Lipid Levels Similar Regardless of Whether Patients Are Fasting Before The Test

Blood SampleAn article in the Archives of Internal Medicine, November 12th, 2012 edition, reviewed the lipid profiles of more than 200,000 patients who had different fasting times recorded before their blood was drawn. Many did not fast at all. The results showed that mean levels of total and HDL cholesterol didn’t differ much at all if the patients fasted or did not fast. Triglyceride levels were the most sensitive to eating or fasting. The data indicated that for the most part, unless your fasting triglyceride levels are 400 or greater there is no need to fast before checking your blood lipid levels.

Diabetics or patients with abnormal blood sugars are required to fast to accurately measure their fasting blood sugar levels. Since science and fact should govern our medical decision making, I changed my office lab testing policy beginning January 1, 2013. We will no longer ask patients to fast before blood drawing unless they are diabetics or have high triglycerides. This will make it far easier for patients who are wondering “what can I eat and drink the morning of my blood drawing for tests?” When we schedule appointments for patients being treated for elevated cholesterol we will no longer ask them to fast or not eat. We will reserve fasting appointments for patients who are suffering from diabetes mellitus or who have a history of elevated triglycerides.

If you are not diabetic and if you do not have extremely elevated triglyceride levels, please take your medications and eat before your scheduled appointment.

I will draw a fasting glucose blood test on all non-diabetic patients annually. Fasting is permitted if your visit is for your annual physical exam.

Statins May Reduce Your Energy Level

Beatrice A. Golomb, MD, PhD. of the University of California San Diego and colleagues discussed the results of their ongoing studies in the Archives of Internal Medicine online edition regarding cholesterol lowering drugs Simvastatin and Pravastatin and recipients’ perception of their energy level. Their research suggested that Simvastatin might leave its users, especially women, feeling tired and drained after exertion.  The scores hinted that almost 40% of women felt more tired and fatigued during physical activity on Simvastatin than without the lipid-lowering drug.

The trial included 1,016 men and women with low-density lipoprotein (LDL) cholesterol screened at 115- 19- mg/dL who were randomized to receive 20 mg Simvastatin, 40 mg Pravastatin, or placebo each day for 6 months. These patients did not have documented heart disease, cardiovascular disease or diabetes.

There was a worsening of perceived energy level and exertion related fatigue in 4 of 10 women on Simvastatin. The effect was much less, and not significant, with Pravastatin or placebo.   In a recent review of statins and adverse effects in the Cleveland Clinic Journal of Medicine, the authors pointed out that muscles performing work required  fats and lipids as a source of fuel and energy to work successfully. They hypothesized the possibility that the goals of cardiology to reduce lipid levels to prevent cardiovascular disease to extremely low levels may create an environment in working muscles where the lipid levels are too low to generate the fuel or energy needed to perform the exercise and work needed to be done.

Clearly, further research needs to be done.  We must remember all these participants DID NOT have vascular disease and this is a primary prevention study to prevent them from developing cardiovascular disease.  Might there be other methods to achieve this?  Is Simvastatin the only statin to cause this type of problem or will the other statins do the same?  Is this a problem of the particular generic brand of Simvastatin used or is it an across the board effect of Simvastatin?  All these questions require additional research to obtain the answers that we need.

Dark Chocolate: Cardiovascular Prevention

A study from Australia predicts that if 10,000 men with big bellies and the “metabolic syndrome” (abdominal obesity, diabetes, hyperlipidemia , hypertension)  ate 100 grams of  dark chocolate daily, it would prevent 70 non-fatal and 15 fatal heart attacks per year.  The total yearly cost of the chocolate is less than $50 per patient.   Recent studies have shown that dark chocolate can reduce high blood pressure and lower lipids.  This study was based on a model that predicted the effects of dark chocolate lasting for 10 years when, in fact, true research studies have not lasted that long.

This is a promising avenue of research involving a food substance that most of us enjoy.  For my patients, almost any food in moderation produces success.

Statins Reduce Risks, Even in the Lowest Risk Groups

Current guidelines for the use of statins in the USA (Lipitor, Zocor, Crestor, Atoravastatin, Simvastatin, Pravastatin, etc.) call for only treating individuals who have a ten-year risk of major vascular event of at least 20%.

European researchers including Borislava Mihaylova, MSc DPhil, and colleagues on the Cholesterol Treatment and Trialists Collaborators team writing in the Lancet question whether the guidelines should be changed to treat individuals with even lower risks. Their large Meta analysis suggests that statins provide substantial benefits for primary prevention – especially in patients with a 5-10% ten year risk of a major vascular event. They looked at data from 27 trials including over 175,000 participants. When they took into account cost and side effects of statins, such as muscle pain and inflammation, rhabdomyolysis, diabetes and hemorrhagic stroke, they concluded that the benefits still far outweighed the risks. They think that the clear-cut affect on lower risk individuals coupled with the fact that almost 50% of vascular events occur in patients without previous cardiovascular disease necessitates the broadening of USA guidelines for treatment of patients. The researchers go on to hypothesize that as more generic statins enter the market, cost concerns will become far less of a factor in the decision to treat or not treat.

They noted that for each 1 mmol/L reduction in LDL cholesterol, there was a 21% reduction in the relative risk of major vascular events, and all cause death, irrespective of age, baseline LDL or previous cardiovascular disease.

This research makes it clear that there is great value in assessing the statistical cardiovascular risk of each individual and being more aggressive in the use of statins than current national guidelines call for.  Incorporating risk tools such as the Framingham Risk assessment plus looking at newer techniques such as the measurement of carotid artery intimal thickness may be appropriate in the decision to choose a statin or not.

I Lost 52 Pounds And Feel Fantastic!

Patients have noticed my recent 52 pound weight loss but, for the most part, have been reluctant to approach me to discuss it. I’m sure many have wondered if this was a planned weight loss or the result of a serious illness.

Let me bring clarity to any concerns. My weight loss was planned as part of a lifestyle improvement program and, as a result of my commitment, I now feel great!

Like many Americans, I had accumulated extra pounds due to poor food choices, large portions and poor health habits. Finally, I decided to get healthy BEFORE I became ill and my doctor insisted on it.  I established certain criteria in choosing a weight loss program. It had to be safe, effective and rapid. I did not want medications or injections to be involved. Any program I was to consider had to have a proven safety record with no patients becoming ill.  There needed to be a sane transition program and maintenance program to teach me how to prevent regaining the weight rapidly and how to move on and live a healthy future life.

After much research I found the Take Shape for Life Program (www.tsfl.com).  Clinical studies by Johns Hopkins, the National Institutes of Health (NIH) and other organizations have proven the effectiveness of this program.  It has been recommended by over 20,000 doctors.

Take Shape For Life provides a network of ongoing behavioral support, education and other tools while using the nutritionally-sound Medifast meal replacements.

TSFL participants eat six small meals per day – all of which are low in fat and sugar but rich in protein and nutrients.  The five daily small Medifast meal replacements are supplied by TSFL and are eaten every two to three hours along with one lean and green meal that you prepare yourself.  These small frequent meals keep you from becoming hungry and getting cravings. As part of the program you have access to a free health coach / guide / cheerleader who assists with recipes, lifestyle tips and helps order product. The low average monthly cost to participate in the TSFL program is about $315.

I started the program in mid January and reached my goal weight in just four months. I am now working on transitioning to the maintenance program. My lovely wife is also participating in the TSFL program and has over 40 pounds to date.

I suggest those of you who are struggling to lose weight discuss it with me.  The program is perfect for diabetics, hypertensives, individuals with heart disease and individuals with gluten sensitive enteropathy.

Please contact me with any questions you may have, to request information or, to begin your journey to achieving optimal health by enrolling in Take Shape For Life.

Statin Use and Diabetes in Older Women

Older women who take statins may be at an increased risk of developing Type 2 Diabetes Mellitus (adult onset). In a study published in the Archives of Internal Medicine, Dr Ma, of the University of Massachusetts School of Medicine, looked at the 154,000 women in the Women’s Health Initiative who did not have Diabetes when the study began in 1993.  Seven percent (7%) of them were on statins at the time through follow-up, 12 years later.  At that point, 10,242 cases of new cases of diabetes were reported. They theorize that this computes to an almost 50% increase in becoming a Diabetic if you are on a statin as compared to women who are not. Surprisingly, this occurred far more frequently in thin women taking a statin than in heavy or obese women.

The salient points taken out of this research are that women on statins need their liver enzymes monitored frequently they need their blood sugars monitored as well. The overriding message is that as physicians and patients we need to make a monumental effort to control elevated lipids by diet , exercise and weight loss without statins if humanly possible.

This also raises the question of whether we should be measuring HDL and LDL subtypes an Lpa levels on all patients before instituting statin therapy?  While this raises doubt about a popular class of drugs that are a crucial part of the prevention of cardiovascular disease, it does not yet make it clear what the clinical implications are for postmenopausal women on statins.

I will reevaluate all my female patients on statins as I see them for follow-up visits.

The Turnovers are the Difference- Medical “Handoffs” Are Continually Fumbled

This is a humbling football season for those of us who root for Florida teams at the collegiate or professional level. It seems that each week after another loss we are listening to the head coach standing at the podium during a post-loss press conference talking about how if the handoffs had not been fumbled, and the ball dropped and lost, his team could have prevailed. It is hard enough to deal with the turnovers and fumbles when rooting for your team. It is far more difficult to deal with it when we are talking about human beings hospitalized and cared for by hospital employed physicians and then turned back to the community without communicating adequately, or at all, with the care team responsible for their continued care at the community level.

Take the case of GH, an 82 year old obese diabetic with high blood pressure, high cholesterol and heart irregularities requiring the use of Coumadin to prevent a stroke. He awoke one morning two weeks after a major auto fender bender and found his underwear stained in bright red and dark brown blood. His wife was unsure if it was coming from his rectum or penis so she called 911 and allowed the patient to be taken to the nearest emergency department.  He was seen by the emergency room staff and admitted to their contracted hospitalist service for presumed intestinal bleeding due to Coumadin toxicity.

Eight days later he was discharged home with an indwelling Foley catheter needed because of the “clots” in his bladder. His Coumadin had been stopped on admission and never restarted. GH could not get out of the bed and walk while in the hospital and he stubbornly refused to go to a nursing rehabilitation center as an interim step until he was strong enough to walk independently.  His frail 80 year old wife, battling a lymphoma herself, was given the task of caring for this obstinate man at home and emptying and caring for his indwelling urinary catheter.

On his first day back home, I received a phone call from his wife informing me of this. She didn’t know what she could possibly do to care for him because he weighed 230 lbs and he couldn’t get out of bed and walk. A nursing service and physical therapist had been requested but had not yet called to schedule a visit.  She was particularly disturbed because 12 hours had gone by since he got home with no urine appearing in the bladder drainage catheter. At the same time his lower abdomen was growing in size and he was feeling pain and discomfort at that spot.  Once again, 911 was called and he was taken back to the same emergency department. Paramedics transport sick patients to the geographically closest facility not necessarily the one his physician sees patients at.

GH was readmitted because his catheter was blocked with clots and needed irrigation and there were concerns about a urine infection. I spoke with the wife and children and asked for the name of his doctor but they could not remember it. They did remember the name of his consulting urologist. I called the urologist who was a bit put out to discuss the case with me. He told me that “our“ patient was bleeding from the urinary tract due to a transitional cell cancer of the bladder that he discovered and treated during a cystoscopy. He felt the prognosis was excellent.

The urologist declined to discuss whether the patient was additionally bleeding from his intestinal tract or if the appropriate evaluation had been done. He suggested I find the hospitalist responsible for the patient’s care. When I asked for the name of the hospitalist he told me he had no idea who it was. “They all look the same to me,” was his actual response.

I asked the patient’s wife to have her husband sign an authorization to release medical records and obtain the medical records of his admissions for my review. She did that and presented it to the medical records department who sent me a brief summary of his second admission. It took three phone calls to obtain the records of the first admission and another to get the emergency department records.  I needed this material because it was quite easy to convince the patient to come to a local rehab facility after this hospitalization with me as his attending physician.  The patient and family had no idea why he was bleeding other than “I had clots” in the bladder. They didn’t know the name of his hospitalist either.  When I received the records it identified the physician. I called the hospital to page her but was told she was “off “for the next few days. Her colleagues on duty did not know or remember the patient.

The patient records finally arrived. His admission diagnosis was bleeding due to Coumadin toxicity, but the INR (a measure of how effective the Coumadin is in thinning the blood) was very low indicating that his blood was not anticoagulated much at all.  An INR of 1.4 doesn’t cause bleeding and is not toxic. The medical record said he had hematochezia (blood in his stool) but there was no documentation that anyone had performed a rectal exam or examined a stool specimen for the presence of gross or microscopic blood.

There was a lab order to type and cross-match the patient for a blood transfusion but certainly no mention that a transfusion had actually occurred. There was a thorough procedure note from a gastroenterologist who looked in his stomach and colon several days after admission and found no source of bleeding. I called the gastroenterologist on the day I received the records but he was gone for the Thanksgiving weekend.  The records indicated the patient’s blood count showed hemoglobin of 9.3 on the day prior to discharge and 8.3 on the day of discharge but there was no mention of an investigation of why the blood count dropped and why he was released with a dropping blood count.  A chest x-ray report on his first admission showed a right lower lung infiltrate but there was no follow-up performed or reported.

The patient arrived at the local rehab facility on Thanksgiving morning. I saw him and performed a thorough history, review of his records and an exam.  He was no longer bleeding, with no black stools noted on my rectal exam and no microscopic blood on the stool occult blood slide test I performed at the bedside. His Foley catheter was draining clear non bloody urine and the patient looked pale but well.

It was really very easy to convince this patient to come to rehab to learn to walk again once I became aware of his hospitalization and condition.  After my initial exam I sat down with the charge nurse and we constructed a care plan for the next few weeks at the rehab facility and explained it to the patient. Then I told the patient he had bladder cancer with a good prognosis. He was completely unaware of that diagnosis until we had the conversation.  I called his wife and children separately and reviewed the diagnoses and care plans for follow-up.

GH entered the hospital on an emergency basis as an unknown. He was appropriately taken to the nearest receiving facility by the paramedics when he was found to be on a blood thinner and bleeding actively.  His inpatient hospital employed physicians prevented a catastrophe and did what was necessary to make sure one was not ongoing. They did little or nothing to insure the loose ends of his medical problems resulting in hospital admission were addressed or understood by the patient and family.  Little or no effort was made to insure continuity of care and appropriate follow-up.

Judging by the editorials in our peer reviewed medical journals, this has become the norm not the exception in our insurance company / employer driven health care system. The devil is in the details. Unless the loose ends are planned for , understood and addressed, patients like this will continue to be bounced back to the hospital as an “emergency”, unnecessarily spending money we do not have and do not need to waste.

Reducing Triglyceride Levels

The American Heart Association along with Michael Miller, M.D., director for the Center for Preventive Cardiology at the University of Maryland – School of Medicine in Baltimore, just released data and recommendations that diet and lifestyle changes alone should be sufficient to reduce elevated triglyceride levels.

The researchers analyzed more than 500 international studies conducted over the last 30 years for the purpose of updating doctors on the role of triglycerides in the evaluation and management of cardiovascular disease risks. The study confirmed that triglycerides are not directly atherogenic but are instead a marker of cardiovascular disease risk.  High triglycerides are commonly seen in diabetes mellitus, chronic kidney disease and certain disorders associated with HIV disease. Alcohol and obesity plus inactivity all contribute to elevated levels with TG levels rising markedly in this country since the mid 1970’s in concert with the obesity epidemic we are now seeing.

Triglycerides are checked on a fasting blood test of optimally 12 hours with the upper limit of normal set at 150mg/dl. Newer recommendations will reduce the level to 100 mg/dl.  If your triglycerides are elevated the study made the following suggestions to lower them to appropriate levels:

  1. Limit your sugar intake to less than 5% of calories consumed with no more than 100 calories per day from sugar for women and no more than 150 calories per day from sugar for men.
  2. Limit Fructose from naturally occurring foods and processed foods to less than 50 -100 grams per day
  3. Limit saturated fats to less than 7% of total calories
  4. Limit trans-fat to less than 1% of total calories.

Elevated triglycerides, especially above 500 mg/dl, are associated with an increased risk of pancreatitis. For individuals with TG levels this high we recommend complete abstinence from alcohol.

Exercise is necessary to lose weight and lower triglyceride levels as well. Physical activity of a moderate level such as brisk walking for at least 150 minutes per week (2.5 hours) can lower your triglycerides another 20-30%.

If lifestyle changes including diet modifications and aggressive exercise do not bring you to target levels we suggest the addition of marine based omega 3 products. Also, eat fleshy cold water fish!

A combination of dietary changes, moderate regular exercise and weight reduction is all that is needed to control most problems with triglycerides.  Referrals to registered dietitians can be very helpful in assisting you with the dietary changes required to be successful.