Thursday, May 31, 2012

Vitamin D and HDL Cholesterol

Vitamin D and HDL cholesterol  
                  Normal Vitamin D levels seem to have a positive effect on HDL. 
This may be an important association  but will require more research to fully evaluate the mechanism  and the effect of taking Vitamin D supplements on cardiovascular risk reduction. I have attached portions of two articles that will provide more detail if you are interested. I have  high lighted areas of interest to this discussion.

Circulating 25-Hydroxyvitamin D Concentrations Are Correlated With Cardiometabolic Risk Among American Black and White Adolescents Living in a Year-Round Sunny Climate
Samip Parikh MBBS, De-huang Guo MD, Norman K. Pollock PHD, Karen Petty PHD, Jigar Bhagatwala MBBS, Bernard Gutin PHD, Chris Houk MD, Haidong Zhu MD, Yanbin Dong MD

The NHANES 2001–2004 analyses including children and adolescents aged 1 to 21 years showed that 25(OD)D deficiency (<15 ng/mL) was associated with HDL cholesterol levels as compared with 25(OH)D levels ≥30 ng/mL (6). The assay-adjusted 25(OH)D data from NHANES 2001–2006 in adolescents aged 12–19 years found that 25(OH)D was directly related to HDL cholesterol (7). In addition, Rajakumar et al. (28) reported that in 237 black and white children (mean ± SD: 12.7 ± 2.2 years), plasma 25(OH)D was positively associated with HDL cholesterol. In theory, vitamin D could affect lipid levels directly, e.g., vitamin D is thought to be essential for maintaining adequate levels of apolipoprotein A-I, a major component of HDL cholesterol (29,30). In addition, the indirect effects of vitamin D on lipids could be through PTH or calcium balance. Furthermore, vitamin D might improve insulin secretion and insulin sensitivity, thereby indirectly influencing lipid metabolism (31). Our results demonstrated that 25(OH)D was positively correlated with HDL cholesterol independent of adiposity (i.e., %BF), which requires carefully controlled interventional and other experimental studies to further understand the observation.
Sent from the ADA Journals mobile app

Prog Lipid Res. 2011 Oct;50(4):303-12. Epub 2011 May 27.

Vitamin D and metabolic health with special reference to the effect of vitamin D on serum lipids.


Endocrinology Research Group, Institute of Clinical Medicine, University of Tromsø, and Medical Clinic, University Hospital of North Norway, 9038 Tromsø, Norway.


Considering that the vitamin D receptor as well as the 1-α-hydroxylase enzyme that converts 25-hydroxyvitamin D (25(OH)D) to its active form 1,25-dihydroxyvitamin D have been found in tissues throughout the body, it is likely that vitamin D is important for more than the calcium balance. Accordingly, low serum levels of 25(OH)D have been associated with mortality, cardiovascular disease, type 2 diabetes, hypertension and obesity. Low serum levels of 25(OH)D have also been associated with an unfavourable lipid profile, which could possible explain the relation with cardiovascular disease and mortality. However, the relation between vitamin D and lipids have so far received little attention and is therefore the main focus of the present review. A PubMed search identified 22 cross-sectional studies where serum levels of 25(OH)D and lipids were related and that included a minimum of 500 subjects, and 10 placebo-controlled double-blind intervention studies with vitamin D where more than 50 subjects were included. In all the cross-sectional studies serum 25(OH)D was positively associated with high-density lipoprotein cholesterol (HDL-C) resulting in a favourable low-density lipoprotein cholesterol (LDL-C) (or total cholesterol) to HDL-C ratio. There was also a uniform agreement between studies on a negative relation between serum 25(OH)D and triglycerides (TG). On the other hand, the intervention studies gave divergent results, with some showing a positive and some a negative effect of vitamin D supplementation. However, none of the intervention studies were specifically designed for evaluating the relation between vitamin D and lipids, none had hyperlipemia as an inclusion criterion, and none were sufficiently powered. In only one study was a significant effect seen with an 8% (0.28 mmol/L) increase in serum LDL-C and a 16% (0.22 mmol/L) decrease in serum TG in those given vitamin D as compared to the placebo group. Accordingly, the effect of vitamin D supplementation on serum lipids is at present uncertain. Considering the numerous other promising vitamins and minerals that when properly tested have been disappointing, one should wait for the results of forthcoming vitamin D intervention studies before drawing conclusions on potential beneficial effects of vitamin D.
Copyright © 2011 Elsevier Ltd. All rights reserved.

Have fun, Be smart and talk to your doctor about Vitamin D
David Calder,MD
vitamin D and blood pressure tomorrow

Tuesday, May 29, 2012

Vitamin D , insulin secretion and insulin resistance

Vitamin D , insulin secretion and insulin resistance

 The mechanisms driving the association between Vitamin D and insulin secretion and insulin resistance is not understood. There are a number of " maybe's " and a few studies.

 Vitamin D  "may " influence and may directly stimulate insulin secretion function and may reduce insulin resistance by the effects of intracellular calcium on insulin receptors.

A few of the few studies

 Diabetes med.2009Jan (1) : 19-27 found vitamin  D3 supplement improved after meal insulin sensitivity in non-diabetic obese males

Int.J. clin Pract. 2003may ; 57 (4) :258-61 evaluated 10 females with Type 2 diabetes and low vitamin D levels. They were treated for 1 month with Vitamin D supplement  and found that 70 % achieved normal vitamin D levels and a 21% decrease in insulin resistance that was not statistically significant.  Their study suggest that  Vitamin D deficiency  " may " contribute to the impairment of insulin secretion and insulin action . "our  results suggest that Vitamin D 3 supplement could be an element in the complex treatment of type 2 diabetes during the winter " Diabetes Care. 2011 May;34(5):1114-9. Epub 2011 Mar 23.

Serum 25-hydroxyvitamin d levels and prediabetes among subjects free of diabetes.
Department of Community Medicine,West Virginia University School of Medicine, Morgantown, West Virginia, USA.
Animal studies suggest that low serum 25-hydroxyvitamin D (25[OH]D) may impair insulin synthesis and secretion and be involved in the pathogenesis of diabetes. Results in studies in humans have not been consistent, however. Prediabetes is a stage earlier in the hyperglycemia/diabetes continuum where individuals are at increased risk of developing diabetes and where prevention efforts have been shown to be effective in delaying or preventing the onset of diabetes. However, previous studies have not examined the association between low serum 25(OH)D levels and prediabetes.
We examined the 12,719 participants (52.5% women) in the third National Health and Nutrition Examination Survey aged >20 years who were free of diabetes. Serum 25(OH)D levels were categorized into quartiles (≤ 17.7, 17.8-24.5, 24.6-32.4, >32.4 ng/mL). Prediabetes was defined as a 2-h glucose concentration of 140-199 mg/dL, or a fasting glucose concentration of 110-125 mg/dL, or an A1C value of 5.7-6.4%.
Lower serum 25(OH)D levels were associated with prediabetes after adjusting for age, sex, race/ethnicity, season, geographic region, smoking, alcohol intake, BMI, outdoor physical activity, milk consumption, dietary vitamin D, blood pressure, serum cholesterol, C-reactive protein, and glomerular filtration rate. Compared with quartile 4 of 25(OH)D (referent), the odds ratio of prediabetes associated with quartile 1 was 1.47 (95% CI 1.16-1.85; P = 0.001 for trend). Subgroup analyses examining the relation between 25(OH)D and prediabetes by sex, BMI, and hypertension categories also showed a consistent positive association.
Lower serum 25(OH)D levels are associated with prediabetes in a representative sample of U.S. adults.

My thoughts
I think it is reasonable to talk to your doctor about  having a 25- hydroxyvitamin D   ( 25[oh]D ) level tested. My wife has prediabetes  and had a low 25 hydroxyvitamin D level . She  now takes a vitamin D3 supplement and is trying to get a little more Oregon sun.  She plans to recheck the test on her next doctor visit.

Have fun , Be smart and consider a testing your Vitamin D level
David Calder, MD
 tomorrow Vit D and HDL cholesterol

Monday, May 28, 2012

Youth and Sunshine does not protect us from Vitamin D deficiency

The May issue of Diabetes Care  has a couple of articles about Vitamin D that I found interesting .I will review these articles with you over the next few days.

Circulating 25-hydroxyvitamin D concentration are correlated with increased cardiometabolic risk
Among Americam Black and white aAdolescents Living in a year- round sunny Climate.

25 hydroxyvitamin D levels were measured in 701 girls and boys ( 14 to 18 ) in and around Augusta Ga.. They found that low levels of 25 hydroxyvitamin D levels were associated with increased cardiovascular risk factors such as inflammation, insulin resistance , increased blood pressure and abnormal lipid profiles.

 Take home message 
                 Youth and sunshine does not protect us from Vitamin D deficiency.

Something to think about . Our fat cells are very busy.
Adipose tissue is recoconized to function as a storage depot for vitamin D and also functions as an endocrine tissue producing cytokines ( leptin, adiponectin , resistin ) and inflammatory markers
 ( hsCRP , fibrinogen , ICAM, and TNF-a )

This article is full of interesting  Vitamin D associations with Diabetes , Blood pressure and lipids.
I will take up each association separately  over the next few days. 

Tomorrow glucose and insulin resistance.

Have Fun , Be Smart and get a little more sun
David Calder, MD

Saturday, May 26, 2012

Type 2 Diabetes. Are you focused on the wrong problem, Glucose.

I will use a recent discussion with a man with type 2 diabetes to illustrate this point.

70 y/o man with type 2 diabetes .
 Medications - glucophage 1000 mg twice daily and glyburide daily ( ? amount )
                       lovaststatin ? dose
                       clonidine twice daily for his BP.
 Lab. test - A1c 7.1
                  Blood pressure - told it is OK
                  LDL, Triglycerides - reported as OK

He considers himself to be in good health, does not smoke , and worries about silent damage being caused by his inability to control his morning glucose. He expects his glucose to stay between 80 and 120 mg/dl. and  checks his glucose before breakfast and dinner. He thinks the DAWN phenomenon is causing some of his problems.

His concerns 
His fasting blood glucose can vary between 80 and 150 mg/dl and afternoon glucose is usually 120 + / -
He is frustrated by the variation in his fasting glucose and he wants to lose 30 #.
"My morning sugar is to high( about 150 mg/dl ) sometimes even though I had the same meal at dinner and bedtime snack when my glucose was 90 ."  Why ?  (More on this tomorrow)
The clonidine makes him sleepy in mornings and was told that sleepiness is expected and to stay on the medication.

He is not concerned about his BP or cholesterol. He has been told they are OK.
He has occasional mild hypoglycemia that he corrects with glucose tablets.
He is not aware of any kidney , eye or nerve problems .

My evaluation
    He is focused on the wrong problem
Diabetes management is always about balancing risk and benefit when discussing treatment.
His risk of a heart attack or stroke ( macrovascular  disease) is much higher than his risk of developing significant eye, nerve  or kidney damage ( Microvascular disease ) within the next 10 years.
His A1c of 7.1 correlates with an average glucose of 154 mg/dl (8.6 mm/l ). This is very close to the recommended target goal of 7 that has been proven to be safe  and significantly reduces his risk of eye, nerve and kidney damage.  Attempts to lower his A1c with his current medications will increase his risk of hypoglycemia . Hypoglycemia has an immediate impact on a persons life. The ACCORD study was an attempt to demonstrate in the benefits of achieving an A1c of  6 or less . The study was stopped early because of increased severe hypoglycemia and death in the treatment group.
Our patient has only had mild hypoglycemia  , however this increases his risk for severe hypoglycemia.

 My suggestions . 
 Reduce the risk of hypoglycemia
Talk to his doctor about other medication choices that will reduce his risk of hypoglycemia ,such as:
  GLP1 agonist - byetta (exenitide ) , Victoza  (liraglutide ), Bydureon (long acting exenitide ) and DPP4    
  inhibitors such as Januvia (sitagliptin) , Onglyza ( saxagliptin ) , Tradjenta (linagliptin )
 please review the these older blogs for more information on GLP 1 Agonist and DPP4 inhibitors
                                 Feb. 19 blog Bydureon is my first choice for a second medication,
                                 Feb . 9 glucophage failed now what should I do, 
                                 Feb 15 the first choice is easy, the second choice is not , 
                                 Feb. 14 New Diabetes meds high cost ! hypoglycemia to the rescue .
The other benefit GLP1 agonist is about a 10 pound weight loss. DPP4 inhibitors are weight loss neutral

Focus  his attention on correcting risk factors that increase his risk of a heart attack or stroke
Blood pressure - set specific a specific goal such as <130/80 with his doctor and discuss medication that may have less side effects such as ACE inhibitors
Lipids- set specific target goals for his LDL cholesterol  <70 mg/dl ( 1.8 mm/l ) and triglycerides < 150 mg/dl (1.7 mm/l ) and adjust his medications to reach those targets. Ask about getting an APO -b test.

Have fun , be smart and focus on the right problem
David Calder,MD

Thursday, May 24, 2012

Antibiotics and cardiovascular risk

I have had a few web site problems this last week. Every thing has been corrected

"Azthromycin and risk of Cardiovascular Death
published in the New England journal of medicine May 17, 2012

This is important to know about because  Azithromycin is part of a large class of commonly used antibiotics called Macrolides.

   Azthromycin  ( Zithromax, Z max )
   clarthromycin ( Biaxin )
   erthromycin    ( Eryc, ery-tabs )
   erythromycin ethel succinate
   fidaxomicin ( Dificid )

This article was reported that during 5 days of azithromycin  that here was a small absolute increase in cardiovascular deaths when compared to people who took no antibiotics or penicillin.
This class of antibiotics includes a caution in their prescribing information that it has the potential to effect electrical conduction in the heart in people with preexisting heart disease .

 This article supports the idea of being cautious when taking any new medication , even antibiotics, if you have known heart disease.

Have Fun , be Smart and make sure study any new medications and how it may effect your individual health situation. Read the package insert and discuss anything that is not clear with your doctor or pharmacist.

David Calder,MD

Saturday, May 19, 2012

The Dash Diet - My first 2 month Experience

My  2 months experience with the DASH diet . My 3 month trial period is about to expire and I will need to decide about my renewal.

Am I really following the DASH diet ?  " Kind of "

My excuse;
   I really want to blame my wife because she never really accepted the idea of the extra effort that would be required by her. I liked the idea of the shopping list and the exact menu to follow. We did go shopping one time but I cannot recall seeing any of meals as presented on the menu.
It is not really all her fault because have a pet peave about diets made up by dietitians that will include unusual foods that require special purchase and is used only one time during the week and then  leftovers rot in the refrigerator.

Patient -Centered care
I still believe the best diet is one that is made by you and a dietitian using your written food diary and then adjusted by you and the dietitian to best meet  your specific medical needs. This approach is not a one shot fix all deal. Individualizing patent care is hard work that requires multiple visit with your dietitian and  physician. I have had the good fortune to have always had outstanding dietitians working with my patients.

The part that  I like best about the DASH diet
I have been a fan of the Mediterranean style diet for years. I believe the Dash diet is one of the variations of the Mediterranean diet ideas. The one thing that initially got my attention was the "Daily Serving Goals". I liked this idea because it is simple and would best fit my eating habits and life style. Even with this simple approach their are some rough spots that still require attention and measurement.
Portion size and daily consistency requires  require almost daily thought. 
The easy part for me is 4 fruit servings, hand a full of nuts and dairy. I eat very little meat and try to make up for that with beans. I like 4 bean salad that I can buy in a jar.  I am still struggling with getting 7 grains and 4 vegetable in my diet each day. I am using a can of V8 juice to work down my vegetable requirement. Changing food habits is alway a work in progress.

Daily Serving Goals
I think this is the best part of the diet. 
This is the take home message that I can remember and apply most of the time . I chose an 1800 calorie diet because my initial goal is to weigh 178 to 180 pounds.

                                                  My serving goals:

fruit    vegetables    dairy    grains    meat/ fish/poultry     nuts/beans      fats      sweets
  4            4                 3             7                  1.5                         0. 5              2            0.5    

I am going to continue using the concepts of this diet and my wife and me are going to start working their actual diet plan into our daily routine. I believe this will help with my grain and vegetable deficiency.

Have fun, Be smart , changing food habits is a life time project
David Calder, MD

PS - Watch my  Diabetes Office Video .  It is focus on Patient - Centered  Care.  I think the goal setting and risk management sections may help in reducing your risk of heart disease.  Thanks

Friday, May 18, 2012

Diabetes management- " any target could (should ) reflect an agreement between patient and physician"

Management of Hyperglycemia in Type 2 Diabetes : A Patient Centered Approach

Position Statement of the American Diabetes Association (ADA) and
the European Association for the Study of Diabetes (EASD)

This position statement was published on line April19, 2012 by the American diabetes Association.  I am not sure when the printed version will become available. I recommend that every patient with type 2 diabetes  read all 12 pages of this paper. It is full of  charts graphs and information that will improve your understanding of this complex disease . This  paper will enhance your ability to become a full partner in your diabetes care.

I took this one little section, Antihyperglycemic Therapy , and started high lighting the areas that I felt were worth emphasis.  You will notice almost every thing is highlighted. It is worth reading every line. I have added my brief comments on the right side.

 ANTIHYPERGLYCEMIC                                                                               comments
Glycemic targets                                                             Correcting your A1c to <7  has the most impact in reducing the risk of eye,
                                                                                       Nerve and kidney damage.
The ADAs Standards of Medical Care in 
Diabetesrecommends lowering HbA1c
to ,7.0% in most patients to reduce the
incidence of microvascular disease (42).

This can be achieved with a mean plasma                                  This is a good answer to a common question. What is my goal for before and after meal glucose ?
glucose of ;8.38.9 mmol/L (;150160
mg/dL); ideally, fasting and premeal glucose
should bemaintained at,7.2mmol/L
(,130 mg/dL) and the postprandial glucose
at ,10 mmol/L (,180 mg/dL).

More stringent HbA1c targets (e.g., 6.0                                  This is good information to know when setting your target goals
6.5%) might be considered in selected
patients (with short disease duration, long
life expectancy, no significant CVD) if this
can be achieved without significant hypoglycemia
or other adverse effects of treatment

(20,43). Conversely, less stringent                                          This is more good information to know when you are setting your target goals.
HbA1c goalsde.g., 7.58.0% or even
slightly higherdare appropriate for patients
with a history of severe hypoglycemia,
limited life expectancy, advanced complications,
extensive comorbid conditions and
those inwhomthe target is difficult to attain
despite intensive self-management education,
repeated counseling, and effective
doses of multiple glucose-lowering agents,
including insulin (20,44).

The accumulated results from the                                            One size does not fit all!
aforementioned type 2 diabetes cardiovascular
trials suggest that not everyone
benefits from aggressive glucose management.
It follows that it is important to
individualize treatment targets (5,3436).
The elements that may guide the clinician
in choosing an HbA1c target for a specific
patient are shown in Fig. 1. As mentioned
earlier, the desires and values of the
patient should also be considered, since
the achievement of any degree of glucose
control requires active participation and
commitment (19,23,45,46).

  Indeed, any                                                                   This is the headline . I did change could to should
target could reflect an agreement between
patient and clinician. 

An important related
concept is that the ease with which more
intensive targets are reached influences
treatment decisions; logically, lower targets
are attractive if they can be achieved
with less complex regimens and no or
minimal adverse effects.

 Importantly, utilizing                                                       This happens and needs to be changed.
the percentage of diabetic patients
who are achieving an HbA1c ,7.0% as a
quality indicator, as promulgated by various
health care organizations, is inconsistent
with the emphasis on individualization

Have fun , Be Smart and read very line of this position statement by The ADA  and ESDA. It is worth your time.
David Calder,MD

Wednesday, May 16, 2012

" Importantly. islet cell dysfunction is not necessarily irreversible

 Management of Hyperglycemia in Type 2 Diabetes: A Patient Centered Approach
Position statement of the American Diabetes Association and the European Association for the study of Diabetes
April 2012

Page 2
 "Overview of the pathogenesis of type 2 diabetes"
  The first paragraph points out that a rise in blood sugar is the result of glucose influx exceeding glucose outflow. 
They point out that abnormal islet cell function is a feature of the 2 diabetes.
 "The functional islet cell incompetence is the main quantitative determinant of hyperglycemia  and 
   progresses over time "

                       " Importantly , islet cell dysfunction is not necessarily irreversible " 

 They recognize the value of weight loss , including bariatric surgery , in decreasing insulin resistance 
  and relieving the secretory burden of the Beta cells.

 They  also mention the role of  the dysfunctional  Alpha cells hyper-secreting glucagon resulting  in
  increased inappropriate glucose release from the liver 

Reading page 2 reminds me of one of the best things physicians can offer their patients is , Hope. 
 " Importantly , islet cell dysfunction is not necessarily irreversible " , provides that little glimmer of hope.

Have fun , Be Smart and thank God for the wonderful medical research
David Calder,MD

 Check out 2 related post from the past 
                                           Oct 8,2011  Lessons from my first patient , Hope
                                           Feb 12 , 2012 Glucagon effects your everyday life

Tuesday, May 15, 2012

You are officially recognized as a full partner in your health care

Management of Hyperglycemia in Type 2 Diabetes: A Patient Centered Approach
Position statement of the American Diabetes Association and the European Association for the study of Diabetes
April 2012

I recommend that you read the full document available from the American Diabetes Association. I plan to review and comment on 2 to 3 pages a day.  These guidelines have done an excellent job of putting into words the activities that are occurring every day in physicians , diabetes educations and dietitians offices around the world .

 Page 1 summary     
 You are officially recognized as a full partner in your health care

People with Type 2 diabetes are at increased risk of heart disease
The introduction  points out " this document refers to glycemic control; yet this needs to be pursued within a multifactorial risk reduction framework".   Preventing heart disease requires aggressive management of multiple risk factors, Blood pressure, lipids , aspirin use and smoking cessation also.

Patient - centered approach
Patient-centered care is defined as an approach to " providing care that is respectful of and responsive to individual patients preferences , needs, and values and ensuring that patient values guide all clinical decisions."

" in a shared decision -making approach, clinicians and patients act as partners, mutually exchanging information and deliberating on option , in order to reach a consensus on the therapeutic course of action "

Page 2 summary
  younger people with shorter duration of diabetes who achieve  A1c targets of <6.5  without  significant hypoglycemia may have a lower risk of developing cardiovascular disease

This page reminds us of the reality of Type 2 diabetes being a leading cause of cardiovascular disorders , blindness , end- stage kidney failure , amputations , and hospitalizations.

They also review the hope and benefits of our current treatment by reviewing  four studies results :
 * UKPDS( UK prospective study )
      - results from reducing A1c from 7.9 to 7 ( treated with sulfonylurea or insulin )
            a signficant reduction in the risk for developing eye , nerve and kidney damage
            a non- signficant reduction  in risk for cardiovascu;ar disease
        -results from treatment with metformin :
             fewer patients experienced heart attacks and had an overall
         -10 year followup of the  intensive treatment group:
              A1c had increased slightly but all intensive treatment groups had a reduction in heart attacks  and
              overall mortality
  *  Three other studies  in 2008 ,ACCORD and VADT had treatment goals of A1c <6 and ADVANCE
       with treatment goals of A1c of <6.5. None of these studies showed any  significant reduction in
       cardiovascular risk in the treatment groups.

      They did demonstrate a significant increase in the risk of hypoglycemia in the treatment groups.

       The ACCORD study had a 22 % increase in total mortality in the patients in the intensive treatment
       group. ( goal A1c <6 ) The increased mortality in this group seem to occur in  older patients
       struggling to achieve an A1c of < 6 .
       There were suggestions that younger people with shorter duration of diabetes and without
       cardiovascular disease benefited  from the more intensive therapy.
   *   finally a meta-analysis of these trials suggest that for every 1 % decrease in A1c may be associated
        with a 15 % relative risk reduction in non fatal myocardial infarction, but without any benefits on
        stroke are all-cause mortality
     Tomorrow- Treatment decisions  

    Have Fun , Be Smart and become a full informed partner in your health care
    David Calder, MD                                                          

Monday, May 14, 2012

Hyperglycemia- New treatment guidelines , Patient-Centered care

 Yesterday , I mentioned the "New Treatment Guidelines for managing hyperglycemia in patients with Type 2  Diabetes " published in April 2012.  A committee of 6 American and 6 European Diabetes Specialist spent over 3 years developing these guidelines. They produced a 12 page document That I will review with you over the next few days.

Patient Centered approach
 I believe this is the most important concept of this document. They focus on the idea of individualized treatment goals . Please review my quote from Ann Peters, MD ( one of the guideline developers) in yesterdays blog.

 I will also ask you to review two other blogs in preparation for our review.
 Jan.19, 2012         You fail to achieve 100% of the goals you don't set
 Feb. 9 , 2012         Glucophage failed , now what should I do

I plan to review 3 pages of this document each day.

Have Fun, Be Smart  and set  diabetes management goals with the help of your physician
David Calder, MD

Sunday, May 13, 2012

Sad News ! setting treatment goals is easier than achieving treatment goals.

Heart Disease is the # 1 killer of people with Diabetes. Numerous studies have have shown the benefit of controlling individual risk factors in preventing and slowing heart disease. An article published in Diabetes Care 2011;34:1337-1343 discussed the evidence ,  showing that  the 10 year coronary risk has improved significantly .  I will  review the risk factors and my failure to reach my goals. I am also offering you a little challenge from someone who is better at giving advice than taking advice.

Individualizing Targets 
 If you have my  book , iPhone or iPad app, Diabetes Office visit, please go to the goal setting section and review your goals as we review these risk factors.Another point I would like to make is ,as  I pointed out in my book ,  treatment goals are very individual , one size does not fit all . My recommendation is that you and your physician discuss each goal and make adjustments as needed . With the iPhone and iPad app it is very easy to adjust the goals to your specific life circumstances.

New Position statement by the American Diabetes Association
I was very happy to see Ann Peters, MD comments in Medscape 4/20/12 , on the new position statement on managing of hyperglycemia to be published by the American Diabetes Association and the European Association for the study of Diabetes essentially focused on patient-centered guidelines.. I think it is good to now have a name for what doctors have been doing in their offices for years. A good example is A1c hemoglobin. I will quote Ann Peters remarks to emphasize the point. "I think each of us can think of patients in our practices who can achieve an A1c  that is even below 6.5, as close to normal as possible. Then their are others who are older, have comorbidities, and are not able to safely get their A1c down that low, so we raise the targets. I think the notion of adjusting targets, individualizing targets, is the key to this position statement ".

 Target goals
      *  A1c < 7
      *  Blood Pressure                        <130/80
      *  LDL cholesterol                      < 100 mg/dl for low risk individuals    Apo B < 90
                                                          <  70  mg/dl for higher risk individuals ApoB  < 80
      *  Total cholesterol                      <200 mg/dl  ( 96mm/l)
      *  Triglycerides                           <150  mg/dl (1.7mm/l)
      *   HDL cholesterol                     > 40 mg/dl for men (1 mm/l)
                                                           > 50 mg/dl for females (1.3mm/l )
      * Albumin / Creatinine ratio        < 30 mg/24 hours  (3.4 mm/l )
      * abdominal girth                        <  38  inches for males (96 cm )
                                                          < 35  inches for females ( 88.9 cm )

Home work -  I am sad to report that ! Achieving goals involves more than just setting goals
     For those of you with Diabetes Office visit App or with the book go to the risk management section and make to make sure your lab reports are up to date and that you have achieved your targets. I just looked at my target goals and reviewed my success in the risk management section.  I am proud to announce that have reached all of the goals except the most difficult ones , my weight and waist size.My goal was to have my weight down to 187 pounds and my waist to < 38 by July 2012.  It is May 13 and my weight is 191 pounds and my waist  is 40 inches. Yipes I will have to lose 4 pounds and shrink my waist by 2 inches by July to meet my goals. It is amazing how fast this year has passed. I think achieving goals requires more than just setting goals. One of my other goals was to be doing 100 pushups /day using the 100 pushups App. I did very well for about 2 months and actually got up to 80 . Then I  missed a day or 2 or 3 or month and did not continue . This same thing happens with food intake and other forms of exercise.
Does any one want to join me in losing 4 pounds in the next 2 months?
Make a comment and a commitment and lets discuss our plans.
  use the comment section or email me at:

Have fun , Be smart , Set treatment goals and then find the hidden inner strength to achieve those goals.

 David Calder, MD

ps. Mark Clifford recommended trying The Live Strong diet tracking app. I am trying the free version and it looks good after my first day look. I must admit that it also requires some commitment. I neglected to put my lunch and Dinner in yesterday.

Friday, May 11, 2012

A better way to evaluate LDL cholesterol

This is a follow up of yesterday post and request that you calculate your LDL cholesterol from your own test results.  My reason for asking you to do the math exercise was to put attention on the fickle nature of the LDL test result  used to evaluate our risk for Cardiovascular disease.

Some of the points to keep in mind are:
   * LDL is usually a calculated number
   * any increase in triglycerides results in a lower appearing LDL and a false sense  of security
   * any increase in triglycerides actually starting at about 100mg/dl is associated with an increase in small
      dense LDL and increased risk of cardiovascular disease.

Is there a better way of evaluating LDL cholesterol ?    Yes
  * Measuring  ApoB is the the easiest, least expensive most consistent way to evaluate LDL Cholesterol.
  * there is one ApoB for each LDL particle regardless of the LDL parcel size.

Treatment guidelines goals
  * American college of clinical endocrinologist ( AACE )
                                        ACCE  LIPID  and Athersclerosis Guidelines
                                        Endocr.Pract. 2012 ; 18 ( supplement 11: 1-78
          Apo B -    < 90 mg /dl in people at risk for cardiovascular disease
                           < 80 mg/dl for people with "established" cardiovascular disease 
                           < 80 mg/dl for patients with diabetes  plus one or more " risk factors "

  * American Diabetes Association  consensus statement on lipid management

          ApoB         < 90 mg/dl  - for people with diabetes  and no other risk factors
                                                - for people without diabetes without cardiovascular disease but with 2
                                                  "risk factors "
                             < 80 mg/dl  - people with "known" cardiovascular disease
                                                   people with diabetes plus one or more additional risk factors

   The official guidelines are catching up with what doctors have been doing for some time , using ApoB test to validate the the accuracy of LDL measurements in predicting risk for cardiovascular disease.

Who are those  "people at risk for cardiovascular disease " and what are those "risk factors" ?
 more tomorrow
Have Fun , Be smart and ask for an ApoB test with your next Lab. evaluation. You do not have to fast for this test.

David Calder, MD
email me at with questions or comments

Thursday, May 10, 2012

Have you checked your APO-b lately ?

What is Apo -b ? 
     Apo-b is an integral part of each LDL cholesterol particle made in the liver . LDL is responsible for carrying cholesterol to tissues in our body. Apo -b is the key opening the door to various cells in those tissues.

   LDL cholesterol  is the primary tool used to evaluate risk for heart disease. I have discussed some of the problems with LDL measurements in previous post. Dec,11,2011

 Basically LDL Cholesterol is produced in our liver in a spectrum of sizes, from small dense particles to large fatty particles. The size of the LDL particle is effected by Triglyceride levels . Triglyceride levels above  150 mg/dl is associated with an increase in small dense LDL putting a person at  higher risk of cardiovascular disease . 

I will ask you now to find your last lipid panel and do a little math.

 * calculate your LDL by subtracting your HDL and 1/5 of your triglycerides  from your total cholesterol

 * Now add  200 to your triglyceride test result and repeat the calculation. What effect did that have on
    your LDL cholesterol result ?

contact me at if you have a question

Have Fun , be Smart , do your math
David Calder,MD

Wednesday, May 9, 2012

Preventing colon cancer is more fun than having colon cancer

                           Colorectal cancer 
                  early detection is the key to survival that many of us overlook

Recommended screening for early cancer detection 2012
American Cancer Society

           Beginning at age 50, both men and women should follow one of these testing schedules

Test to find polyps and cancer
                     * flexible sigmoidoscopy every 5 years , or
                     * colonoscopy every 10 years ,or
                     * double - contrast barium enema every 5 years , or
                     * CT colonography ( virtual colonoscopy ) every 5 years

Test that primarily find cancer
                    * yearly 3 card fecal occult blood test( FOBT) , or
                    *yearly fecal immunochemcal test ( FIT ) every year, or
                    * stool DNA test (sDNA) , interval uncertain

 Colonoscopy and fecal blood test are probable the most common test done.

 Comment and selection of the most user friendly look at a colon
After years of medical practice , with analysis of my patients experience and my own personal experience with these test,  I have selected the "most beneficial " and  "user friendly " of the above test.

Colonoscopy is the winner based on my experience
   The prep was a small very effective vial of liquid the evening before. My visit to the colonoscopy center at our hospital was a very pleasant experience . I exchanged my cloths for theirs and was ask to lie down on a gurney. The gastroenterologist walked by and said , without  breaking his stride , Dave , I will do a good job. Another doctor walked by and said , I am your bartender.
 My next awareness was a nurse telling me the test was ok and that I could get dressed. She made sure that I had a ride home

A study published in the Archives of Internal Medicine 2012;172 (7) : 575 - 582  reported on 997 patients; 58% agreed to have colorectal cancer screening  .They could chose between colonoscopy or fecal blood test to be completed within 12 months.

 38% of those selected to have colonoscopy actually completed the test within 12 months
 67% of those selected to do a fecal blood test actually completed the test within 12 months

Why not do both .
  A study , published in the " The Journal of Family Practice Nov. 2005. vol. 54 #11 compared  studies using 3 card fecal blood test  and colonoscopy , found no specific comparison .  They did find that the odds of dying from colorectal cancer were lower for patients who had had a colonoscopy compared to people who did not have a colonscopy.They also found in multiple trials that people with a positive 3-card test for blood followed by a colonoscopy had a significant reduction in mortality from colon cancer.

Who is ultimately responsible for maintaining your good health ?
 Don't look around , it is you.  Ask your doctor about doing yearly 3 card occult blood test and a colonoscopy every 10 years.

Have fun , Be Smart and take care of your body
David Calder,MD

Monday, May 7, 2012

ACTOS side effects by MARK

I have attached a copy of something written by my friend Mark Clifford and posted on his web Page. His short blog does a great job describing  the primary side effects of  of glitazones , ACTOS( pioglitazone)  and Avandia ( rosiglitazone)

Click on his title below and it will link you to his web site.

Have You Taken Actos? Are You Still On Actos?

I was on Actos and after Patti my Wife read an article about the side effects we talked with my then Cardiologist who said to stay on Actos. Later when I decided to take myself off Actos, approved of course from my Internist, I immediately lost 20 pounds of water weight and the pressure around my heart went away as well as my raspy voice that seemed to prove I had lots of fluid within my lungs.

Read this and learn more. 

Have fun , Be smart and read the package insert  that comes with each of your medicines.

David Calder,MD

Saturday, May 5, 2012

ACTOS , the efficiency expert, involved in a bladder cancer problem ?

Glitazones - Actos (pioglitazone ) Avandia ( rosiglitazone ) 
Hint - it is time to retire and join sulfonylureas in the" has been" room

I loved the mechanism of action and hated the side effects. I will outline the mechanism of action below for anyone other than me who may be interested.  I was shocked to learn that ACTOS is one of the most commonly prescribed drugs in the world for treatment of Type 2 Diabetes .

I never prescribed Avandi because I did not like its effect on lipids but I did use ACTOS in a limited manor. The side effects of edema (swelling ) , weight gain and the tendency be associated with congestive heart failure in older people limited its usefulness in my patients.

Both drugs now have FDA warnings 
 AVANDIA for it's association with increase risk of heart disease
 ACTOS  with a possible like to bladder cancer.

  We have better safer medications .

Mechanism of Action with " light "((embellishment to make a better story
One good thing about these two drugs is this mechanism of action that caught my attention a few years ago.A researcher using sophisticated imaging techniques was able to demonstrate the process discussed below.I am not sure if this research was confirmed by others.

Insulin connects to a insulin receptor on a cell . This signals the nucleus  ( the business office ) in the cell to send a message to the Glut 4 transporters ( the Teamsters ) to go out to the surface of the cell and pick up a glucose molecule and return it to the office ( nucleus) to be used for fuel .

Type 2 diabetes 
 The business office in the cell ( the nucleus ) is not efficient and fails to send a memo to the Teamsters to make the trip. This results in glucose piling up on the loading dock outside the cell and an increase in blood glucose levels.

ACTOS is hired as an efficiency expert
  ACTOS quickly correct the" office inefficiencies " , the correct memo gets to the "Teamsters", and
 the glucose is pickup and delivered to the right address in the cell .

Have Fun , Be Smart and chose your medications carefully.
Enjoy your week end, the sun is actually visible in western Oregon.

David Calder, MD

Friday, May 4, 2012

Tiredness- a little history of B12 treatment

Vitamin B 12 (cyanocobalamin ) Has been available for many years. The early treatment of pernicious  anemia was a little tough to swallow- large quantities of raw liver had to be eaten daily in 1934. Fortunately cobalamin(vitamin B12 ) was isolated from liver  in 1948 making treatment  a little more palatable .

A little history of the treatment of tiredness.
The use of B12 injections was a common treatment in older people complaining of tiredness. It apparently worked in some people because B12 injections was common practice for many years . My medical training labeled this use of B 12 as something just a little short of witch craft and I recommended that patients stop the B12 injections . It turns out that I may have been right about 80 % of the time . Recent studies have shown that about 20% of elderly people are at risk of B12 deficiency.
Another little bit of history about the treatment of tiredness in years past involved thyroid hormone use. The diagnosis of hypothyroidism was not as easy as it is now. I recall one older OBGYN doctor who decided that all women were tired so they must all be deficient in thyroid hormone. He started all of his patients on thyroid hormone. He used desiccated thyroid hormone which contained the active ingredient T3. This resulted in an initial buzz  of energy until their own thyroid gland turned off. The availability of accurate laboratory test ended the above treatments.

The treatment of B12 deficiency is very easy now.

Vitamin B12( cyanocobalamin )

Vitamin B12 is available by injection ( least expensive )
                                             oral ( moderate cost )
                                             intranasal spray ( most expensive )

Most multivitamins contain B12 and folic acid
many cereals are fortified with B12 and folic

Pernicious anemia
The injection of B12 is recommend for the treatment of Pernicious Anemia .

Metformin users
The treatment for Metformin induced B12 deficiency can be done with oral B12 supplements . Calcium supplements  also  improve B12 absorption in this situation.

Senior citizens 
    one study reported in J.AM Geriatr Soc. 2002 Aug; volume 50(8) pp. 1401-4 reported that the amount of B 12 found is multiple vitamins ( 2 - 35.5 microg/day ) may be sufficient  to correct the deficiency . The dose can be adjusted based on laboratory test

Have fun Be Smart and Defeat Diabetes and the Pills we use to treat it.
 David Calder,MD

Tomorrow :  what about those Glitazones  ( ACTOS and Avandia )