Vitamin D Supplements and Pregnant Women

According to this article in the American Journal of Clinical Nutrition, pregnant women have an even greater need for Vitamin D supplements than non-pregnant women. http://www.ajcn.org/content/79/5/717.full If she were my wife, I would have her on two Vitamin D 5000 IU gel caps — one in the morning and one in the evening 12 hours later. Vitamin D works slowly.

Vitamin D 5000 IU softgels Vitamin D 5000 IU softgels

FDA and Intravenous Vitamin C Cancer Therapy

If FDA officials actually listened to patients, they wouldn’t be trying to cut off the use of intravenous ascorbic acid (IAA) as a cancer-fighter..

orange slices orange slices

Persistently high HbA1C levels even on a low glycemic index diet

Later this year I may try Carnosine, which has been shown to reduce or eliminate advanced glycation end products. But Carnosine is somewhat expensive, and it helps with cleaning up the effects of too much serum glucose, but does not actually lower the glucose levels.

LCarnosine500mg LCarnosine500mg

Natural Sulforaphane from Broccoli Sprouts: A Supplement with Antioxidant, Antidiabetic, Anticarginogenic, and Anti-Inflammatory Functions

Researchers at the University of Michigan (U of M) Comprehensive Cancer Center believe that sulforaphane could become both a novel and highly effective treatment for breast cancer. Current chemotherapy treatments attack rapidly dividing cells but do nothing to stop cancer stem cells — the small number of specific cells responsible for fueling the growth of cancerous breast tumors. [2] In laboratory experiments, sulforaphane was shown to target and kill cancer stem cells and prevented new malignancies from growing.

broccoli sprouts broccoli sprouts

Checklist of Treatments for Alzheimer’s Disease Part 1 of 3

For approximately ten years, I have cared for a parent with slowly advancing Alzheimer’s disease. Contrary to all of the horror stories portrayed in the national media, I have found that the burden of caring for an Alzheimer’s sufferer is less onerous than I originally expected. The primary reason that my burden has been lightened [...]

alzheimer's disease brain alzheimer's disease brain

Vitamin K and Arterial Calcification

Posted by Michael A. S. Guth on January 22nd, 2012

I see that you are interested in drugs used to treat cardiovascular disease and also coagulation.  I was wondering if you had time to look at the scientific literature related to therapeutic doses of Vitamin K.  As you know, Vitamin K gets its name from the German word “koagulation.”  We know that Vitamin K plays a vital role in bone health, but not many physicians seem to appreciate the importance of Vitamin K, particularly menaquinone-7 (MK-7), in cardiovascular health.

 

It is well known that vitamin K antagonists, such as warfarin, double arterial calcification in humans.  One of my research interests is whether the converse is true:  large doses of Vitamin K can actually remove arterial calcifications and put the calcium back in the skeletal structure where it belongs.  Several doctors at Life Extension in Florida have told me that it does, but I have not seen a clinical trial on this topic in the medical literature, perhaps because it would be too expensive to determine arterial calcification before and after treatment.

 

If we speak by phone sometime, I would like to spend 5 minutes on this topic and see if you read anything about treating arterial calcification with safe but high doses of Vitamin K.

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GETTING INSURANCE TO PAY FOR PREVENTIVE HEALTH UNDER THE ACA

Posted by Michael A. S. Guth on January 13th, 2012

The Affordable Care Act (ACA) mandates that health insurance companies pay for preventive health visits. However, that term is somewhat deceptive, as consumers may feel they can visit the doctor for just a general checkup, talk about anything, and the visit will be paid 100% with no copay. In fact, some, and perhaps most, health insurance companies only cover the A and B recommendations of the U.S. Preventive Services Task Force. These recommendations cover such topics as providing counseling on smoking cessation, alcohol abuse, obesity, and tests for blood pressure, cholesterol, and diabetes (for at risk patients), and some cancer screening physical exams. BUT if a patient mentions casually that he or she is feeling generally fatigued, the doctor could write down a diagnosis related to that fatigue and effectively transform the “wellness visit” into a “sick visit.” The same is true if the patient mentions occasional sleeplessness, upset stomach, stress, headaches, or any other medical condition. In order to get the “free preventive health” visit paid for 100%, the visit needs to be confined to a very narrow group of topics that most people will find vert constrained. The “preventive health visit” portion of the ACA has given patients incentives to withhold information from their doctors lest any possible diagnosis code be written on the claim form during these visits.

Similarly, the ACA calls for insurance companies to pay for preventive colonoscopy screenings for colon cancer. However, once again there is a catch. If the doctor finds any kind of problem during the colonoscopy and writes down a diagnosis code other than “routine preventive health screening,” the insurance company may not, and probably will not, pay for the colonoscopy directly. Instead, the costs would be applied to the annual deductible, which means most patients would get stuck paying for the cost of the screening.

This latter possibility frustrates the intention of the ACA. The law was written to encourage everyone — those at risk as well as those facing no known risk — to get checked. But if people go into the procedure expecting insurance to pay the cost, and then a week later receive a surprise letter indicating they are responsible for the $2,000 – $2,500 cost, it will give people a strong financial disincentive to getting tested.

As an attorney, I wonder how the law could get twisted around to this extent. The purpose of a colonoscopy is determined at the moment an appointment is made, not ex post facto during or after the colonoscopy. If the patient has no symptoms and is simply getting a colonoscopy to screen for colon cancer because the patient has reached age 45 or 50 or 55, then that purpose or intent cannot be negated by subsequent findings of any condition. What if the doctor finds a minor noncancerous infection and notes that on the claim form? Will that diagnosis void the 100% payment for preventive service? If so, it gives patients a strong incentive to tell their GI doctors that they are only to note on the claim form “yes or no” in response to colon cancer and nothing else. Normally, we would want to encourage doctors to share all information with patients, and the patients would want that as well. But securing payment for preventive services requires the doctor code up the entire procedure as routine preventive screening.

I would be curious what solutions, if any, others on this discussion board might have for this payment dilemma.

COMMENT:  Michael: This problem won’t go away unless the government steps in and redefines the intent. I have numerous clients that have encountered this problem and they place the blame on the insurance company or the provider. If a polyp is removed the provider is going to code it as a surgical procedure regardless of the intent to screen for colon cancer. If the government were to revise the law with a special coding it may alleviate this problem.

You raise a good point. The question is how do consumers inform the government of the need for a special coding or otherwise provide guidance on preventive screening based on intent at time of service, not on subsequent findings? I could write my local congressman, but he is a newly elected conservative Republican who opposes health care and everything else proposed by Obama. If I wrote him on the need for clarification of preventive health visits, he would interpret that as a letter advising him to vote against health care reform at every opportunity. I doubt my two conservative Republican senators would be any different. They have stand pat reply letters on health care reform that they send to all constituents who write in regarding health care matters.

To my knowledge, there is no way to make effective suggestions to the Obama administration.

Perhaps the only solution is to publicize the problem in articles and discussion forums like this one. My local newspaper is the Knoxville News-Sentinel. Perhaps I could try writing an op-ed piece and see if the newspaper will publish it.

COMMENT:  I live in a liberal state, CT. Everytime I write any of my congressman or senators I also just get a “canned” response. This matter has been published throughout the healthcare community and all over the USA. Perhaps a formal letter to my congressional rep’s. will work.

DIFFERENT COMMENT:  I keep seeing words like Government stepping in, Government getting involved, writing Congress, etc.. Our Congress wrote this bill and voted it into law, all the while excluding themselves from having to subject themselves to this quagmire they’ve dealt upon us. We need to repeal this law ASAP and remove Govt from out healthcare system. The AMA knew what was in this bill prior to backing this, and knew that doctors could only do a minor procedure to bill a patient a tremendous amount (they have their own kids tuitions to pay for too), now they’ve backed away from it and trying to kill it after the fact. Now the Govt has cut Medicare reimbursements by 29.5%, and doctors are sending letters to their patients informing them they’re no longer accept Medicare payments, and that it is cash only (my father has received two such letters).

PPACA is not Healthcare Reform, it doesn’t deal in anyway with medical cost reductions or real in Big Pharma, its simply traction into private industry and measure for the Govt to tell Privately held companies how they can treat their contracts with their clients, and what they can pay their employees and contractors. Reagan warned this of this back in 1961.

There is a clear and absolute need for government to get involved in the health care sector. You seem to forget how upset people were with the non-government, pure private sector-based health care system that left 49 million Americans uninsured. When those facts are mentioned to people abroad, they think of America as having a Third World type health care system. Few Japanese, Canadians, or Europeans would trade their existing health care coverage for what they perceive as the gross inequities in the US Health Care System.

The Affordable Care Act, I agree, completely fails to address the fundamental cost driver of health care. For example, it perpetuates and even exacerbates the tendency of consumers to purchase health services without any regard to price. Efficiency in private markets requires cost-conscious consumers; we don’t have that in health care.

But for you to continue with this string of posts calling for government to get out health care completely is pointless. The Medicare program is highly, highly popular, as is Social Security. Any time a political party or pundit talks about cutting Medicare or Social Security, the public rises up with indignation.

I am glad the ACA was passed. It is a step in the right direction. As noted, there are problems with the ACA including the “preventive health visits” to the doctor, which are supposed to be covered 100% by insurance but may not be if any diagnostic code is entered on the claim form.

Congress is so polarized on health care that the only way to get changes is with a groundswell of popular support. I don’t think a letter writing campaign is the correct way to reform payment for the “preventive health visits.” If enough consumers advise their doctors that this particular visit is to be treated solely as a preventive health visit, and they will not pay for any service in the event the doctor’s office miscodes the visit with anything else, then the medical establishment will take notice and use its lobbying arm to make Congress aware of the problem.

But I don’t want this thread to become distracted with posts about a “no government role” in health care. Our purely private health care system costs twice as much per capita as the next most expensive system, but ranks around 24th globally in terms of performance. Any economist knows there are classic examples where private markets break down and fail, and public goods are necessary. Let’s keep this thread focuses on payments for preventive health, and not try resurrect old debates on the role of government long since put to rest.

 COMMENT: Should there not be an agreement up front between both parties on what actions that will be taken if said item is found or said event should be seen or occur? Should their be a box on the pre-surgical form giving the patient the right to denying the doctor to take proper action (deemed by whom?) if they see a need to? Checking this box would save the patient the cost of the procedure, and give them time for a consult. If there is not a box to check, why isn’t there one?

SECOND COMMENT: Do you really think that a doctor is going to not perform a necessary medical procedure because the patient has checked a box on the authorization form? Let’s be realistic here.

There are two separate questions posed by the checkbox election for procedures. First, does a patient have a legal right to check such a box or instruct a physician/surgeon orally or in writing that he does not give consent for that procedure to be performed? The answer to that question is yes.

The second question is does it serve the economic interest of the patient to check that box? For the colonoscopy, in theory the patient would get his or her free preventive screening, but then be told the patient needs to schedule a second colonoscopy for removal of a suspicious polyp. In that case, the patient would eventually have to pay for a colonoscopy out of pocket (unless he had already met his yearly deductible), so there is no clear economic rationale for denying the physician the right to remove the polyp during the screening colonoscopy.

But we are using the much less common colonoscopy example. Instead, let’s return to the original posting subject, which concerned preventive care with a primary care doc. Should a patient have the right to check a box and say “I want this visit to cover routine preventive care and nothing more”? Certainly. There is way too much discretion afforded physicians to code up whatever they want on claim forms such that two physicians seeing the exact same patient might code up different procedures and diagnostics for the exact same preventive health screening visit.

When I expect to receive a “zero cost to me” preventive screening, I do not imply that I am willing to accept a “bait and switch” change of procedure and payment due to the doctor from me. The “zero cost to me” induces consumers to go to the office visit; it is actually paid for out of the profits earned by the health insurance firms to whom consumers pay monthly premiums. Consumers need to hold doctors financially accountable for their claim billing practices. If you are quoted a “zero price” for a visit, the doctor’s office better honor that price, or it amounts to fraud.

It is all too easy to find any little old thing to justify billing a patient for a sick visit instead of a wellness visit. However, it is up to the patient to prevent that kind of profiteering at his or her expense.

 COMMENT:  This matter should not be afforded legal action. Since, the ACA dictates coverage to the carriers, all it really needs is clarification regarding the coding of the claim submission. HHS should be able to handle this directly with the carriers.

Yes, I agree it would be wonderful if HHS would give carriers the proper code or specify that other diagnostic codes cannot negate the preventive screening code used for a wellness visit. That is not happening now. DHS has been bombarded with so many questions and suggestions for health care reform that the department has a fortress like mentality. So realistically, consumers cannot expect DHS to address the coding issue for preventive health screenings any time soon. That leaves the full burden to fall on each consumer to ensure the doctor’s billing practices match the patient’s expectations for a free preventive health office visit.

 COMMENT: I most commonly work with self employed and small business owners responsible for 100% of their premium and out of pocket expenses. Each of these “free” physicals and tests add to their costs, costs less and less can afford to pay.

A question I would like all to consider (but in a separate thread I will start later),

A fundamental rudimentary question nearly each asks me is, “I am trying to keep my premiums low. If I want a test I will pay for it, Why am I forced to pay for yearly physicals and diagnostic tests if I don’t want to get?” (this is another example of “nanny state” getting involved in people’s lives when they should not).

ehealthinsurance.com shows dozens of health insurance policies where no preventive health benefit is covered. These so-called “nanny state” customers must be complete morons if they have not found plenty of low cost health insurance policies with no coverage for preventive health. Actually, as a small business owner myself who pays 100% of premiums, I have easily secured those policies for the past ten years. I was surprised to find that for basically no additional premium cost, i.e., policies that cover preventive health and those that do not seem to be charging approximately the same monthly premium, I can now get limited preventive health coverage on some of these policies. It is the sole reason why I dropped my carrier for the past 7 years and switched to a new policy in January 2012.

Forcing health insurance companies to pay for preventive health is one example of how health care reform is working to achieve positive results. The private market was certainly free to offer preventive health screenings at zero cost to the consumer for the past 50 years, but it chose not to do so. Given that preventive health screenings are a net positive for society, we could go so far as to say the past fifty years illustrative a market failure. Instead, it took the an Act of Congress to shake up the health insurance industry and start implementing cost effective reforms.

Let’s try to keep the posts in this thread germane to the issue of private health insurance paying for preventive care and not drift to old, worn out debates over whether the government has any role in health care.

COMMENT:  Another perspective. For the colonoscopy example, I thought it was more likely that polyps were removed on the screening colonoscopy, but the patient would (1) have another diagnosis added to their record that may affect insurability in the future; and (2) recommendation for more frequent follow up that would then be no longer “preventive” because something was found in the past. From what I’ve been told, if a previous colonoscopy is “clean” the following one is preventive (a factor for those who have a history of polyps and undergo colonoscopies every 5 years). 

Also, if a patient goes for a “preventive” visit but brings additional issues to address, a physician can “split bill” and code for a preventive and a non-preventive visit on the same claim because a medical issue was also addressed and significant time was taken on that issue. I’m not a coding or billing expert – are these scenarios correct?

You are correct on both points concerning the colonoscopy — that is how it is done as a matter of course now. The more fundamental question is should people be encouraged to get screening colonoscopies, and if so, then what impact will having to pay the costs of the colonoscopy have on people’s willingness to get screened? In other words, regardless whether any lesion or polyp is found, or any other condition for that matter, if the patient signs up for a “preventive” screening, then it should be recognized and billed as a preventive screening regardless of findings. Anything short of that will provide a financial reason not to get screened.

The ACA in 2014 would prevent health insurance companies from using prior findings of polyps to exclude applicants from coverage. In general, pre-existing conditions will not be a basis for denying coverage after 2014. A question remains how high insurance companies can jack up the premiums for an applicant who discloses prior findings or conditions.

On your last point, a doctor could split bill a single patient encounter, but most would refuse, because that amounts to double paperwork. Instead, if the patient has problems to discuss, the patient should book a regular/sick visit appointment. Depending on how long it takes to go over the problems, the doctor may have time for the “free preventive health” portion. If not, the patient should make a separate appointment for solely for a wellness visit and explain at the outset that the patient only wants the services covered by the ACA’s “preventive health visit” policy. The patient should explain to the front desk staff and the doctor that there is no copay and no cost to the patient for the preventive health visit — that sets up a legal expectation for no surprise bill from the doctor’s office. I have put that into effect, and it works.

COMMENT:  Just a follow up on the split billing issue. In the case where I saw it discussed, it was actually encouraged because (1) patients did not want to make 2 separate visits to the physician (in fact, many won’t come back if you say, “make another appt to discuss your medical issues”); (2) many patients with chronic conditions do bring issues to manage to their preventive visits; and (3) many patients in this stage of the game don’t understand the difference between these different types of visits and really don’t want to. When they get the bill and they have to pay, it gets their attention, but even at that point they blame either their clinic or their insurance company rather than try to understand the nuances of what’s included in their benefits. I don’t think people appreciate how difficult this is for non-healthcare people to grasp – especially if they are very busy with their lives and/or they have a serious disease that requires much time and attention to get the care needed and causes them significant emotional distress as well! I truly empathize with these people! And as for the assertion that you can’t be denied insurance if you have a finding on a colonoscopy – if the cost is prohibitive for the individual, isn’t that essentially denial?
You are right that for most patients the nuance between a wellness visit and a sick visit is unclear. However, those patients who read about a new preventive health benefit available at zero cost to them will take the time to learn what is included and what is not. If they expect to pay a copay and part of lab costs anyway, then the wellness visit benefit is not going to have much value above what they would have received anyway.
With regard to pre-existing conditions, if insurance premiums are scaled up so high that they are unaffordable by those in need, then I agree that price effectively denies them insurance coverage. I suspect the ACA imposes limits on how high an insurance company can scale up its premiums, but I have not checked the details. A second consideration is that millions of Americans will qualify for federal subsidies on insurance beginning in 2014. It is possible that a policy premium that looked unaffordable on first impression would be affordable with the subsidy kicking in.

COMMENT:  There will be limits but will they apply when there has been a change in condition? I thought most of those administrative restrictions have not affected actuarial realities, which this seems to be. It’s hard to believe insurance companies would support a bill that says they’re limited on how much they can charge when someone acquires a new condition or disease. As far as qualifying for federal subsidies – I think most people will not welcome this. I’m sure the paperwork will be significant, and it seems to me that many people just don’t want to think of themselves as being dependent on the govt. Maybe that’s changed, but when it’s a label (not the case with Medicare and Social Security where everyone qualifies), it can be an indication that you’re not as successful as most people. A hard pill to swallow for many people, I think.

DIFFERENT COMMENT:  PPACA to my knowledge only makes plans guarantee issue, but does not take into account pre-existing condition or risk rate-ups. In the State of Michigan a carrier can rate up a Child only policy 500%, and an adult 200%. this would make a $500 premium $1500 per month – which is much more expensive then the current State HIPAA plans and Open Enrollment HMO plans that are available to every resident in the State. From what I understand, with 2014 PPACA, there is consideration for discontinuing the State HIPAA plans as fixed price/guarantee issue. If this occurs, all PPACA has done is increase rates up so high for some they will have to go uninsured.  It is my opinion that PPACA was written so poorly, it is meant to drive this nation to socialized Single Payer system.

Tell the “morons” that you mention in your post to go to the following web link: http://www.ehealthinsurance.com/ehi/st/all-plansAs of today’s date, Jan. 4, 2012, I located 88 separate health insurance plans available in my state, Tennessee, that do NOT provide preventive health visit coverage, as most of these policies do not provide doctor visit copay benefits. Until the plan deductible is met, any trip to the doctor — whether well or sick — is picked up by the patient for most of the 88 policies. Preventive health coverage payment is excluded by all 88. They provide coverage up to one year, which can be renewed, and they are affordable — the lowest prices available on the Internet for major medical coverage.

The small business owner clients are not the morons here. You clearly have a political agenda to point out how the big bad federal government is ruining health care. Unfortunately, what you know about economics could fit in a thimble. You argue that $460 in preventive services is passed along to the consumer at $38/month. That assumes that consumer demand for health insurance is completely inelastic — a fact directly contradicted by evidence of lack of coverage and consumer shopping for better coverage — and thus costs can be shifted onto consumers dollar for dollar. In fact, consumer demand for health insurance is both price elastic and income elastic — meaning demand for insurance decreases with premium increases or income reductions.

But if all that theoretical evidence were not enough, your argument completely fails when we look at the real world premiums for health insurance. I just spoke to a representative at ehealth on the toll free number 1-800-977-8860. He confirmed that there was no jump in prices circa September 2011 when insurers began covering preventive health visits at 100%. For most plans by United Healthcare and Blue Cross, the two largest insurers in my state, the premiums for Tennessee resident single male policies in January 2011 are close to or identical to the premiums for the exact same policy in January 2012. Prices have not jumped up by $20/month or $30/month or $40/month to pay for preventive health. The representative from ehealth mention some pundits were expecting a price increase, but the competitive pressure of the private markets kept the premiums from rising. He noted some states, such as New Jersey and Massachusetts experienced premium rises, but that was due to changes in state laws, not the ACA.

I investigated the web sitehttp://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html and discovered some inconsistencies. For example, the site purports to list the services covered under the “preventive health” coverage benefit, yet it omits the annual physical exam. Also, the site states that colorectal cancer screening are provided for people age 50 or older. However, I have been advised in writing that United Healthcare will cover preventive screening colonoscopies for people under age 50. In essence, that government web page is a good start to learn about preventive health care benefits, but a better source would be each consumer’s own health insurance carrier. For those with temporary insurance or who are without any insurance coverage, unfortunately, the preventive health benefit of the ACA will not have any practical consequence.

Concerning Aetna’s claim that it “will” raise premiums across the country to account for the preventive health benefit, I would be more impressed if Aetna could points to precise states where it did indeed raise rates. Health insurance policies operate in competitive markets, and the market competition will become heightened by 2014. Aetna does not have power to raise its rates without losing customers to other carriers.

Again, instead of dealing with forecasted changes in premium rates and focusing instead on the actual market prices that prevail for health insurance policies, a representative at e-healthinsurance.com said for the vast majority of states (40+), there was no increase in premiums after Sept. 23. The were available before and are shown for now, and I can verify that my state, Tennessee, has not seen price rises. The representative did single out Massachusetts, New Jersey, and CT, and said those three states experienced price increases. California has its own story with above-normal increases in health insurance premiums both before and after the ACA was passed. I would be curious what caused Nevada premiums to increase.

Finally, the Commentator did raise one important and unresolved question: where will the money come from for the preventive health screening visit to a primary care doctor as well as the screening colonoscopy? We have to look at different scenarios. If the patient indeed has preventive health screenings with no other medical diagnoses, then the patient will be charged $0 for these services, and they will be paid for by the insurance carrier. The insurance carrier will pay these costs out of its operating income or profits. There is simply no other source for payment. The government has not offered to pay the insurance companies for these services.

If the patient is hit with various medical diagnostic codes during these preventive health screenings, then he or she will pay his customary charge for the primary care doctor’s office visit and the contract-negotiated price (typically in Tennessee a 40% reduction in price billed to insurance initially) for the diagnostic colonoscopy. In that scenario, the consumer will be paying most of these costs, although the visit to the primary doc may be limited up to any applicable copay amount.

It is not a big shock or surprise to say preventive health care is going to be borne by health insurance carriers. The extent to which these carriers can pass along costs to consumers through higher rates depends on the degree of competition in their markets. Ehealthinsurance.com advises me that for the vast majority of states, the insurance carriers have NOT been able to shift these costs onto consumers through higher rates. That may change in 2012 or 2013. However, the trend is clearly moving in the direction of more power for consumers, more options and carriers available to supply health insurance in their states, which means greater competition and lower prices.

 
COMMENT:  This is not really a PPACA matter, per se. The a la carte billing system we use as a rule today is the central actor in this play. Preventive screens pay poorly. Sick codes pay more. Docs and facilities make more when they up-code (use codes that include diagnoses) or bill multiple codes. Providers are presented with a stronger financial reward to treat the sick than those that are well. Hippocratic oath notwithstanding, providers are engaged in the pursuit of wealth — and so, up-code they shall. This is no judgment on free enterprise or capitalism however, we should not be surprised that providers are behaving this way given the facts. In the end we should not expect PPACA or any other legislation to stop the behavior. Instead we need to fix the way we pay providers, period. Remember, PPACA is essentially a reform of SOME health insurance practices and some taxation. Nothing more. The law overlooks the obvious problems. But now I know I am preaching to the choir.

I would like to follow up on a few comments you raised in your post. Anyone is welcome to answer. I understand that “sick codes pay more.” Is there anything wrong with a new patient, or even an existing patient who wants to maximize the benefit of the preventive health screening coverage, to advise the doctor that although the patients is aware the doctor can make more money on this appointment by up-coding, for this one visit the doctor is to focus on the patient’s need, which is to receive a preventive health visit when that is what the patient has requested. I wonder if consumers can expect their physicians to respect their wishes and not try to sell them on talking about non-preventive health matters or get other tests during the same visit.

You are correct that the PPACA or other legislation will not stop the incentive each doctor has to make his medical practice more profitable by recommending high margin (read high profit) procedures or tests. The best protection for consumers is to prepare a note to place on the medical chart before the doctor even sees the patient. The note should say “I am here today for my preventive health screening benefit which should be no cost to me. Please limit your claim for this visit solely to the preventive health screening code and do not use this appointment to enter further diagnoses that will lead to me having to pay for the visit and any lab work.”

This is not some theoretical suggestion. I am going to visit two different primary care doctors for the first time in February, and I expect each visit to be $0 cost to me as preventive health screening. By writing out that note, I have strengthened my position vis-a-vis the doctor’s billing department, and I will tell them emphatically that I will not pay for miscoded office visits.

COMMENT:  There is nothing at all wrong with a written request to a doctor. As a society we fear confrontation with our medical professionals and so rarely question what they do, when they do it or how much they charge. Our system quite intentionally disguises real cost from the buyer. Providers and payers are in collusion to ensure that real cost stay out of the hands of consumers until well after a service is delivered. And even then, the charges are hidden in an unintelligible mess professional, facility and ancillary bills. The confusion is topped of with the pinnacle of confusion, the EOB. Like some heinous, evil Maraschino cherry on top. That PPACA missed the opportunity to require, under the law, that costs be fully revealed to the buyer, in advance is shameful. There is no transparancy in PPACA.
SECOND COMMENT:  I had a client who got caught up in the colonoscopy nonsense. He got an individual policy through BCBS of TX. The plan summary for the plan he chose of course said that colonoscopies were covered 100%. He called me freaking out after he got the policy because he called his doctor to make an appointment and the billing person told him that as long as the test was clear, it was covered. But she added that if they found anything, a polyp, etc, the procedure would be changed from preventive to a “procedure” and BCBS wouldn’t cover it. When he first said this I was confused about who he had talked to. He told me and it was all I could do to not drive to that doctor’s office and call that billing clerk and insurance “expert” out into the parking lot. You won’t hear me giving medical advice. Why is she trying to tell my client what his insurance covers? 

When I first start running quotes for an individual client, I BEG them to ask questions. Tell them there are NO bad questions. But they don’t ask. I can hint around at certain situations that could affect their coverage but they never take the bait. Now, when clients call me, pissed off at the carrier for doing or not doing something they could have asked about I tell them to call. They want me to do it and I say no. And truthfully I can tell them that the carriers will tell me little to nothing about their coverage once they have been approved. For so long, when you had insurance you just accepted what they said, even when it sounded wrong or unfair. We trusted too much. And they ran roughshod over us. I tell my customers to call and tell these carriers that they are upset and ask them to fix the situation. All the carrier can say is no. But you don’t know if you don’t ask. I’m slowly bringing people around to the idea that they have to be present and active and proactive when it comes to the insurance that they are paying for. Ask questions, say no, try to bargain. I hope that one thing that comes out of this crazy situation is that people become more involved. Educate themselves about their options and know what they are paying for.

DIFFERENT COMMENT:  you hit on the head. The insurance carriers changed all DRG codes for preventitve care. If you go for that colonoscopy and they snip a polyp the doctor than puts in a surgical code and no longer preventitve care. This is an on going battle wth how the law was written and no information on where it all cmae from. Doctors want to make up for losses to Medicare and Hospitals also. I tell my clients at employee meetings when you go for your check up do not talk about anything else that may bother you because the codes will change to what you started complaining about.

I am going to see a new primary care doctor in a couple weeks, and I am bringing with me a one-page typed sheet captioned “Medical Reasons for Lab Tests as Preventive Care.” Aside from the usual lipids panel and diabetes tests, I am requesting, e.g., T3 and T4 thyroid hormones. I note there is nothing to suggest that these values should be high or low. However, as a preventive measure it would be wise to check these in light of the fact that I am taking the prescription drug Armour Thyroid. I have made convincing arguments for why these costs should be treated as preventive health checkups. However, merely mentioning the fact that I take a prescription med may trigger the one-year limitation for no coverage for preexisting conditions. I will need to call my health insurer this week to see if it is going to be able to exclude payment on that ground.

So many people are upset about constantly fighting with their insurers for coverage. The health insurance companies should be forced to put answers to questions posed by insured in writing, so the insured can rely on those written statements. Right now they seem refuse to answer anything in writing, except to quote from their sanitized marketing brochures.

COMMENT: I agree with your proposed requirement on insurer disclosure. However, as I mentioned in my previous post this is a two part problem. The providers and facilites also refuse to disclose. That is becuase they are in contractual collusion with the insurers. They both promise, in writing, not to spill the beans on contracted rates. It is unadulterated collusion. God forbid the Blues find out that their “most favored nation” prcing amounts to <5% difference from the other carriers. Whatever the rationale, it is compelte bunk. BOTH the carriers AND the providers should be required by law to disclose cost, upfront.

SEPARATE COMMENT:  I must agree with you on this. But we both know as long as they do not disclose and keep away from transpairency they will both carriers and doctors! The reason docs are leaving the networks have found out many years ago the make more money out of network than in.

Today I learned the health insurers have one important means to deny payment for laboratory blood tests as part of an annual wellness visit. If the doctor orders any blood test related to medications the patient is currently taking, that blood test implicitly amounts to a diagnosis that something might be wrong with the condition being treated by the medication. Consequently, the health insurance underwriting team will infer a diagnosis, even if the physician codes up the lab test as simply a preventive health check, and force the patient to pay the lab costs as part of his or her annual deductible.

When I purchased my new health insurance policy, I was told that it would cover preventive health office visits and associated labs at 100%. I asked the insurance company over and over again (at least 4 separate phone calls to the benefits department) and was repeatedly told that if the doctor orders 7 or 8 blood tests and codes each one as preventive health, then the insurer would pay 100%.

Earlier in this thread, I mentioned that I had typed up a medical justification for the lab tests I planned to request from my primary care doc in a couple weeks. I thought it would be a good idea to summarize the medical justification for the tests to the insurance carrier and verify these reasons would support the preventive health code. That is when I learned that payment coverage for virtually each of the lab tests would be excluded during the claims review process.

It goes without saying that the insurance carrier has contradicted itself multiple times, where I have four separate recorded phone conversations in which I was assured that blood tests would be paid 100% during the preventive health visit, even when I identified the test by name, e.g., blood test of T3 and T4 thyroid hormones. Normally, the story ends with the consumer being frustrated and upset and feeling deceived, but there is nothing he can do about it, and so he just accepts this outcome.

Doing nothing is highly inefficient. Economic efficiency requires movement, change, and dynamics. So I have decided that I will cancel this health insurance policy after the first month and revert back to my cheaper old policy with a different carrier. If my present carrier had lived up to its promises of paying for lab tests coded as preventive health checks, then I would have kept it. But note, the deception comes with a cost: abrupt cancellation by the insured. If everyone did that, or even if 1 million people did that, then the insurer would be more honest and forthright about coverage to avoid all the underwriting and administrative costs in setting up a policy, processing a few claims on it in the first month, and then canceling everything.

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Radiation Damage of CT Scan Equivalent to 700 Chest X-Rays

Posted by HSI Online on January 6th, 2012

It’s pretty amazing when you think about it. With just a few button pushes, a radiologist can produce a multidimensional view of your heart — a remarkably accurate diagnosis tool.

But if you don’t have any clear symptoms of artery problems or heart disease, is it reasonable to use a CT scan as a precaution?

Last year I told you about a Johns Hopkins study that compared outcomes in about 1,000 people who received a scan, and 1,000 who didn’t. A year and a half after the scans, subjects in the CT scan group had been given more heart procedures, more follow-up tests, and more medications (primarily statins and aspirin) than subjects who didn’t get scanned.

And what was the benefit of all that extra treatment?

www.hsionline.com

Nothing.

Rates of heart attacks, heart disease deaths and other cardiac events were the same in both groups.

Obviously, if there’s no clear heart risk, there’s no reason to scan. And yet, the overuse of CT scans is fairly common. And here’s the scandal that’s quietly flying under the radar: In many cases, this overuse is not driven by concern for patients, it’s driven by profits.

———————————————————————
Scan scam
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Imagine if your doctor told you he needed to take 700 X-rays of your chest.

Even the most timid, trusting patient would probably speak up with two questions:

1) Are 700 X-rays really necessary?

2) Won’t that expose me to a dangerous amount of radiation?

The answers, of course, are 1) No, and 2) Absolutely!

But if your doctor approached it another way and just told you he needed to do a double CT scan of your chest — one using an iodine contrast to examine blood flow and one scan without the iodine — you might simply go along with the plan. After all, he’s the doctor. He knows best.

That’s exactly what’s happening with thousands of patients every year.

Now here’s the disturbing reality:
* A double CT scan is almost never necessary (the rate of double scans compared to single scans at major university teaching hospitals is about one percent)
* Medicare pays out millions of dollars every year to cover unnecessary second scans
* Two CT scans deliver the same amount of radiation as 700 standard chest X-rays
* Exposing patients to that level of radiation is very dangerous, but doing it unnecessarily is wildly unethical

In recent years, the Center for Medicare and Medicaid Services (CMS) has taken steps to alert hospitals, radiologists, and doctors to the high rates of unnecessary double CT scans.

Some hospitals that were previously out of control have brought their double scan rates down to the level of five percent or lower, which is where they should be. But according to the New York Times, a number of hospitals continue to have rates as high as 80 percent. And in 2009, more than 200 hospitals used double scans on at least 30 percent of Medicare outpatients.

Judging from the Times article, these hospitals aren’t held accountable in any way. Apparently the only repercussion is a poor report from the annual CMS review, which stings just a little bit less than a mild slap on the wrist.

As is so often the case, we can’t wait for Health and Human Services or some other oversight organization to step in and take control. Please forward this e-mail to anyone you know who relies on Medicare and has cardiovascular problems that might require a CT scan.

And most importantly, never be afraid to ask detailed questions about any medical procedure or test that seems odd or fishy. Trust your intuition and get answers before agreeing to anything — especially if radiation is involved.

Sources:
“Impact of Coronary Computed Tomographic Angiography Results on Patient and Physician Behavior in a Low-Risk Population” Archives of Internal Medicine, Published online ahead of print 5/23/11, archinte.ama-assn.org “Some heart screenings may do more harm than good” Monifa Thomas, Chicago Sun Times, 6/25/11, suntimes.com “Medicare Claims Show Overuse for CT Scanning” Walt Bogdanich and Jo Craven McGinty, New York Times, 6/17/11, nytimes.com “Prolonged TV viewing linked to increased risk of type 2 diabetes, cardiovascular disease” Medical Xpress, 6/14/11, medicalxpress.comThe information in this e-mail is offered as a general guideline, not one-size-fits-all medical advice. Talk to your doctor before making any changes in your personal health care regimen.
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Is the head-to-toe physical exam cost effective for healthy new patients who are asymptomatic? Or is it a legacy of primary care physicians’ desire to bill health insurance as much as possible?

Posted by Michael A. S. Guth on December 31st, 2011

Is the head-to-toe physical exam cost effective for healthy new patients who are asymptomatic? Or is it a legacy of primary care physicians’ desire to bill health insurance as much as possible?

As a health economist, I try to keep abreast of new trends in health care insurance. One trend I have found is that consumers can now purchase health insurance policies that will pay for doctor visits if the patient is sick, but they will not pay for the standard “complete physical” associated with an initial visit. Some primary care doctors will not see a new patient unless the doctor can bill insurance for $350 – $500 for a comprehensive visit. If you search on the Internet for “head to toe physical” and “outdated,” you will find many web pages that provide arguments and evidence that the complete physical is indeed not necessary but may be reassuring for some patients. In contrast, the blood tests are ten times more important than a complete physical for new patients.

An RN with 20 years experience felt that a good base line physical exam with lab work is important and can help engage the patients in their own care as well as idnetify those patients at risk for heart disease, diabetes, and other problems. The patient centered medical home model is built on coordination of care, not sick care.  She advocates comprehensive physicals.  According to the nurse, doctors may bill a patient for $500.00 but because of allowables they rarely get paid the full amount.  She feels people who buy policies without any preventative care because it is cheaper or not offered may not realize how important this can be.  She has seen people with this kind of insurance use ERs, and urgent care for their sick care.  She worries they may never go to a PCP who knows them and neglect their diabetes preventative care and run into serious complications later.   She feels the system is flawed that does not offer a basic benefit package that includes preventative care and at least one comprehensive physical a year.

I am looking for a new primary care physician and will be seeing one at the end of the month. This appointment is for a new patient and will be coded for insurance as “wellness visit, physical exam” even though there will be little or no physical exam. Instead, I plan to use the time to tell the doctor what blood tests I want on this visit to establish a baseline, and in the process of explaining why I want them, he will learn about my medical history. I doubt there will be any time remaining in the appointment for even a limited physical exam, but we shall see. My cholesterol numbers are not simply excellent, they are outstanding. The same is true for my C-reactive protein (a measure of heart attack risk) and homocysteine (a measure of stroke risk). I have not had a complete physical exam in over 20 years and have not missed them one bit. I find it appalling that any physician would palpate my abdomen and then tell me I don’t have any tenderness there, as if I did not already know that. I am all in favor of preventive health care, but I agree with the U.S. Preventive Health Task Force that the complete physical exam has not been shown to be cost effective at preventing disease. Blood testing, on the other hand, is critical to monitoring overall health and critical to formulating a strategy to prevent diseases and medical conditions.
COMMENT:   I have been asking primary care docs for several years now if they have ever found an abnormality on physical exam in an asymptomatic patient that was not picked up as part of standard screening (PAP smear, colonoscopy, lab testing, etc.) I have had minimal positive responses. (I think one doc found an oral cancer). the thing about standard screening is that it probably would be done much more effectively and efficiently by non-physicians as part of a public health campaign – think the Polio vaccination campaigns of my childhood.
Having said that, I think a consultation with the patient/client for health planning purposes – identifying what is important to him/her and the impact of health issues on those things that are important and then coming up with a mutually acceptable plan on how to achieve those goals is probably invaluable, especially if the physician has no financial interest in the choices that are made. It remains to be seen if there are virtual apps that can do the same thing.
I agree with your comments on both the amazing lack of evidence to support “annual physicals exams” leading to early detection of problems as well as the value in finding a “good” doctor (not just any old doctor) who will work with the patient to develop a health plan for the patient’s greatest health concerns.  On this first point, I invite the proverbial interested reader to check out this NIH pubmed link:
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1318009/?page=2
In examining a population of junior high and high school student athletes who were required to get “participation physicals” in order to play on sports teams, one study found of 1268 students, 5% were referred to specialists, but only 0.2% were disqualified from playing the sports activity.  The author concludes that the majority of those disqualified would have been discovered by obtaining a detailed medical history alone.   Another study of 763 student athletes found 3 positive referrals total.  Factoring in the cost of all the health workers involved, each of these three findings came at a cost of $4563.  In addition, a total of 16 medical problems were found during the course of the 763 student physicals, BUT 15 of the 16 problems were, and could have been identified, from taking the patient’s medical history alone.
COMMENT BY DOCTOR:  I want to practice somewhere I can get $300-500 for a NP visit…….And to answer your question …no there’s no reason except teachers at medical schools who fail to teach the students what the literature suggests is accurate

How do you think most primary care physicians would react if a new patient went over his medical history but declined more than a cursory physical exam in favor of getting his desired blood tests? Would the typical primary care doctor simply note “patient declines complete exam” and move on, or would he/she badger the patient into getting a complete physical, because that the way the doctor always handles new patients? One problem with health care is that patients are generally obsequious and fall into lockstep patterns of getting certain exams or tests even though they have little to no benefit on overall health.

 

COMMENT BY DOCTOR:  No consistent answer to the question. Some of us stopped such actions years ago in favor of the “wellness” problem focused visit with appropriate exam and more discussion of risk and history while others including the AMA have clung to the CPE without scientific basis for their thoughts.

 

COMMENT BY SECOND DOCTOR:  May have to disagree with my colleague here.  The biggest complaint I hear from dissatisfied patients coming from other offices or consultants is “the doctor never touched me!”  Granted, the “physical exam” may have limited value, but then it may uncover skin lesions, new murmurs, new atrial fibrillation, abdominal masses, etc., and truly takes only a few minutes — and all the while I am talking to patients, getting more history, reviewing symptoms, in an organized fashion.
I agree that the value of the PE is limited next to the history, but would also that the knee-jerk reaction to order some test and move on to the next patient is inadequate and expensive. Many studies, the most recent out of Britain, have demonstrated that 90% of the time the diagnosis can be made from history.


Medicare has finally acknowledged the value of prevention, by paying $110+ dollars each year for a practice that sits down with the patient, reviews preventive services, and encourages those that are missing. That activity is simple, but currently paid at the same rate as the most comprehensive level Medicare exam (which would include a complex history, review of 11 different systems with at least two components of each system) that I could bill for.


The reality is that the physical exam part of the “annual visit” is a small part, but there are not effective ways of getting adequately paid from private payers for history taking, education, encouragement to schedule colonoscopies, etc.  The actual touching of the patient does play an important role in compliance, patient satisfaction, and, I think, treatment. Agreed hard to prove.

 

I frequently hear from foreign-born and foreign-trained medical doctors that “here in the US, doctors spend too much time on treating people after they get ill and not enough time of preventing the illness from occurring.” But what does this mean in practical terms? (1) doctors should be ordering more blood tests to determine average glucose levels (HbA1C test) such that all patients know their HbA1C numbers and whether they are inching towards diabetes. Other helpful blood tests would include a hormone panel for all middle-aged or older patients, and then the doctors need to learn about optimal levels for these hormones, rather than ignorantly dismissing results that fall in the “normal average” range but may be sub-optimal. (2) doctors need to have staff who can answer patients’ health questions, e.g., whether the patient should start taking magnesium, without placing a burden on the doctor to answer all these questions. (3) patients need to be given targets for HbA1C, HDL, total cholesterol/HDL ratio, cortisol, etc., to achieve through their own proactive, informed selection of food choices.

 COMMENT:  Question: can/will a physician order a blood test for the sole purpose of the patient being aware? Or, will this be looked upon as ordering an unnecessary test that is not supported by a diagnosis? Insurance companies promote “decrease in testing” as efficiency markers and then sell them as P4P programs. Hospitals want more tests to support their in-house laboratories and imaging services (but only if they are paid for). Physicians are pressured for more production via ancillary service support (but only if it will get paid for) . This is a mess that leaves our patient paying out-of-pocket for information that they need to know. Oh, don’t look now but the whole conversation has now shifted away from health and preventative care…..and right back to the hospital, employed physican and insurance company triad that works against itself.

I can’t think of any blood test that would be ordered solely to make a patient aware. As a general rule, no physician would be able to estimate the results from a blood test, e.g., no physician can estimate HDL cholesterol or total cholesterol just from talking to a patient and getting his medical history. You have touched upon an important point: when insurance companies stress preventive health, they always emphasize doctor exams over laboratory tests. But again, no doctor exam can reveal 3-month average glucose, or iron deficiency, or elevated liver enzymes. It sounds like some insurance companies want to do preventive health on the cheap, and with that attitude, they should not be surprised that the limited type of preventive care they support is next to worthless.

Over the next month, I am going to push the envelope as far as possible. I am going to visit a couple of new primary care physicians and see how many different blood tests they would support as routine preventive care. For example, I am interested in getting my COQ10 levels measured, because statin drugs interfere with the body’s ability to snythesize COQ10. Most physicians would never think to test for COQ10 levels even for patients on statin drugs. What may sound like an exotic test is actually very useful for preventive care, as low COQ10 levels will lead the heart to wear out.

 

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REASONS TO OPPOSE FDA REGULATION OF SUPPLEMENTS

Posted by Michael A. S. Guth on December 26th, 2011

I sense Wayne Gorsek is unfairly being forced to defend the supplement industry, when instead the focus should be on defending consumer rights to obtain medications (called supplements) to manage their own health. Anyone interested in personal autonomy should recognize that with the power to regulate comes the power to restrict and thus prevent consumers from having access to valuable supplements. The proponents of supplement regulations claim they are needed to remove harmful products from the marketplace. Are you aware that regulations with even the best of intentions have unintended consequences? What if your regulations inhibit or raise the cost of my already expensive Ubiquinol supplement? No one wants supplement prices to skyrocket along with drug prices. So before we talk regulation, let’s be sure that we have adequate restraints on the FDA and other regulators so that there is not even the possibility of the FDA (which has extremely close ties and constantly rotating personnel to and from the pharmaceutical industry) using the power of the government to favor one industry (pharmaceuticals) over another (supplements).

Because the proponents of supplement regulation have not been able to identify any, not even one, built-in constraint on abuses of power in these regulations, I have no choice but to oppose these regulations in their current form. Consumer access to affordable supplements is far more important than singling out a few supplements here and there that should be banned. Actually, the FDA already has the power to ban supplements that it can prove are harmful — as Wayne Gresak stated repeatedly, but apparently his message fell on deaf ears.

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Vitamin D Supplements and Pregnant Women

Posted by Michael A. S. Guth on December 26th, 2011
Vitamin D 5000 IU softgels

 

Do you think my expecting wife can take 5000 Vit D?

 

Vitamin D has little or no side effects.  However, for your own peace of mind, you should ask her doctor before starting her on this supplement.  One caveat, if she has a doctor who makes the statement “People don’t need to take any dietary supplements or vitamins; they just end up in the person’s urine….” then the doctor should be fired on the spot!  Americans absolutely have dietary deficiencies — these are well-known and published in articles by national news services about once every two weeks.

 

Keep in mind that Vitamin D is actually a hormone and not a “vitamin.”  Because she is pregnant, she may be producing excess estrogen or have a small imbalance in her hormone levels.

 

According to this article in the American Journal of Clinical Nutrition, pregnant women have an even greater need for Vitamin D supplements than non-pregnant women.  http://www.ajcn.org/content/79/5/717.full

 

If she were my wife, I would have her on two Vitamin D 5000 IU gel caps — one in the morning and one in the evening 12 hours later.  Vitamin D works slowly.  It takes 2 months of prolonged use at high enough doses to boost the immune system and the skeletal structure.  Also, high serum Vitamin D levels of 50,000 nG/ml are correlated with a low incidence of colon cancer, which is the 3rd most prevalent form of cancer in the USA.

“By some estimates, 90 percent of the population is D deficient. But evidence shows you can move yourself closer to the fortunate 10 percent by following one simple habit.  Cleveland Clinic researchers asked a group of 17 subjects to take D supplements with their largest meal of the day.  Results: Over three months, absorption of the vitamin was improved and blood levels of D increased, on average, by more than 55 percent! And that held true for nearly all subjects, whether their intake was just 1,000 IU daily, or 50,000.  So simple, but given the enormous importance of vitamin D in fighting cancer, improving heart health, and preventing type 2 diabetes, depression, and cognitive decline, this little study may prove to be a very big deal.”  hsionline.com

Sources:
“New daily recommendation for vitamin D is off by THOUSANDS” Jonathan V. Wright, M.D., Nutrition & Healing, 2/25/11, wrightnewsletter.com

“Vitamin D Supplement Doses and Serum 25-Hydroxyvitamin D in the Range Associated with Cancer Prevention” Anticancer Research, Vol. 31, No. 2, 2011, iiar- anticancer.org

“Taking Vitamin D with the Largest Meal Improves Absorption and Results in Higher Serum Levels of 25-Hydroxyvitamin D” Journal of Bone and Mineral Research, Published online ahead of print 2/8/10, jbmr.org

Michael A. S. Guth

________________________

Note added December 26, 2011:

 

Vitamin D is one of the areas I have researched in some detail. I teach a course, Health Economics, for a college of nursing, and in Week 2 or 3 of that course we critique the National Institute of Medicine’s study concluding Vitamin D supplements have no benefit on health. It is very easy for my undergraduate (nursing) students to point out all the faults in that study, and it perplexes me how doctors who are members of the National Academy of Sciences could not understand their own shortcomings in their methodology and conclusions.

In any event, to derive a therapeutic effect on the immune system from Vitamin D, people need to strive for serum Vitamin D levels of about 50 ng/pL. I get very little sun, aside from the summer months, so I was taking 10,000 IU of Vitamin D daily. That dose was very safe and posed no side effects. My serum Vitamin D level rose to 75 ng/pL. I have since cutback to 7,000 IU/day.

Vitamin D takes several months to accumulate in the body. I would not advise anyone to test his or her serum Vitamin D levels until he or she has been taking at least 5,000 IU of Vitamin D for at least 3 months. Taking between 2,000 and 3,000 IU of Vitamin D left me at serum levels of about 25 ng/pL. I would be surprised if a low dose like 2,000 IU of Vitamin D would be enough to boost anyone into the therapeutic range of 50 ng/pL.

I cutback to 7,000 IU when a doctor at Life Extension Foundation told me I should not boost the serum Vitamin D level above 80 ng/pL.


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Recommended tests for every person interested in proactively managing his or her health.

Posted by Michael A. S. Guth on December 19th, 2011

Recommended tests for every person interested in proactively managing his or her health.

Life Extension Foundation (lef.org) has a recommended testing protocol for all men and women. I am more familiar with the recommended annual test for men and will comment on them here: CBC/Chemistry Panel — includes liver enzymes and lipids, free and total testosterone (important to check for signs of andropause), estradiol (elevated values pose significant health risks), DHEA-S (it is surprising how many people feel lethargic with too low DHEA-S levels), PSA, C-reactive protein, and homocysteine.

To that list I would add a test for HbA1C values to determine prediabetes status, if any. For those patients who are taking at least 5,000 IU of Vitamin D daily (I take 7,000), I would add a serum Vitamin D test.

Despite the fact that these tests would cost insurance about $250 (and they are all available for individuals to purchase from lef.org around that combined price), they represent vital pieces of information to ensure a patient is in good health. Heart attacks are expensive; strokes are expensive; diabetes is expensive. Rational patients should willingly spend a little more on these preventive tests than wait until the onset of various diseases.

 

COMMENT:  Pretty low value on an annual basis.

 

If you test for high cholesterol values, why not test for low hormones? It is a physiologic certainty that middle-aged patients will have lower hormone levels than when they were younger, and these hormone levels will decline further as they advanced into senior years. While America now has an epidemic in the incidence of diabetes, very few primary care physicians are smart enough to test the T3 and T4 hormones for thyroid function. If these are low but still in the normal range, they need to be brought up to optimal levels. Unfortunately, from an economics standpoint, we don’t have enough (male) patients on hormone replacement therapy to be able to conduct a large scale study and show a decreased risk for cardiovascular disease, osteoporosis, and even a decline in obesity. Yet the evidence exists that low testosterone hormone levels in men add risk of cardiovascular disease, increase the incidence of osteoporosis, and are highly correlated to abdominal fat in obesity.

COMMENT:   ”Very few PCPs are smart enough enough to test T3T4″ – this is an absurd statement and tells me you are not a practicing clinician.Many PCPs including myself check T4/TSH. It is part of annual exam in addition to CBC, CMP, A1c and Lipid panel. There is very little evidence based medicine to support checking testosterone levels or DHEA – sure it would be nice to check everything but the questions is “what SHOULD we check” and not “what do we WANT to check”. Many concierge practices do check these and I check them also if patient wants to pay for it.In terms of CV risk my approach is to recommend diet low in sat fat, white carbs and combination of resistance/aerobic exercise to get BMI to 25 – the most cost effective way to improve physical and mental health for the aging popultation. It also does wonders for BP, LDL and A1c. I also recommend screening EKG stress test depending on risk factors and occupation (fire fighter, police eg.).There is plenty of recent convincing argument against checking PSA – please google this for the latest. I would also argue against routinely check CRP and homocysteine.

Before doing any test we have to not only consider economic factors but also the question of “so what if it is abnormal?” What would you do if you check homocysteine and it is abnormal and what research do you have to back it up? 

I never recommend virtual colonoscopy for e.g. because what if there is a polyp – you still need colonoscopy – given the high incidence of polyps it makes little sense to recommend virtusl colonoscopy.

“Many PCPs including myself check T4/TSH.” Many is not a majority. In fact the VAST majority of doctors do not check T3 and T4. T3 is the more active hormone, and patients can have normal T4/TSH and still have low, very low T3. I suspect you are not aware that patients within the “normal” range of T3 but at the low end of the spectrum can still exhibit serious side effects of hypothyroidism, including insulin resistance and a tendency towards Type II diabetes. It goes without saying that many, if not most, of these patients with low T3 levels also have poor ability to convert T4 to T3 as needed.

 

Because of the growing literature on anti-premature aging medicine and life extension medicine, the importance of hormone replacement therapy continues to garner growing attention in both the medical community and the general public. In medicine, it is one of the hottest topics at the American Academy of Anti-Aging Medicine conferences. For the general public, hormone replacement therapy is now often featured in pamphlets providing guidance for newly discovered diabetics.

 

Several physicians have told me that I am about 10 years ahead of the general public in monitoring my health, but in a forum dedicated to proactively managing health, the general need for hormone replacement with aging is a pertinent topic.  As a professional health economist, I advise clients and the general public on how to select a good doctor.  As an attorney, I can speak to the issue of medical malpractice. I would advise any member of the public age 45 and above who has a primary care physician who does not check for hormone levels to (1) order the doctor to check them, or (2) find a new doctor. Given the vast number of papers in medical journals related to symptoms of andropause, it almost rises to the level of medical incompetence for a physician to ignore hormone level tests when a patient complains of general fatigue and loss of energy with aging.

 

But once the patient has the test results, he or she cannot rely on the PCP to know what the optimal values should be for estrogen in women or testosterone in men. Instead the patient needs to educate himself and in part educate his own PCP on what those values should be. I have sampled various primary care physicians with no specialized training in hormone therapy. It is clear that they erroneously assume any value in the very wide normal range is fine, and no therapy is warranted. Then we see the results of that failure to adequately treat with greater exhaustion, greater incidence of heart disease, greater incidence of osteoporosis, etc., as these patients age. By the time these diseases set in during the senior years, it is difficult to reverse the damaging effects of decades of inadequate hormone levels.

 

I did a quick sample of people attending an exercise class with me at the local fitness center. There were 10 – 12 people in the class comprising mostly middle-aged men and women. None of the people had their sex or thyroid hormones tested as part of a physical or other doctor visit in the past year. That is only anecdotal evidence, but it certainly casts doubt on the statement that “many PCPs check these hormones.”

On the PSA test, I am somewhat ambivalent. Even though it can yield both false positives and false negatives, the PSA does provide one piece of evidence, and most men would prefer imperfect information rather than no information at all. Perhaps the best use of the PSA is to flag velocity changes, and then it is worth exploring reasons for a sudden rise in PSA from one period to the next.

 

The CRP blood test is one of the best measures available to determine risk of heart attacks. I would strongly advise patients to avoid doctors who choose to ignore either CRP or homocysteine, which has been shown to closely correlate to risk of stroke. DHEA-S is inexpensive. If these levels are low and possibly the cause for fatigue, that conditions can be corrected easily with DHEA-S supplements.

 

Homocysteine can be lowered with small but significant doses of Vitamin B-12 and Folic Acid (another B vitamin). CRP can be lowered through a variety of mechanisms, but the most common for Americans is through a statin drug to treat high cholesterol.

 

COMMENT:  Thank you for your splendid review of endocrine physiology because I must have slept through those lectures in med school. Some one of your caliber should certainly understand economics of healthcare. TSH is a screening test. If it is abnormal most go one to check T3T4. There is a difference in cost between screening and confirmation test. If screening test is [+] you go ahead with confirmation. Such protocol exists for every test. I wish I can test everyone hormone you mentioned for every patient.
All I can say is that I’m glad your views and this website which I took a quick look at does not determine mainstream medical practices.

“You can lead a horse to water but cannot make him drink.”  Here are some actual numbers from a case study that illustrate that normal TSH values can mask low T3 levels.  Patient is prediabetic with HbA1C = 5.8% and the normal range is [5.0%, 5.6%].  His most recent TSH = 1.748 and the normal range is [0.300, 4.900].  Using the commentator’s criterion, with TSH in the normal range, no further testing of T3 or T4 would be required.  Thank goodness this patient had access to better quality medical advice from a general practitioner who had specialized continuing medical education training in hormones.  That doctor recommended the patient test his T3 and T4 values, because he considered TSH = 1.748 to be low even though it fell within the so-called “normal” interval.
That doctor’s suspicions turned out to be absolutely correct.  The patient’s T3 was found subsequently found to be 1.79 and the normal interval is [1.71, 3.71]:  the patient was just barely within the normal range and almost met he clinical definition for hypothyroidism.   T4 came in at 1.05 on the normal interval of [0.70, 1.48], or approximately in the lower 1/3 of the interval.  Because of the excellent medical advice this patient received, which is far superior to the normed “mainstream medical practices” advocated by the commentator, this patient began Armour Thyroid therapy (containing both T3 and T4) and not the more common Synthroid (synthetic T4), and raised his thyroid hormone levels.   Raising thyroid hormone levels dramatically cut this patient’s diabetes risk, so that his HbA1C dropped dramatically in just three months from 5.8% to 5.3%, which means this patient is no longer prediabetic and is in the normal range.  Perhaps more importantly, the reduction in average serum glucose levels represented by the HbA1C added years to this patient’s life that would have been lost from premature aging of glycated cells.
There are important lessons to be learned about proactively managing one’s health:  (1) a patient must be persistent to get to the root cause of his ailment, even if it takes years to exclude other explanations, maintain a low glycemic load diet, and change medications followed by blood tests to see if the condition has improved.  (2)  Not all doctors are equally knowledgeable.  The general practitioner with CME training in hormones turned to be much more knowledgeable than even some endocrinologists and other primary care physicians.  (3)  Being in the normal range will often be far different from being at the optimal level.  I hope patients and doctors will invest the time to learn what those optimal levels should be.  For example, I could tell you what optimal level for T3 that I have advised this patient to seek based on a review of the literature, but there is knowledge gained from the process of doing research that would be lost if I simply posted that optimal level here.   Doing research on optimal health provides its own rewards.
NOTE ADDED DEC. 29, 2011
I prefer to teach managing one’s own health by example, rather than words.  This morning I took the same tests that I recommended at the top of this discussion thread.  Today marks the third consecutive year that I have gotten these Male Panel tests, and using the results, I have changed and added and dropped medications as needed.  To the Male Panel test, I also added four additional tests that are somewhat unique to my circumstances:  Vitamin D, T3 and T4 thyroid hormones, Cortisol, and HbA1C.  When I get the final results back in a week direct to my email inbox (without any visit or request for results from a doctor’s office), I will explain how a patient who proactively takes charge of his health will use this information to optimize his nutrition and medication regimen.
In the past I have purchased blood tests from a variety of different suppliers, but I decided Life Extension provides the best bang for the buck.   I purchase a year’s worth of blood tests during Life Extension’s annual sale in April and May, and those prices reflecting a 25% sale off the current prices, represent in general the lowest prices available off the Internet for these tests — particularly for a cluster of tests such as the Female Panel or the Male Panel.  BUT the real selling point for me is that Life Extension provides its purchasers with a toll free number where they can call and speak to a medical doctor about their blood test results for up to 30 minutes at no additional cost!!  What is the value of 30-minutes of undevoted attention by a M.D. to your health concerns?
Because of the large batch of tests I ordered, I will probably have multiple questions, and so I will arrange for 2 or 3 of these 30-minute consultations with Life Extension medical doctors to discuss my results.  That way I am not being limited by any one doctor’s biases concerning causes and suggested treatments, but instead I can obtain a range of views and then pick the optimal course based on my own research and knowledge as well.  For anyone interested in taking steps to prevent disease and premature aging of the body, these very detailed phone consultations are invaluable.  I have learned more from Life Extension doctors over the past three years than from speaking to local doctors over the past 40 years COMBINED!
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How should the doctor-patient relationship change with knowledgeable patients who proactively take charge of their own health?

Posted by Michael A. S. Guth on December 17th, 2011

How should the doctor-patient relationship change with knowledgeable patients who proactively take charge of their own health?

Suppose a doctor encounters a patient who is (1) educated and knowledgeable about preventive health, (2) orders his own blood tests and knows what HDL, LDL, and other lab result acronyms mean, (3) takes various supplements and vitamins for which ample evidence exists of beneficial impact on disease prevention and other medical conditions, and (4) adopts a low glycemic load diet to reduce inflammation caused by spikes in serum glucose. In other words, these patients have spent scores of hours reading about personal health issues relevant to their ages and life circumstances. How should the doctor interact with this patient vs. the typical patient who comes to the office, does not know anything about health, and is completely dependent on the doctor for maintaining his or her health?

COMMENT:  I realize the question is posed for a physician to answer however, I’m going to weigh in, from a patients perspective. The scenario you describe is actually how I consider myself, when I present to the doctor. My expectation is that the physician listens to me and takes the time to lean how and why I have come to be familiar with my health and relevant biomarkers. I need the physician to dig into my reasoning for my focus and appreciate the relevance to my family history, past medical history and (more importantly) what I am trying to achieve (weight loss, improved cardiac performance, training for a marathon, recovering from an injury, etc.) to remain in what I consider a great state of health.

I want to be spoken to as if I am in control and ready to take responsibility for whatever we AGREE is necessary to remain healthy and support the lifestyle I have chosen.

So, I’m ready to take responsibility – is the physician ready to give it?

 

Actually, my question is not posed just to physicians, as I strongly endorse the patient empowerment concept of the Affordable Care Act. We consumers are paying for the office visits. Where dollars flow out of our pockets, we have more than a 50% say in how the office visit is conducted. When I visit the doctor, I always bring a typed out sheet that explains the reason for the visit, “Patient presents today for ….”, as well as a section on my medical history. Doctors really seem to appreciate it. I can also write a few sentences like “I have researched the drug Cytomel and believe it is appropriate for me for these reasons….” and “I discussed Cytomel with three other doctors, and they agree the benefits outweigh the risks for me.” That kind of message clues that doctor in (1) I have done my research, (2) I expect to be treated as an intelligent decision maker and not a passive patient who does what he is told, and (3) I have connections to other doctors so I will likely get the treatment I want with or without his approval. There are many facets to establishing a trust relationship between a doctor and patient. For me, that relationship is going to begin with the doctor treating me as a peer.

SECOND COMMENT:  OK – my (small-l) libertarian leanings are going to show here. I think that patients (customers) would be better off and physicians’ practices would be more rewarding (not necessarily more lucrative) if the relationship was more like that between a financial counselor and his/her client. I find it interesting that medicine is the only arena of which I am aware that one has to “buy” someone’s permission to buy something else. How many office visits occur in which the only reason for the visit is to procure a prescription that the patient/customer/client knows that he or she needs. There is data suggesting that when a patient comes into a doctor’s office requesting a specific medication, they walk out with a prescription for it 85% of the time. We have been very good lobbyists in protecting our economic interest.

 

Excellent comment.  As an economist, I have long recognized that vesting doctors (and other physicians such as nurse practitioners) with the sole power to write prescriptions creates monopoly profits for the medical industry.  I have written articles that appear on the Internet in which I advocate changing the federal law to allow patients to purchase non-narcotic drugs without prescriptions.  In this idealized world, most drugs would be available over the counter, and consumers would safely purchase them just as they purchase current over-the-counter drugs that could be harmful if overdosed.

Here is a quotation from the March 2011 issue of LIFE EXTENSION MAGAZINE that summarizes my views precisely:  “There was a time when the public was so ignorant about medical issues that a doctor’s prescription was required for most drugs to be safely and effectively used.  That has changed. An enlightened individual can use the Internet to learn about drugs that lower blood pressure, glucose, and lipids, along with the drug’s side effects. At-home blood pressure devices are more effective in monitoring real-world blood pressure than periodic visits to a doctor’s office.  Enlightened patients can precisely individualize dosing of anti-hypertensive medications to bring their blood pressure to optimal levels (below 115/75 mm Hg in most people).”

Some naysayers may jump in and talk about the horrible tragedies that will ensue if people recklessly start taking drugs without supervision.  But that same argument could be made about people who buy cars and drive them recklessly causing accidents.  That is not an excuse or pretense to deny the vast majority of people the right to obtain legal and safe medication without having to wait 1 hour in the lobby, and 30 minutes in the exam room, for a quickly 8 minute consultation with a doc to obtain a prescription, and, mind you, be charged $125 for the 8-minute visit.

All this talk about a doctor shortage and not being able to meet the demand for medical services of the aging baby boomer generation could be eliminated in one fell swoop:  take away the monopoly power of physicians to restrict/control access to drugs.

 

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Conversation With Family Medicine Practitioner in FL

Posted by Michael A. S. Guth on December 10th, 2011

Florida MD: A pleasure meeting you Michael.  Would you mind telling me what kind of interventions are you researching on currently? I understand if you cannot disclose details, but just to know what areas are you exploring

MG:  Certainly, I am not bound by confidentiality on anything I am researching at the present time:  (1) optimal compounded testosterone gel + Clomiphene 50 mg/day to achieve free T levels in the range of 20 – 25;  next (2) optimal Armour Thyroid (60 mg tablets, twice per day or three times per day) dose to lower HbA1C to 5.0 or below for patients with normal thyroid atrophy with aging;  (3) dose of virgin coconut oil required to boost HDL for average man, e.g., from 35 to 55, also factoring in concentrated doses of EPA 500 mg gelcaps.   Then I have some research on optimizing health insurance benefits.

Florida MD: very interesting, do you document TST deficiencies as well as declined Thyroid function to enter those patients in the studies? at what ranges? why Armour and no other thyroid derivatives? what percentage of improvement do you expect on the HDL levels?

I have a friend having problems with his current insurance, he is 58 yo, do you have any recommendations for a plan that will cover his HTN, HLD and Bladder Ca without incurring in substantial expenses?

MG:  I am not sure what TST means.  I looked it up on the Internet and web pages came up about Vitamin B-12 and Folate.  So then I called a medical doctor colleague and read your message.  She had never heard of TST.  We both thought you might have mistyped and meant TSH.  If so, I am not keeping track of TSH, because Armour Thyroid would cause the pituitary to produce less TSH.

Armour Thyroid was chosen, because it is the oldest and perhaps best known of the desiccated porcine thyroid drugs.  NatureThroid and WestThroid are identical drugs; Armour contains dextrose and one other corn product as filler.

As far as HDL, we are not looking at total % gain in HDL.  Instead, we are looking at the critical Total Cholesterol/HDL ratio and striving for values less than 3.1 — which seems difficult for 99% of Americans to achieve.

Your friend should go to ehealthinsurance.com and fill in his age and location and look at the 100+ results that come up.  I’m afraid with a pre-existing cancer diagnosis, most plans will automatically exclude him.  Your friend will benefit from 2014′s health care reform where pre-existing conditions will no longer be allowed to exclude coverage.  I’m afraid your friend’s only option may be to seek a state-run health insurance plan aimed at people with expensive conditions.

Florida MD: TST is one acronym used for testosterone.

MG:  We use capital T.  Yes, T values are monitored — free and total.

MG: I don’t think there is controversy; there is a lot of stupidity.  Total T numbers can float wherever they need to go, but optimal free T for middle aged and senior men is 20 – 25.  Having said that, I would not have a problem with a patient setting free T to reach 30, if he is feeling weak when working out and trying to feel more normal.  Excess T as you know can cause heart attacks and brain cancer — in essence we learn from the mistakes of steroid abusers treating them almost like guinea pigs.

This kind of article and the 35+ references has shaped my thinking:

http://www.lef.org/magazine/mag2004/feb2004_cover_test_02.htm?source=search&key=optimal%20testosterone%20level

Florida MD: This approach reminds me of the WHI (Women’s Health Initiative) a few years back when HRT (Hormone Replacement Therapy) was advocated; only through research definitive answers can be elucidated

MG: True.  I find it puzzling that low testosterone has been found to be a risk factor for heart disease.  But the multivariate statistical models used show, e.g., an 8% increase in risk of heart attack from 25% to 33% for men with low T values.  Yet high T values can trigger heart attacks as well.  Finding that delicate balance is really tricky.  Without Life Extension’s advocacy, I would not have gotten interested in andropause and HRT for men.  At times, I feel almost like it makes no difference long term.  So that ambivalence helps me treat pro-HRT articles with a degree of skepticism.  The range of 20 – 25 for free T is based on the level of free T in a healthy 20 year old.

Florida MD: All hormones and in general the entire homeostasis requires very precise fine tuning, even thyroid hormones as beneficial as they can be, when not within proper range could be deleterious, hence the relevance of self regulating mechanisms with stimulatory and inhibitory pathways and circadian rhythms, very hard to be accomplished with external supplementation.

MG:  How many patients do you have in your practice?  Of those patients, how many are males over 45 who have asked you about starting HRT?

Florida MD: HRT for men is still a very incipient topic, most straight men are not so concerned with hypogonadism since there is not a well established concept of such in the general population as of yet, this topic is way more prevalent among MSM and particularly HIV male patients

MG: Interesting.  The American Academy of Anti-Aging Medicine holds annual conferences in Orlando and Las Vegas.  For the last few years, those conferences, and all the anti-aging docs locally, have focused on hormone therapy.  Now HRT for women has been around for 30 years.  So if HRT is now the focus of anti-aging physicians, then it is the men that attract their attention.  I find it curious that they are not focusing instead on the most important topic:  the inflammatory diet and stopping premature aging by having elevated serum glucose.  But instead the anti-aging medical crowd wants to talk about T and T therapy.

Florida MD: As scientific as we could be in our cognition, there is always room for sexual rationalization hence the relevance of libido, performance and well being as part of the hedonistic human nature; one of the biggest problems in the American society is the secondary development of medical conditions stemming from unhealthy life styles and the development of remediating strategies once the damage is done, hence sustaining a very profitable industry that would not be so prolific if preventive medicine was implemented from very early.

MG:  You and I agree 100%.  I have said at every opportunity, and I teach this in my Health Economics course, the American health care system is focused too much on treating people after conditions arise and not enough on prevention.  That is how I became interested in the metabolic syndrome and prevention, because docs seemed incapable of stemming the epidemic of obesity, diabetes, and to a lesser extent cancer.

Florida MD: I am a true believer and kind of a good example of effective preventive medicine,  that has been my personal approach most of my life.

MG:  Although I will be voting for Obama in 2012, I readily admit “health care reform” is dead in the water without shifting emphasis to prevention.  Obama thought he was doing a great thing by creating the yearly physical exam benefit for seniors.  Instead, he would have done better to create a yearly blood test benefit with suggested and optimal ranges for lipids, hormones, and HbA1C levels.  If I walked into your office as a new patient and displayed a vast knowledge of prevention + (more importantly) a dozen proactive measures I was taking for prevention, would you be thrilled?

Florida MD: as I told you before, I definitely prefer patients that take ownership of their well being, I encourage healthy and individualized choices, since one size does not fit all for sure.

MG:  Like FL, TN has no income tax.  My former primary care doc in Oak Ridge just opened up his own solo practice.  But he is about 65, so I was surprised he would split from his partners.  He is one of many examples of a doctor who could benefit from taking on a new partner and then eventually retiring within a few years.  Knoxville would have even more opportunities for you, but it also comes with more congestion and probably higher overhead costs.  Oak Ridge has a greater shortage of primary care docs, in general, but high quality primary care docs, in particular — which is why people like me look in Knoxville for docs.

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Checklist of Treatments for Alzheimer’s Disease Part 2 of 3

Posted by Michael A. S. Guth on November 24th, 2011
Vitamin E gelcaps

2. Vitamin E combined with Vitamin C. Vitamin E is a powerful antioxidant that should be taken by nearly all people, not just those afflicted with Alzheimer’s disease. Antioxidants help remove so-called “free radical” oxygen that is harmful to cells, especially nerve cells in the brain. It turns out that Vitamin E is more potent in the body when taken simultaneously with Vitamin C. These two vitamins have a synergistic effect.

For Alzheimer’s treatment, I recommend a morning and evening dose of 500 mg of Vitamin C. Then Vitamin E, which is sold as an oil contained in softgels, should be taken as two 400 I.U. (international units) or possibly one large 1,000 I.U. softgel, once a day, either in the morning or the evening. We have large pill containers for the morning and regular size containers for the evening. As a result, I give my mother the Vitamin E – Vitamin C combination in the morning, but for years I previously gave her the combination at night and found the same effect.

Unfortunately, not all Vitamin E is the same. Natural Vitamin E is called d-alpha tocopherol. The synthetic form of Vitamin E is dl-alpha tocopherol. I asked several pharmacists if the natural and synthetic forms of Vitamin E were equally good antioxidants. Without exception, each of the pharmacists incorrectly informed me that the two were equivalent chemically, but that the synthetic form required a larger quantity to yield the 400 I.U. standard. Therefore, if a 400 I.U. natural Vitamin E were placed side-by-side with a synthetic Vitamin E softgel, the natural E softgel would be smaller than the synthetic E softgel.  The chart below show the chemical structure of natural Vitamin E and its isomer, Synthetic Vitamin E.

Natural Vitamin E vs. Synthetic Vitamin E

Natural and Synthetic Vitamin E Chemical Formula

However, it turns out all of these pharmacists were dead wrong on the body’s ability to use synthetic Vitamin E as an antioxidant. The synthetic form of Vitamin E is an isomer of the natural molecule, but the body can readily detect the change. Whereas natural Vitamin E is a powerful antioxidant, the synthetic form of Vitamin E may or may not have any antioxidant properties for any given patient. In fact, a physical chemist at Oak Ridge National Laboratory expressed it to me this way: “The synthetic form of Vitamin E hopefully will not cause harm, but it does little good in the body.” The interested reader is encouraged to search on the Internet for web pages describing “synthetic Vitamin E” along with “natural Vitamin E” to find hundreds of web pages decrying the use and efficacy of synthetic Vitamin E.

Most synthetic Vitamin E softgels contain a water-insoluble oil that could conceivably clog arteries similar to very low density lipoproteins (VLDL). When the mainstream news media puts out medical alerts that Vitamin E can cause heart attacks, they are invariably reporting on findings using solely the synthetic form of Vitamin E.

Natural Vitamin E is a wonder drug and has numerous other properties that aid the cardiovascular system, e.g., it thins the blood and creates easier flow to capillaries. At a time when my mother was taking the anticoagulant drug Warfarin (marketed under brand name Coumadin), a board-certified cardiologist said she should stop taking Vitamin E, because it interfered in the Coumadin testing. I promptly responded under NO CIRCUMSTANCES would she stop taking Vitamin E, and we would simply reduce the dosage of Coumadin. If your doctor is not smart enough to realize that Vitamin E can easily be taken concurrent with anticoagulant therapy, then fire the doctor.

Caring for a patient with Alzheimer’s disease requires intelligence. Anyone who would stop giving an Alzheimer’s patient Vitamin E because of faulty reports on adverse effects in the media should not be entrusted to make decisions on behalf of the Alzheimer’s patient. Everyone needs to understand once and for all that natural Vitamin E is truly an important scientific and medical discovery with very significant good effects on the human body. Never let the media deter your decision to give Alzheimer’s patients 800 I.U. each day.

Why give the patient 800 I.U. and not 400 I.U. or 1200 I.U.? Most of the clinical trials testing the efficacy of Vitamin E for treatment of Alzheimer’s disease have settled on 800 I.U. as the dosage. Also, that dosage has been studied in long term use by patients and has been found to be safe. Higher doses may cause side effects long term.

Most discount stores sell the cheap form of Vitamin E: the synthetic form that has dubious benefits and potential risks to human health. Any time a store offers a “buy one, get one free” sale on Vitamin E, that is usually a tipoff that the store is selling the poorer quality synthetic chemical, dl-alpha tocopherol.

I give my mother a “mixed tocopherol” blend of d-alpha, d-beta, d-gamma, and other tocopherols. This product is sold by specialty vitamin retailers. By ordering it in large quantities, I can obtain the good form of natural Vitamin E for a price only slightly higher than what the discount stores charge for the junk synthetic form.

Two 500 mg pills was selected as the dose of Vitamin C to help compensate for inadequate fruit and fruit juices in most Alzheimer’s patients daily diets. Alzheimer’s patients who daily consume fruit in abundance may only need one daily 500 mg tablet of Vitamin C.

NOTE ADDED DECEMBER 2010:   At the time I wrote this short article in 2006, the best for of Vitamin E commercially available was a mixed tocopherol containing alpha, beta, gamma, and delta tocopherols.  Now, the best form of Vitamin E contains both mixed tocopherols and mixed tocotrienols.

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