Michael Carlston, M.D. - Family Practice & Complementary Medicine

Carlston, M.D.
Family Practice and Complementary Medicine

www.carlstonmd.com

December 3, 2008

Dear Patients,

Most people tell me they had a wonderful Thanksgiving this year. I hope you did too.

There has been a flood of interesting and controversial medical research published lately. To help you digest it all, I have been writing equally as voluminously. The consensus essential medical textbook on alternative medicine (Micozzi’s FUNDAMENTALS OF COMPLEMENTARY AND INTEGRATIVE MEDICINE) will be in its fourth edition soon. As the author of the homeopathy chapter again, my writing load has been even heavier. Writing and reflection each seem to be natural elements of this time of year.

Recently I’ve received a number of questions about the flu vaccine. This is an annual event in response to efforts to promote and expand use of the vaccine. If you wish you can read through my previous comments on the flu vaccine for the details, but the bottom line is that I am not a supporter of the vaccine for a number of reasons. That said, there are a small percentage of people for whom I would recommend it. People who are very ill with chronic debilitating disease are vaccine candidates, especially if their chronic disease is of a respiratory nature. However, those patients and any others who are concerned about serious illness developing as a consequence of influenza or other respiratory infection should first consider pneumococcal vaccination.

My apologies to those of you who were unable to purchase my MVM multiple vitamins from our office. The last batch sold faster than anticipated and the manufacturer was slower this time around. In recompense, we will give a discount of 10% off of all purchases of 2 or more bottles of my MVM before December 20. To order you can either call the office 707-545-1554 or send an email to vitamins@carlstonmd.com

In the interest of reducing unwanted email, if you do not wish to receive this newsletter, please reply from the address you would like removed, indicating that you would like to be removed.

Best
Michael Carlston, MD
www.carlstonmd.com

Vitamin D Blood Test Reminder
Recent Vitamin Studies
GERD Drugs and Nasty Bacteria
Heart Disease, Stroke, Depression and Exercise
Spontaneous Remission of Breast Cancer

Vitamin D Blood Test Reminder
Remember that if you can only check your vitamin D once a year, the time to do so is approaching. As it is almost impossible to overdose on D, if your ability to have lab tests performed is limited, you can get away with checking your D at its lowest point. That low point is usually determined by the sun’s own low point, and so your exposure. The absolute ebb lags a bit behind the winter solstice. I recommend testing somewhere from January to March, depending upon your winter travel plans. While I heartily recommend chasing the sun if you can, such a pursuit will change the proper timing of a winter vitamin D blood test.

GERD Drugs and Nasty Bacteria
The proton pump inhibitor (PPI) drugs such as Prilosec (omeprazole), Protonix (pantoprazole), Prevacid (lansoprazole), Aciphex (rabeprazole), Nexium (esomeprazole) and Zegarid (rapid release form of Prilosec) are now strongly linked to increased risk of Clostridium difficile infection, especially among hospitalized patients. Infection with C difficile is a growing problem, with the word “epidemic” often used. The rise in C difficile has paralleled the rise in diagnosis of gastro-esophageal reflux (GERD) and the prescription of these medications to treat GERD. The Centers for Disease Control estimate that C difficile causes somewhere over 5,000 deaths annually in the USA. For many years studies have found an association and theorized that the drop in acidity that is the intended function of this class of drugs lowers the body’s resistance to this bacteria. A similar association has been discovered between C difficile and the other class of drugs which lowers stomach acid - the H2 blockers Zantac (ranitidine), Pepcid (famotidine), Tagamet (cimetidine) and Axid (nizatidine). Use of either class of drugs appears to, at a minimum, double the risk of this common, potentially life-threatening infection. Interestingly, these drugs are commonly used along with antibiotics in the treatment of another infection, H pylori.

Recent Vitamin Studies
A study of 14,000 American physicians ingesting a vitamin C supplement and a vitamin E supplement garnered attention when the authors concluded the supplements did not reduce the risk of cancer or heart disease. Unfortunately again, this study was seriously flawed. Oddly, the authors quoted data summarizing the positive effect of a daily dose of 700 mg of vitamin C or more, and while they used a dose of 500 mg a day. They did not control for dietary intake. Many of us believe that the form of vitamin E used in the study is at best not very good, and potentially harmful. Adding this data to what we have already seen over the years does not sway my judgment that taking moderate doses of these and other vitamins is a safe and reasonable health choice.

A study of the mental effects of a multiple vitamin and mineral supplement on 8-14 year old children found an improvement in measures of attention. This English study was relatively small (81 subjects), but the fact that they found a measurable impact over such a short trial (12 weeks) is impressive. The authors concluded "Whilst it is possible that the significant improvements following treatment were due to non-significant numerical differences in performance at baseline, these results would seem to suggest that vitamin/mineral supplementation has the potential to improve brain function in healthy children. This proposition requires further investigation."

My Approach to Vitamins
When I began my medical studies nutritional research was in its infancy. To warp the metaphor, now nutritional research is infantile. More accurately, I should say that the dissemination of nutritional information is infantile. Every new study leads to over reaction. Instead of careful reflection, considering the new data as part of a whole, the tendency is to forget everything else we know. The Chicken Little, “The sky is falling” approach predominates. The latest information becomes confusing and disturbing. You need to decide what to do, but without spending hours every day studying the nutritional research like I do, how can you? Remembering a few simple principles will help.

Medicine is not about theory; it is about helping people feel better. Although we are supposed to know more, every practicing physician is in the same position you are. We have to determine the best course of action with only uncertain knowledge.

My approach to vitamins derives from awareness of these issues. I balance many factors in my considerations, but a few simple ideas underlie my decision-making process.

Vitamins are, by definition, essential to life. We need them. Not only to be healthy, we need them to live. With the passage of time we identify more diseases, many of them nonlethal, caused by insufficient intake of vitamins and other nutrients. Ironically, in this land of excess, surveys tell us that nutritional deficiencies are common. As our nutritional knowledge increases, we identify more nutritional issues.

Consequently, when I read a study suggesting that multiple vitamin use might not be good for children, I recall US government survey figures showing that the majority of children at certain ages are deficient in certain vitamins. Please note I wrote “majority”, not “many”. The anti-vitamin study is interesting, but almost certainly less important than the massive government survey. So too are conflicting bits of information from all sorts of studies of various vitamins and minerals. Truthfully, I find the disagreements most informative, as careful thought about the reasons for the disparity usually lead to a much deeper understanding of optimal health/treatment.

SCIENCE IS ESSENTIAL – We cannot simply accept that our life-experience is universally applicable and that our linkage of apparent cause to apparent effect is TRUTH. Careful scientific investigation generates ideas and can confirm the real world impact of theoretical principles.

REALITY IS CLINICAL – The test tube is not the real world. Clinical studies are always flawed, at the very least, because YOU, with your precise mix of physiology, genetics and lifestyle, were not in the study. It took me many years to accept the connection between the superior health of some of my most elderly patients and their self-selected vitamin use. It made sense, but I had to consider the relative importance of any other factors that might explain the differences. Common sense always has a place at the table.

MORE IS NOT BETTER – Just because a vitamin is good for you, it does not mean you should take as much as you can. Anything that can help can also harm. Too much can also be a problem.

EVERYONE IS DIFFERENT – We are absolutely certain that nutritional needs vary from person to person due to genetics, diet, lifestyle and environmental factors. For one example, nearly 20% of us lack a certain enzyme and so those bodies do a poor job of changing folic acid into the form our bodies need.

NUTRIENTS ARE DIFFERENT - See above. Those people lacking that folic acid converting enzyme are prone to developing heart disease, cancer and other problems, even when they have a good diet. Most vitamin supplements contain forms of vitamins that are not those our body uses. Some vitamins exist in families (particularly E and the carotenoids). In some cases, research suggests that taking these incorrect forms or incomplete families may be harmful.

RISK VERSUS BENEFIT – If a nutrient is unlikely to harm you if you take it without needing it and not taking it likely to cause harm if you need more, it makes sense to take more of that nutrient. Similarly, if a certain amount is likely to be quite helpful and not very risky, but a higher dose much more likely to be harmful, it makes sense to take a more modest dose. There are some dietary components (eg polyphenols) about which we know only so much, but appear to be promising and low risk. Again, it makes sense to take a moderate dose of those.

Balancing all of these considerations leads to my nutritional recommendations and multiple vitamin design.

In the MVM, I set the doses at an amount ensuring a safety net of nutrients, not megadoses. The MVM does contain “mega-doses” when there is very strong scientific evidence that the usual recommendations are way too low (Vitamin D) or that our individual needs vary widely (B vitamins). It also contains a number of low-risk, potentially high-benefit nutrients.

On the food side of my nutritional recommendations, I strongly encourage patients to view their diets as the all-important foundation. Supplements should be used to overcome dietary deficiency and therapeutically address specific problems. Popping pills of any sort, including vitamins and minerals, is NOT a substitute for a healthy diet! Eating unprocessed, local, organic and low on the food chain is a wise mantra. Although supplements are useful and can be essential to restoring health and preventing disease, they are never as important as eating well.

Heart Disease, Stroke, Depression and Exercise
A decade ago we learned that those who were depressed after suffering a heart attack were dramatically more likely to die in the following six months. A UCSF study of over 1,000 patients with heart disease or history of stroke found that antidepressant medication did not help. The good news is that the study discovered that those who started an exercise program completely eliminated that risk increase. This study was very well designed, so this is a convincing and compelling finding.

Cancer Rates Drop – WHY?
Newly analyzed data show that during the years 1999 to 2005 the rate of cancer diagnoses and the death rate from cancer both fell for the first time in the US. Investigators suggested that the drop was caused by declining smoking rates, removal of cancer-forming polyps on colonoscopy and a sharp drop in the usage of hormone replacement medication. When you consider that the usage of vitamins, especially among the elderly, most cancer-prone segment of the population, rose dramatically over the same period, it is clear that identifying causative relationships is problematic.

Spontaneous Remission of Breast Cancer
It appears that breast cancer, even serious forms, undergo spontaneous remissions (cure?) at a much higher rate than previously believed. A new study of over 200,000 middle-aged Norwegian women published in the Archives of Internal Medicine found that women who had mammograms had a 22% cumulative higher rate of cancer than women who did not. http://archinte.ama-assn.org/cgi/content/abstract/168/21/2311?lookupType=volpage&vol=168&fp=2311&view=short

The most likely explanation, women’s bodies healing these cancers on their own, is one that few would have seriously considered before. The American Cancer Society discounted these findings based upon their unexamined presumption that screening is good for women and that this study might have discovered early breast cancers, leading to a higher incidence rate among women more thoroughly screened. The ACS logic is quite poor and seems to reflect either a superficial reading of the study or a wanton misinterpretation.

Some of you might be wondering if the radiation from the mammography increased the rate of breast cancer. That interpretation would also be incorrect, as the 22% increase would then have been seen only in the number of breast cancers seen in the final mammograms at the end of the study because of the cumulative effects of the radiation exposure. In reality, the 22% increase was a sum of the cancers detected throughout the study not just at the end.

I wonder if this finding might lead to an explanation for one of the other great puzzles of medical epidemiology. As I have written before, while most breast cancers are discovered by women or their partners, the then counter-intuitive evidence is that breast self examination (BSE) does NOT reduce breast cancer death rates. There may actually be an association between BSE and increased death rates from breast cancer. Might it be that identifying cancers, a significant percentage of which are going to vanish without outside intervention, might actually be harmful? That is a very interesting, confusing and concerning thought.

This might be a good time to revisit information I have posted on why you might want to carefully consider cancer screenings, including Gilbert Welch’s book (SHOULD I BE TESTED FOR CANCER? Maybe Not And Here’s Why)
http://www.carlstonmd.com/newsltrs/nl090804.htm

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