of Melatonin daily. Usual effective dosage ranges from 0.3mg to 5mg taken 30-60 minutes before bed. I prefer short-acting, sublingual tabs. There are many things that we do that disrupt our sleep cycle and we should always look first to correct those sleep disrupters. Read more about how to treat insomnia.

Peri-menopause/menopause – Women with symptoms of hormone imbalance during the perimenopausal and menopausal life stage often respond to an herbal combination of herbs such as wild yam, black cohash, dong quai, and red clover such as MedCaps Menopause. Exercise and good nutrition is also helpful for hormone balance. Read more about how to balance hormones naturally.

Attention Deficit Disorder, depression, osteoarthritis, autoimmune disease: high dose fish oil (start at 3 grams per day) has been shown to be helpful for some patients who have mood and attention disorders, arthritis, and autoimmune disease.

Osteoporosis/Osteopenia -The category of supplements that I am most excited about are those that provide flexibility and strength to our bones. I have seen more reduction in bone loss with these supplements than with prescription drugs for osteoporosis. Instead of blocking the bone renewal process, this approach gives the body what it needs to support the normal process of renewal and replenishment of our bones. Choline-stabilized orthosilic acid (ch-OSA) provides the collagen matrix that calcium and other minerals need to attach to the bone. Osaplex combines this ch-OSA with high quality MCHC calcium and Vitamin D. Read more blogs about bone health and osteoporosis.

Diabetes – Chromium, cinnamon, alpha lipooic acid, and green tea extracts have been shown to improve blood sugar control and insulin metabolism. Some companies make combinations of these vitamins and herbs, such as Xymogen CinnDrome X

High Cholesterol - Red Yeast Rice is an herb that helps reduce LDL cholesterol by 20-30%. It is a naturally occuring herb that works similar to medications like statins and has the same potential side effects (rarely achy muscles and elevation in liver enzymes) so it is essential to be monitored by a physician.

Prostate enlargement – Saw Palmetto helps to shrink the prostate and reduce symptoms of prostate enlargement like frequent urination.

Just to summarize this blog series on supplements… It is ALWAYS best to get our nutrients from a diet full of whole, nutrient-dense foods including colorful fruits and vegetables, fresh herbs, whole grains, legumes (beans), nuts/seeds, plant-based oils, leans meats, and oily cold-water fish. For those who are concerned that they aren’t getting the nutrients for optimal health, some of the supplements you may consider are fish oil, Vitamin D, B-Complex, Calcium/minerals, and a multivitamin. The quality of supplements is extremely important in order to get the benefit from them. For those who missed some of the blogs or want to review, click here to see all the blogs on supplements.

10 Steps to Hormone Balance (for men and women)

Step 1 – Nutrition

•Avoid non-organic meat and dairy. Meat and dairy raised with hormones and antibiotics can affect your hormone metabolism.
•Eat more good fats. Good fats from healthy oils (such as olive, walnut, grapeseed, avocado), nuts (such as walnut, almond, pecans, Brazil), and fish are necessary for the production of our hormones. Avoiding intake of these good fats can be detrimental to your health, especially when it comes to hormone balance.
•Buy organic for the “dirty dozen” on your produce list. Pesticides may interfere with normal metabolism and regulation of hormones.
•Avoid sodas (diet and regular). Artificial sweeteners, high fructose corn syrup, and excessive caffeine can also contribute to symptoms of hormone imbalance and work against optimal metabolism.
•Avoid caffeine. Caffeine increases hot flashes, decreases absorption of minerals such as calcium and magnesium which are important components of metabolism and bone health, and increases the production of stress hormones.
•Eat whole foods such as fresh fruits and vegetables, nuts, legumes, lean cuts of meat, chicken, and fish. Avoid processed foods whenever possible. Eating poorly can contribute to weight gain that is often experienced along with age-related decrease in hormones.

Step 2 - Get Enough Sleep

Adequate sleep is essential for hormone balance. Allow at least 7-8 hours or enough sleep so that you feel rested in the morning. Insomnia caused by night sweats is a common symptom of menopause which can be a “catch-22″ in that menopause is causing insomnia which is making the hormone imbalance even worse. If you suffer from chronic insomnia, read more about sleep.

Step 3 - Make time for Relaxation

Stress is one of the biggest disrupters of hormone balance. Stress triggers the body to release stress hormones such as cortisol and adrenaline which wreak havoc on the body. Activation of the stress hormones also disrupts the reproductive hormones, mimicking or exacerbating the symptoms of menopause or low testosterone. It is so important to have relaxation techniques that counteract the stress response, such as reading, listening to music, prayer, meditation, progressive relaxation, controlled breathing or relaxing forms of exercise such as yoga or Tai Chi.

Step 4 – Try Supplements, or Herbs

Take 2,000-4,000 mg of good quality Omega-3 fish oil supplement.
Take a good quality multivitamin with calcium and minerals.
Get your Vitamin D (25-OH Vitamin D) level checked. Take a Vitamin D3 supplement for a goal level of 50-70. If you do not get your level checked, a good dose to start with is Vitamin D3 2,000 IU daily.
Herbs: Women can try an herbal combination of black cohash, dong quai, wild yam and other herbs such as Xymogen MenoFem. For men, an herbal combination such as Xymogen Testoplex can also help with symptoms of low testosterone.

Step 5 - Exercise

Exercise has been shown to be very effective to reduce hot flashes. Exercise can also help improve energy levels and mood. Exercise at least 30 minutes 5 days per week and include cardio, strength training, and flexibility. Consider working with a personal trainer. Make sure to avoid exercise right before bedtime since it can interfere with sleep.

Step 6 – Rule out other causes

If your symptoms are still not improved, get blood tests to rule-out other causes of your symptoms. I usually check a complete blood count (CBC), iron stores (Ferritin), Vitamin D level (25-OH Vitamin D), thyroid hormones (TSH, free T4, and free T3), and a complete metabolic panel (CMP).

Step 7 - ADAM or EVE checklist

Check your symptoms on a hormone balance (EVE for women and ADAM for men) questionnaire to see if it fits a pattern of hormone imbalance.

Step 8 - Get your hormones checked

The saliva test is currently the best test to evaluate reproductive and stress hormones. I usually check estradiol, progesterone, testosterone, DHEA, and cortisol.

Step 9 – Consider B-HRT

If hormone levels are not normal, consider trying a bio-identical hormone (B-HRT) cream formulated individually for you by a compound pharmacist. It is very important to be monitored and followed by your doctor.

Step 10 – Monitor symptoms

Monitor any changes in your symptoms and make sure to have hormones rechecked periodically.

The top 6 supplements you should consider taking… #5 – Multivitamin

Physicians seem to be polarized regarding whether people should take multivitamins. Traditionalists say that there is insufficient evidence to recommend multivitamins for the general population and until evidence shows otherwise, they won’t recommend them. On the other side of the argument are physicians who believe that very few people in developed countries eat a balanced diet rich in vitamins and minerals. Our world is filled with “food deserts”, fast-food restaurants and grocery stores filled with processed foods from factories, not from farms. Most of us don’t live by the rule, “eat most of your foods that come from a plant, not foods made in a plant”. We could also argue that our soil is depleted of nutrients and our produce is genetically modified to grow faster, resulting in nutritionally inferior fruits and vegetables. It is difficult in our high-tech, fast-paced world, to get high quality, nutritionally dense foods.

I will not argue that it is best to get our nutrients from foods. Studies show that people who eat a healthy diet have lower incidence of disease but studies to date have not shown that taking a multivitamin has the same effect. However, we could argue that the studies were done using poor quality, cheap, synthetic vitamins. So the bottom line is that the “jury is still out”.

My approach is to test for nutritional deficiencies and treat based on the findings (see the Micronutrient Test from previous blogs). If I see multiple nutritional deficiencies, I recommend either significant dietary changes or a multivitamin. A very convenient and cost efficient product for those patients is Xymogen Active Essentials which provides a high quality multivitamin, calcium with minerals, fish oil, and antioxidant packaged together in an individual daily pack. These are great for traveling since you can just grab the number of days needed for your trip.

There is not a one-size, fits-all approach to medicine. Each patient has to be evaluated using a holistic approach. My recommendations are based on family history, medical conditions, symptoms, and Micronutrient testing to design personal nutritional recommendations. Read more about multivitamins. Read more about eating a healthy diet.

The top 6 supplements you should consider taking… #4

The #4 supplement you should consider taking is a B-Complex. If you need to get caught up, read the previous blogs about whether to take supplements, how to check quality, and the top 3 supplements. Connect with us on facebook or twitter to get the blog feeds and all kinds of other great health articles and quotes.

B-Complex includes the 8 known B-Vitamins: Vitamin B1 (thiamine), Vitamin B2 (riboflavin), Vitamin B3 (niacin), Vitamin B5 (pantothenate), Vitamin B6 (pyridoxine), Vitamin B7 (biotin), Vitamin B9 (folic acid), and Vitamin B12 (cobalamin)
Foods rich in B-Vitamins include meat, eggs, dairy, whole grains, and green leafy vegetables. B-12 is the one B-vitamin that is only obtained from animal sources including seafood, beef, eggs, and cheese.
B-Vitamins are important for brain health (mood, concentration, memory, and nerve function); heart health (prevention of coronary artery disease), production of blood cells, and metabolism (energy and weight control). B-Vitamins are also essential to the liver’s ability to cleanse the body of toxins, medications, and pollutants.
Deficiency of B-Vitamins is the 2nd most common deficiency that I see (Vitamin D is the most common).
It is important to take a good quality B-Complex. Most vitamin companies used cheap forms of B-vitamins. A quick way to check is to read the ingredients. If B-12 is “cyanocobalamin” and not “methylcobalamin“, it is the cheaper form To review the importance of vitamin quality, read this blog. A good quality over-the-counter B-Complex is Jarrow B-Right. A good pharmaceutical grade B-Complex is Xymogen B-Activ.
Patients with fatigue, depression, anemia, or migraines should have their B-12 level checked. I have had patients who were treated with chronic medications for these problems for years that were simply fixed by correcting the B-12 deficiency.

Stay tuned next week for the #5 supplement…

The top 6 supplements you should consider taking… #3

The #3 supplement you should consider taking is calcium with minerals. If you need to get caught up, read the previous blogs about whether to take supplements, how to check quality, and the top #1 and #2 supplements. Connect with us on facebook or twitter to get the blog feeds and other great health articles and quotes.

The best source of dietary calcium is not dairy. The best sources of calcium and minerals are greens (kale, collard, mustard, turnip), fresh herbs, nuts (almonds and Brazil), seeds (sesame and flax) and oily fish (herring, salmon). These foods are rich in calcium and minerals that are essential to life.
Calcium is not the most important nutrient for bone health. There are over 10 nutrients (vitamins, minerals, and hormones) essential to bone health and all work together to constantly renew our bones.
Taking calcium without Vitamin D is like taking a nutrient without the vehicle to get it where it needs to go. Read more about Vitamin D…
In my opinion, the best form of calcium is MCHC (MicroCrystalline Hydroxyapatite Concentrate) followed by Calcium Citrate Malate (CCM), Calcium Gluconate and lastly Calcium Carbonate.
If you don’t think you get the nutrients you need for bone health, you should take a supplement with calcium and minerals. You need to make sure they are good quality and forms of the vitamins that your body can use. My favorite over-the-counter (OTC) bone health supplement is Jarrow’s Bone-Up.
If you are a women over 40 or have ever been told you have osteoporosis or osteopenia (“slightly decreased bone density”), you must get this test for bone turnover. If you have accelerated bone loss, the supplement Osaplex can significantly reduce bone loss more effectively than medications like Fosamax which block the bone renewal process. Osaplex contains calcium, Vitamin D, and ch-OSA which provides the collagen binding sites for calcium within the bone, providing bone flexibility and resistance to fracture.

The top 6 supplements you should consider taking… #2 is the “sunshine vitamin”.

What is Vitamin D?

Although called a “vitamin”, this important element of health is actually a potent hormonethat affects over 2,000 genes and at least 36 organs of the body.
Once linked to only bone diseases such as rickets and osteoporosis, the “sunshine vitamin” is now recognized as a major player in total overall health.
We get most of our Vitamin D from sunshine and a smaller amount from foods such as fish, eggs, and fortified dairy products.

Why is it important?

Vitamin D deficiency has been linked to a myriad of common diseases including obesity, diabetes, hypertension, heart disease, cancer, osteoporosis, Alzheimer’s Disease, Multiple Sclerosis, migraines, asthma, autoimmune diseases and more.
More recent studies have shown that Vitamin D deficiency is associated with muscle weakness and pain and as well as increased risk of falls in the elderly populations.

Why are we deficient?

We have been trained to either stay out of the sun or cover ourselves with clothing and/or sunscreen. This fear of the sun combined with our spending more time indoors in front of electronics has contributed to a widespread deficiency of this essential hormone, even here in sunny St. Petersburg, Florida.
Even those who spend uncovered time in the sun can be deficient because as we age, our skin is not as efficient at converting sunshine into vitamin D.
Although government organizations report that Vitamin D deficiency is not widespread, I have found that 30% of my patients have deficient levels (less than 30) and 10% have severely low levels (less than 20).

How do you know if you are deficient?

You can have your Vitamin D level checked with a simple, inexpensive blood test. Make sure you get the 25-OH VItamin D level (not 1,25 Vitamin D).
Studies have shown a decrease in prevalence of colon, breast and kidney cancer, diabetes, multiple sclerosis, and fractures when Vitamin D levels increase from 30 to 55.
Studies have shown that healthy adults who get plenty of sunshine can naturally attain Vitamin D levels up to 65 in the absence of supplements. Well-designed research studies are still needed to determine the optimal levels of Vitamin D. At this time, I recommend a level of 50-65.

What to do about it?

It is true that Vitamin D supplements probably wouldn’t be needed if we spent more time in the sun, approximately 15-20 minutes each day (without sunscreen and most of our skin uncovered). If you can’t get to an optimal blood level with sunshine alone, I would recommend taking a Vitamin D supplement.
DO NOT take high doses (greater than 2,000IU) of Vitamin D without having your levels checked? Unlike water-soluble vitamins whose excessive amounts can be excreted in the urine, excessive intake of fat-soluble vitamins like Vitamin D can increase to toxic levels. Too much of a good thing is not always better.
If you are not going to have your level checked, I recommend taking Vitamin D3 2,000 IUdaily. Make sure it is Vitamin D3 (cholecalciferol = the form our body naturally produces) not Vitamin D2 (ergocalciferol).

If you missed the #1 supplement in the last blog, read it now.

Read more about Vitamin D and sunshine…

What does it mean to be “fasting” for a blood draw? It may not mean what you think…

Most people think fasting means nothing to eat or drink after going to bed the night before a blood draw. Most patients make the mistake of avoiding anything by mouth, including water and medications. Fasting technically means nothing to eat or drink EXCEPT water and medications for 8-12 hours prior to a blood draw.

The reason for fasting is because of 2 tests – blood glucose (sugar) and the cholesterol panel. The only foods that will affect this are sugar or fat. Black coffee, plain tea, or other non-caloric beverages will not affect the results. Hydration with water actually helps make the veins more pronounced , maybe for an easier blood draw. Medications should NEVER be skipped for a fasting blood draw.

The #1 supplement that we all should consider taking…

Out of all vitamins and supplements, fish oil has the most proven benefit. There is very strong evidence that fish oil is beneficial for heart health and brain health.

There is a lot of confusion about the difference between Omega-3 from flax seed versus Omega-3 from fish. There are three types of Omega-3, DHA and EPA which come from fish and ALA which comes from plants and nuts including flax seed. The strongest evidence of benefit is for Omega-3 from fish, not Omega-3 from plant sources. Although flax seed and other sources of ALA are healthy, they should not be the primary source of Omega-3′s because your body has to convert ALA to DHA and EPA and conversion is not always efficient.

The following are key points that you need to know about Omega-3 from fish:

Fatty fish such as salmon, herring, sardines, anchovies, and mackeral has the highest amounts of Omega-3′s, approximately 1-2 grams of omega-3 per 3 ounce serving. See a list of fish high in omega-3 and low in contaminants.
If you are healthy and already eat these types of fish on most days of the week, you probably don’t need to take a fish oil supplement.
If you don’t eat much fish or if you have high triglycerides, heart disease, risk factors for heart disease, arthritis, depression, or attention deficit disorder, you should consider taking a fish oil supplement (1.5 – 3 grams per day which is equal to 1500-3000 mg).
Omega-3′s, especially DHA, are essential to brain function.

How to choose a fish oil supplement:

Make sure the source of fish is identified. Best sources are anchovies and sardines from clean/cold water sources such as Norway. Larger fish like tuna and salmon are more likely to contain contaminants. I don’t think krill oil is yet proven to be as beneficial as fish oil. Those who say krill oil is better are probably selling it. I am not jumping on the krill oil “band-wagon” yet.
Make sure that the milligrams of fish oil equals the milligrams of omega-3. For example, if you are buying 1,000 mg fish oil capsules and the back of the label says the total omega-3 is 400mg then you are getting 600mg of “mystery oil”. This is not a high quality product.
I could not find a good quality fish oil at Walgreens or CVS. A couple of good over-the-counter brands are Carlson’s and Nordic Naturals. I am sure there are many other quality brands. You can eliminate most of the poor quality brands by using the above rules. My favorite pharmaceutical grade fish oil is Xymogen OmegaPure 820.

If you need to get caught up with this blog series about supplements, read the previous blogs about whether you should take vitamins, how to read vitamin labels, and vitamin terminology.

Connect with us on facebook and twitter to get the blog feeds and all kinds of other great health information.

Knowledge is power… what you must know if you take vitamins.

Almost all vitamin/supplement companies use vitamin “isolates“, vitamins that are isolated in a laboratory then put into a capsule. They are often combined with other isolated vitamins, minerals, or herbs to create a vitamin combination such as a multivitamin, B-Complex, immune support, etc… Sometimes the vitamins they use are synthetic vitamins (i.e. a vitamin produced in a lab and not found in nature). Synthetic vitamins are often cheaper than non-synthetic. Mass-marketed vitamin companies often use synthetic forms.

Pharmaceutical grade vitamins and supplements are only sold through a licensed health care provider. Generally speaking, they are better quality, use better forms of vitamins (see last blog), use good manufacturing processes (c-GMP), and have 3rd party quality monitoring. Some of these companies include Xymogen, Orthomolecular, and Metagenics. My favorite of these companies is Xymogen.

Beware of “whole food vitamins“. There are many companies that dehydrate a little bit of fruit, put them in a capsule, and add low quality vitamins (see my last blog). “True” whole food vitamins are a wonderful idea. Vitamins are packaged by nature in a combination of vitamins, minerals, enzymes, amino acids, antioxidants, etc… that all work together to provide a certain function in our bodies. By purifying whole food and putting it into a capsule provides the benefit of the “whole package”. Two companies producing what I consider “true” pharmaceutical grade, whole food supplements are Standard Process and Innate Response.

Do not buy vitamins online unless you already know it is good quality. Anybody can package vitamins out of their garage or pest-infested warehouse and sell them online (scary). They can easily convince you to buy their product through slick marketing.

Knowledge is power… iff you haven’t read the last blog about reading vitamin labels, read it now…

How do you tell if your vitamins are good quality?

In the case of vitamins and supplements, I believe that you get what you pay for (or what you don’t pay for). My patients are always telling me that they got this great 2-for-1 deal on multivitamins at the big-box discount store. Buying cheap vitamins for the most part is a colossal waste of money. Inexpensive vitamins contain the cheapest forms of each vitamin and a plethora of additives, preservatives, and sweeteners. It is ironic that most people who take vitamins do so because they want to be healthier. And yet, these vitamins are the equivalent of mass-produced, unhealthy processed foods, filled with synthetic ingredients and preservatives.

There are three major factors to look at when you are evaluating a vitamin/supplement:

What forms of vitamins they contain
Whether they contain potentially harmful, unnecessary ingredients
Whether the manufacturing process is monitored and the product is tested for quality

1) The vitamin form – for vitamins to be effective, it is essential that the vitamin is in a form that is recognized and utilized by the body.

A perfect example is Vitamin B12. There are 4 forms of Vitamin B12 (aka cobalamin). Which of the following would you choose as the best form to take as a supplement?

Cyanocobalamin: a synthetic form of B12 that DOES NOT occur in nature. In order for your body to use it, you have to cleave off the cyanide and convert it to methylcobalamin or adenosylcobalamin.
Methylcobalamin: the main form of B12 used by the human body and most commonly found in food.
Adenosylcobalamin: also found in the human body primarily in the liver.
Hydroxycobalamin: a natural form produced by bacteria.

I would guess that most of you would choose methylcobalamin, since it is utilized by the body and is the form in the foods that we eat. Almost all over-the-counter vitamin manufacturers use cyanocobalamin, the synthetic form, because it is cheap and has a longer shelf life. If your multivitamin lists “B12″ on the label and doesn’t specify the form, it is cyanocobalamin. Most physicians when giving B12 shots use cyanocobalamin, again because it is very inexpensive, costing pennies per dose.

So does the form make a difference? I have found that patients who are taking inexpensive multivitamins often still have vitamin deficiencies but those that take a vitamin with better forms such as methylcobalamin, are not deficient. A good test to evaluate your nutritional status is the Micronutrient or FIA test which measures the nutrient levels inside your cells. This test can be used to see if your vitamins are getting to where they need to go, inside the cell.

There are many other examples where inexpensive vitamin companies use an inferior form:

Vitamin E: most companies use the synthetic dl-alpha tocopherol instead of the natural form d-alpha tocopheroland

Vitamin D: many companies use ergocalciferol (D2) instead of the more bioavailable form cholecalciferol (D3).

So how do you figure out which vitamin manufacturers are good quality? Well, just read the label. Here is the Centrum label. Notice how it does not give the form of the vitamin next to each vitamin. Now look down at the ingredient list? You will find cyanocobalamin and dl-alpha tocopherol, both synthetic forms.

Now compare Centrum with a pharmaceutical grade multivitamin such as Xymogen Active Nutrients. Each vitamin has the form listed next to it and each is the best available, best absorbed, most bio-available form. Minerals are in the more bio-avialable chelated form instead of the inorganic highly bound form.

2) Other ingredients: If you are conscientious about your health, you probably read food labels and avoid eating foods that contain additives, preservatives, trans-fats, and sweeteners. Did you notice all the additives on the Centrum ingredient list? Do your vitamins really need FD&C Yellow No. 6 Aluminum Lake (food coloring), hydrogenated palm oil (trans-fats), modified food starch (may contain MSG), talc (anti-caking agent), sucrose and maltodextrin (sugars)?

3) Quality control: Look for c-GMP to make sure they follow Good Manufacturing Practices. For over-the-counter vitamins, look for the USP verified stamp to see if the company has their vitamins tested for purity?

So is it worth spending more to get the higher quality? In my opinion, yes. There is no comparison.

What is the cost difference? Centrum multivitamins run on average 10 cents per tablet. A pharmaceutical grade such as Xymogen Active Nutrients runs about 16 cents per capsule. Is it worth the 6 cent/day difference? In my opinion… absolutely. Pharmaceutical grade supplements can only be purchased through a licensed health care provider. In the upcoming blogs, I will recommend some over-the-counter brands that are good quality.

Do you need vitamins and supplements?

Americans spend over $20 billion dollars per year on vitamins and supplements. So here is, literally, the billion dollar question… do we need to take supplements? And the answer is… it depends on what reason you are taking them.

1) Multivitamins and antioxidants for prevention of disease

Studies to date have not shown that multivitamins or antioxidants prevent disease or promote longevity. Many of my patients have figured out how to quickly find out my opinion about a topic. Just ask what I do or don’t do. So do I take supplements for this purpose? Yes. And here is why…

Although I make a pretty good effort, I do not eat a perfectly balanced diet. I don’t eat enough fruits and vegetables in all colors of the rainbow, legumes, fish, nuts and seeds, and healthy oils. This is how we should get most of our vitamins and minerals. It is always best to get vitamins and minerals from the foods we eat; however, in order to do so, you really have to eat these foods at every meal.
I don’t live on a farm or get all my produce from locally grown, organic farms. Mass produced produce that come from far, far away have been depleted of their vitamins and minerals, probably 30-40% of their nutrients. The food industry has genetically modified seeds (GMO) in order for them to grow faster, look prettier, and resist pesticides so that they can make more money, all at the detriment to the nutritional quality of the food.
Although studies to date have not shown a benefit of multivitamins in preventing disease, these studies were not done using high quality supplements and quality is important (more on that topic next week) .

2) Vitamins and supplements taken due to a deficiency

Are you getting the vitamins and nutrients you need? Most of us do not know because we are not checking. See my blog on “6 tests that your doctors may not tell you about” for more about the FIA Micronutrient test. We can also do blood tests for Vitamin D (25-OH), Vitamin B12, and Iron (Ferritin) which are common deficiencies that can cause symptoms. For this purpose, vitamins and supplements are very important if the levels can’t be adequately increased through changes in diet.

3) Vitamins and/or supplements taken for a specific disease process

This is also another area that supplements can be extraordinarily helpful. Why not give your body something to assist the body with the healing process rather than give a drug that blocks the body’s normal processes. There will be much more on this later…

7 Steps to fighting insomnia

Sixty percent of adults get inadequate sleep and 10-30% of adults suffer from chronic insomnia.
Inadequate sleep causes irritability, decrease in memory and learning, and a decrease in the body’s ability to fight infection.
When you don’t get enough sleep, your body increases the production of stress hormones which cause headaches, heartburn, anxiety, depression weight gain, and high blood pressure.
Chronic insomnia increases the incidence of diabetes, heart disease, depression, cancer and obesity.

If you think you are suffering from inadequate sleep, print out this list, highlight your “issues” and start working on them.

1) Figure out how many hours of sleep you need. We are all different. Most people feel well rested after 7-8 hours of sleep but some people need less and some need more.

2) Re-evaluate and prioritize your activities. If you “don’t have enough time” to sleep for 7-8 hours (or whatever your magic number may be) then you are doing too much. Getting adequate sleep is more important.

3) Practice good “sleep hygeine“. Factors such as noise, temperature, routine, light exposure, exercise, diet, caffeine, and alcohol can affect your ability to sleep. If you have chronic insomnia, you must read this article. This is one of the most complete articles I have seen about sleep hygeine. Print this out and highlight any factors that may be contributing to your insomnia.

4) Rule-out medical conditions and medication side effects. The most common medical conditions that can affect sleep are sleep apnea, restless leg syndrome, acid reflux, depression, prostate enlargement, chronic pain, and night sweats due to menopause. If you think you have a medical condition that is interfering with sleep, see your doctor. Also, some medications can cause sleep disturbances, most commonly medications used for seizures, depression, anxiety, attention deficit disorder, asthma, and thyroid disorder. If you think your medications may be interfering with your sleep, talk to your doctor about alternatives.

5) Watch for excessive alcohol use: Many people drink alcohol in order to get to sleep. Alcohol and other sedatives interfere with the body’s ability to get into deeper stages of sleep. So even though you may be able to get to sleep easier, your sleep will be less restful.

6) Try Relaxation techniques: In my opinion, many cases of insomnia are caused by stress. Stress increases the release of stress hormones that cause you to feel anxious and awake. Stress also inhibits release of the “sleep hormone” melatonin. Stress reduction techniques such as controlled breathing exercises and progressive relaxation can naturally help to reduce stress hormones and increase melatonin.

7) Supplements or medications:

Melatonin: If relaxation techniques fail, you can also try supplementing with melatonin before bed. Melatonin is also helpful for insomnia caused by jet lag or night shifts.
Valerian: This herbal supplement has shown to alleviate insomnia in some studies at doses of 300-600mg.
Other herbal combinations: There are many herbs that are thought to promote relaxation. Some companies have formulated herbal combinations that may help with insomnia that is caused by an inability to relax due to stress and/or worry. One example is the Xymogen supplement SerenX
Over-the-counter and prescription sleep medications: The ingredient in over-the-counter sleep medications is almost always a sedating antihistamine. Almost all prescription sleep medications are central nervous system sedatives. Both over-the-counter and prescription sleep medications cause some degree of morning or daytime grogginess or fatigue and decrease in concentration. Prescription sleep medications can also cause dependence and worsening insomnia when stopping them. Also concerning is that they can increase the risk of falling in the elderly. I discourage people to use these medications except for short-term use.
It is always a good idea to talk to your doctor before trying any supplements, herbs, or over the counter medications for insomnia.

6 Tests Your Doctor May Not Tell You About… #6 Saliva Testing for Hormones

Hormones are the body’s messengers, allowing communication to occur throughout the body. What happens when people don’t communicate with each other? There can be a total breakdown of a process where things do not happen the way they are supposed to happen and errors occur. Usually there is a domino effect where multiple other processes are adversely affected. The same occurs in the human body when hormone balance is disrupted. Hormone imbalance can cause a wide variety of symptoms, most commonly fatigue, sleep disturbances, decreased libido, weight gain, foggy thinking, irritability, and headaches.

The most powerful and far-reaching hormones are the steroid hormones which include the reproductive sex hormones (estrogen, progesterone, testosterone, DHEA) and the primary stress hormone (cortisol). To see if your symptoms might fit a pattern of hormone imbalance, you can look at the ADAM checklist for men and the EVE checklist for women. Attention men, you may want to look at the adrenal excess and adrenal fatigue sections (lower right) of the EVE questionnaire for symptoms of adrenal imbalance.

These hormone levels can be measured in the blood but because steroid hormones are fat soluble and require binding proteins to dissolve in blood, the level in the blood doesn’t accurately measure the active levels that are available to the organs and tissues.

Saliva levels are thought to be a better indicator of active, available hormone levels. Saliva testing is more sensitive than blood testing for evaluating reproductive hormonal changes that occur as we age and adrenal hormone changes caused by stress. We can often alleviate the symptoms related to hormonal imbalance with changes in nutrition, exercise, relaxation techniques, bio-identical hormones, and supplements.

If you are interested in the finding out more about saliva testing and live in the Tampa Bay area, call our office at (727) 329-8859 or email us to find out more about our Wellness Program.

To read about the other tests your doctor may not tell you about, check out our blog.

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6 Tests Your Doctor May Not Tell You About… #5 The ALCAT Food Sensitivity Test

The ALCAT blood test evaluates for food sensitivities that can be the cause of digestive disorders (such as acid reflux and irritable bowel syndrome), headaches, obesity, chronic fatigue, skin disorders, asthma, and Attention Deficit Disorder.

The ALCAT Test measures the cell’s immune response to various foods, additives, coloring, molds, and environmental chemicals. Standard allergy testing only measures for the presence of antibodies, which indicates exposure rather than intolerance.

If you are interested in the finding out more about the ALCAT test and live in the Tampa Bay area, call our office at (727) 329-8859 or email us to find out more about our Wellness Program.

Check out our website.

6 Tests Your Doctor May Not Tell You About… #4 – A Simple Urine Test for Bone Loss

It is estimated that 52 million men and women in the U.S. have osteoporosis. Women start losing bone mass at age 30.

Wouldn’t it be ideal if we could measure in real time whether you are losing bone strength rather than wait until a bone density test shows that strength has already been lost?

Your bone is living tissue, in a constant dynamic state of renewal, building up and breaking down to create new, healthy bone. The breakdown products can be measured in the urine to determine the rate of bone loss. This test can be repeated to see if changes in nutrition, supplements, vitamin D levels, and exercise are improving the rate of bone loss.

There are 2 tests to check for bone loss, the Urine Pyrilinks and the N-Telopeptide (NTx) test. Both detect bone breakdown products in the urine. These tests are usually covered by Medicare and many private insurance plans for those who are at increased risk or who already have osteoporosis or osteopenia. Even if it is not covered, the test is affordable with the Pyrilinks test only costing $80.

There is an incredible book on nutrition and bone health called The Whole Foods Guide to Strong Bones. I would highly recommend it for anyone who is concerned about osteoporosis.

If you are interested in the finding out more about bone loss and live in the Tampa Bay area, call our office at (727) 329-8859 or email us to find out more about our Wellness Program.

6 Tests that Your Doctor May Not Tell You About… #3 Micronutrient Test

The #3 Test that your doctor may not tell you about is the Micronutrient Test (FIA) or nutritional testing.

Have you ever wondered whether you are getting enough nutrients in your diet or whether your vitamins are being absorbed and utilized by your body? This blood test measures 29 different vitamins, minerals, amino acids, fatty acids, metabolites and antioxidants inside the cell (not just in the bloodstream). It also includes a test of your total antioxidant capacity (Spectrox), the ability of your body to neutralize free radicals (toxins) that can cause heart disease and cancer.

If you are interested in the Micronutrient Test and live in the Tampa Bay area, call our office at (727) 329-8859 or email us to find out more about our Wellness Program. For more information on the test, go to the Spectracell website and click on Micronutrient Test. You can also find a physician or draw site in your area on their home page.

6 Tests that Your Doctor May Not Tell You About… #2 Coronary Calcium Heart Scan

The #2 Test that your doctor may not tell you about is the Coronary Calcium CT Score or Heart Scan.

Have you ever wondered whether you already have some degree of heart disease?

Coronary Calcium CT Score is a noninvasive test using a limited heart CT scan to measure the amount of plaque in the coronary arteries. Although this test does not tell you whether the plaque is restricting blood flow to the heart muscle (that would be a stress test), it does tell you whether you are forming coronary plaque, which can help determine how aggressively to treat risk factors such as high blood pressure and high cholesterol.

This test is especially helpful if you have borderline elevated cholesterol. The LPP test (The #1 test your doctor may not tell you about – see last week blog ) is also essential in determining the risk of a borderline elevated cholesterol.

There is much controversy about the heart scan, mostly whether it is “cost effective” (i.e. whether it is worth the insurance companies or government to pay for the test). Most insurance companies do not cover the cost of a heart scan; however, many radiology facilities are offering low cost heart scans ($99 in our area). I do think that deciding whether to treat high cholesterol with medications is a decision not to take lightly and one that requires a comprehensive evaluation of heart disease risk so I sometimes recommend the heart scan for my patients. The heart scan does expose you to a small amount of radiation so it should not be done frequently.

If you are interested in the heart scan and live in the Tampa Bay area (we are in downtown St. Petersburg), call our office at (727) 329-8859 or email to schedule a complimentary cardiac risk assessment.

6 Tests that Your Doctor May Not Tell You About… #1 Advanced Cholesterol Testing

#1 Advanced Cholesterol Testing

Heart disease is the #1 cause of death in men and women and determining heart disease risk is the first step in preventing heart attack. Remember when the only thing your doctor looked for was whether your total cholesterol was over 200? Then we decided that the most important number was the ratio of your bad to good cholesterol. Cholesterol testing has come a long way since. Would you believe it isn’t the amount of cholesterol that determines heart disease risk?

Lipoproteins are the vehicles that carry cholesterol around the body. Now we know it is the type of lipoprotein particles that carry the cholesterol through the body and not the cholesterol within them that is responsible for the plaque production that causes cardiovascular disease. These lipoprotein groups are the most advanced method of evaluating cardiac risk; however, the majority of patients still only have their cholesterol (Total, LDL, HDL, triglycerides) measured.

Furthermore, there are many other markers that can predict a higher risk of heart disease including homocysteine, cardiac CRP, Lipoprotein (a), Apo-E genotyping and HS-Omega 3 Index. I use Spectracell laboratory which offers the LPP test and includes the lipoprotein fractionation along with other risk markers. Medicare and most insurance companies will usually cover the test.

The LPP profile helps to determine which patients are at higher risk, especially in those patients that have LDL in the mildly elevated (130-160) range. To find a doctor familiar with the LPP test, go to SpectraCell.com or if you live in the Tampa Bay area (downtown St. Petersburg), call me at (727) 329-8859 to schedule a complimentary cardiac risk assessment and find out more about the LPP test and our Cardiac Wellness Program.

Would free medical school shift the medical workforce to primary care?

I think most would agree that we have a looming “perfect storm” in medicine which will result in a huge shortage of primary care physicians. This oncoming perfect storm will be due to an influx of patients because of health care reform and the aging baby boomers combined with fewer physicians choosing primary care specialties. Peter B. Bach, the director of the Center for Health Policy and Outcomes at Memorial Sloan-Kettering Cancer Center and Robert Kocher, a special assistant to President Obama on health care and economic policy published an article in the New York Times, Why Medical School Should Be Free. Their argument is interesting; however, I wonder if the basic assumptions are true.

They say that debt is why doctors shun primary care. I wonder how they came to this conclusion. I chose Family Medicine because I loved the relationship with patients, the continuity, the variety of patients and problems, and the challenge of being on the front line of medicine. I never thought about the money. Because I was in the Air Force, I did not have much debt so you could argue that the paucity of debt is why money didn’t play a role in my decision. My husband on the other hand had over $150,000 in debt and chose Anesthesiology. His decision was based on lifestyle and ability to spend time with his family, not on money. I would argue that almost all physicians choose their specialty based on interest in their chosen specialty and desired lifestyle, not money and debt. I don’t think that free medical school and stipends would impact these choices significantly. This proposed plan would be a drastic change in our medical education system and to assume this will solve the primary care shortage seems like a stretch to me.

Chronic Fatigue Syndrome and Fibromyalgia… real or imagined?

“Just because you can’t measure it, doesn’t mean it doesn’t exist.” This was a tweet by the husband of a someone with fibromyalgia (FM). This tweet lit a fire under me. Fibromyalgia is a condition that many physicians believe is psychosomatic, in other words physical symptoms originating from mental or emotional causes. This widespread belief is also true of chronic fatigue syndrome (CFS). Why do we believe that these conditions are psychosomatic? Simply because there is no objective test that proves it exists? How narrow-minded are we? There was a time when we thought the world was flat, because we couldn’t prove otherwise.

Don’t get me wrong. I used to roll my eyes when a patient told me they had CFS or FM. I told my patients that there was nothing wrong with them when the limited panel of “knee-jerk” labs for work-up of fatigue and muscle pain were normal. Then I put them on an anti-depressant and gave them a referral to a therapist. What changed my mind? Two things: 1) seeing patients over and over who had a similar pattern of unexplained, devastating symptoms without any mental or emotional problems and 2) reading the book Osler’s Web, an 800+ page fascinating report about CFS and the doctors who were swallowed up into the labyrinth of searching for a cause. This book was recommended by a patient and forever changed my view of CFS, FM, and Multiple Sclerosis.

Do I know what causes CFS or FM? No, I don’t know the cause but I do know that it is real. I know that it is a dysfunction at a cellular level that affects every system of the body. I do know there are objective findings that have been ignored for decades by mainstream medicine. I do know that patients are devastatingly disabled and unable to work or participate in the lives of their friends and families. Being involved in these patient’s lives has given me a new appreciation for my health that I so often take for granted. And it has inspired me to look outside my scope of knowledge to find a way to help them, rather than turf them to the psychologist or specialist like I used to do. I now look for those objective findings and show them that they are not crazy. I experiment with different strategies to optimize their sleep, nutrition, hypothalamic-pituitary function, and energy levels. Are they cured? No, but if they improve, it is a win.

I believe that someday we will know the cause of CFS and FM, whether it is the XMRV retrovirus, mitochondrial dysfunction, a primary hypothalamic pituitary or some other cause. I believe that CFS, FM, and Multiple Sclerosis (MS) are all spectrums of the same disease process. MS is believable because there are objective findings. CFS and FM are not believable because there is not one specific, objective finding to explain the symptoms. They are invisible diseases. They are not believable because the symptoms are widespread and nonspecific. They are not believable because we don’t look beyond the scope of what we know to be true. And that is the error in our thinking.

“I have bad news for you… you don’t have a disease but it is severe!”

I read a dexascan report today that summarized the patient’s results as “severe osteopenia”. This statement highlights the insanity of our current mentality about disease. Why are we creating these “pre-diseases”? I don’t think it was a physician’s idea to create pre-hypertension, pre-diabetes or osteopenia. What is wrong with saying to someone, “you don’t have diabetes yet but if you continue on the same path, you might develop it.” I have seen many patients who have never been diagnosed with diabetes come into my office on diabetes medications. And patients with osteopenia on drugs for osteoporosis. Obviously, the marketing efforts of the drug companies are behind the scenes feeding into our paranoia about diseases that don’t exist. And money is the driving force.

There was a great article in the LA Times called Diagnosis is a Disease pointing out that these diagnoses that we are creating are increasing healthcare costs. I couldn’t agree more. The article points out that our thresholds for disease have become too low, and in turn, our thresholds for treatment have become low. I agree with this but, more specifically, our thresholds for pharmaceutical drug treatment have become too low. I really like the idea of knowing if someone is at risk for developing a disease but our focus needs to be on treating the real cause.

Diseases such as diabetes, obesity, heart disease, high blood pressure, and osteoporosis are the end result of poor nutrition, sedentary lifestyle, lack of sunshine, lack of sleep, and chronic stress. These diseases are the body’s reaction to a deficiency of what the body needs to function optimally. Until we really believe that and shift our focus, these diseases are going to continue to increase.

Concierge/Direct-Care is a symptom of the broken health care system

I read with interest the family medicine chat a couple weeks ago about the ethics of concierge medicine. Some argue that concierge medicine is unethical and a failure to uphold the medical profession. I missed the chat so I would like to throw in my “2-cents”.

After 10 years practicing medicine within the confines of the insurance-driven health care system, I jumped ship, so to speak, and started a concierge/direct-care practice. This wasn’t a decision that I took lightly. It took several years of contemplation and introspection and was a difficult decision. I had to work through the guilt of abandoning my colleagues who are struggling through a dysfunctional system. I had to work through the argument that I was making accessibility worse by caring for fewer patients. Most importantly though, I had to make sure it was the right decision.

Ultimately I decided that the health care system would likely not be fixed within my lifetime and that I could make a more significant contribution by caring for a few hundred patients exceptionally well than caring for thousands of patients poorly. I decided that I would be of little use to anyone, my patients and my family, if I continued in a state of poor health and burn-out. I decided that I could help patients change their health by bringing back the integrity of the doctor-patient relationship. To me, that was the right thing to do. It was a personal decision, one that I made in the best interest of my family, myself, and my patients. Another reason that I decided to jump off the hamster wheel is that it would give me more time to give back, volunteering time that I didn’t have before and focusing my efforts on educating patients on how to stay healthy.

I would like to address the most common misconception about concierge medicine: that it is only for the wealthy. My patients are a mixture of patients without insurance, patients with catastrophic or high deductible insurance, patients with low deductible employee insurance plans, and those with Medicare. What they all have in common is that they are frustrated and disillusioned with our health care system. Their needs are not being met.

Concierge Medicine is not about selecting wealthy patients. It is about getting the insurance company out of primary care. Primary care is not in itself expensive. It is expensive when there is a 3rd party between doctor and patient. It is expensive when you call it insurance when it is really a health plan. Insurance is meant for catastrophe and spreads out the risk of an unlikely event among a large group of people. But when the coverage is for something that is not unlikely and will be required (primary care), it is expensive. Who pays the 3rd party? The patients, in high premiums, and the doctors, by taking discounted payments and paying someone to collect from the insurance company. The players in the system who are hurt are the patients and the doctors. For patients, they pay more and get less of what they need, access and personalized care. For doctors, they have to care for more patients than they can handle which often leads to poor health and burn-out.

Is concierge/direct-care the answer to the problem with our health care system? Maybe… maybe not… but concierge/direct-care models would not exist if there wasn’t’ a demand. Again, it is a symptom of our broken health care system.

10 Tips to reading food labels

Read the ingredient list, not the grams of fat, carbs, protein, etc… Quality of ingredients beats quantity every time.
Choose foods with few ingredients… less than 5, you get an “A”.
The ingredients should be recognizable and sound like they belong on a recipe, not in a chemistry lab.
Avoid high fructose corn syrup and foods that have many different sugars (ingredients ending in “ose” or “ol”, maltodextrin, corn sweetener, barley malt, any kind of “syrup”, fruit juice concentrate).
Avoid anything partially hydrogenated or hydrogenated (trans-fats).
Avoid any grains or flour that are not “whole”, such as unbleached or bleached enriched flour. Look for the word “whole” in front of the grain (ex: whole wheat flour).
Avoid artificial colors and flavors.
Avoid MSG (monosodium glutamate or anything “autolyzed” or “hydrolyzed”).
Avoid nitrates (sodium nitrite)
And last but not least… eat more foods that don’t have a food label (foods in their natural state).

What prevents cancer, helps us lose weight, makes us look younger, and doesn’t cost a dime?

Sleep has a powerful impact on how fast we age. Sleep literally makes our bodies new.

During sleep, those wonderful hormones that build and renew are released. At the same time, the stress hormones that break down our bodies decrease. Human Growth Hormone (HGH) increases while we sleep. HGH is the “fountain of youth” hormone. People are paying to be injected with HGH so they can look like the 60-something year-old physician in the glossy magazine who has the body of a 25 year-old. The natural way to increase this hormone is to just give your body the sleep it needs.

While we sleep, proteins are built up, building bone strength and lean muscle mass. Other hormonal changes that occur during sleep results in an increase in fat metabolism. And yes, it is proven that lack of sleep makes us fat.

The most amazing thing that happens while we sleep is that the genetic material (DNA) that programs our body to have life and to function as a living organism is repaired while we sleep. Damage to our DNA is what causes cancer. While we sleep, DNA damage is repaired.

So if you didn’t get at least 7 hours of sleep last night, go back to bed. If like me, you can’t go back to bed then at least go to bed earlier tonight.