Drug-Drug Interactions Put Elderly at Risk

Barry called me when he read thisarticle in MedPage Today. Why don't people understand the problems polypharmacy cause and especially when they don't talk to their doctors about all the dietary supplements and complementary and alternative medicines (CAM) they are taking? Barry said he talks about all medications he is taking and if the doctor ignores him, he asks the doctor why.

I commented that many people do not because in the past many doctors would tell their patients not to take non-prescription medications and were none too polite about telling them this. Other doctors would belittle them for taking CAM.

Barry agreed and said that these people are putting their lives in jeopardy. He said his friend that ignored the pharmacist and died a few days later was a huge wake-up call for him. I added that many people today are not concerned and feel that the doctors don't care or they would be asking the proper questions. Some people have been told by the homeopathic practitioners that the medications they order are natural and not to talk to medical doctors about them. This is because of medical doctors in the past talked against homeopathic medications and CAM.

I found this very much on point and a warning to our doctors!

Action Points

• One in six U.S. seniors might be potentially at risk for a major drug-drug interaction, and 25% of adults did not disclose herb or supplement use to primary care physicians.
• Note that one study found that one-third of the population used complementary and alternative medicine.

Based on the 20 most commonly used medications and the 20 most commonly used supplements, the researchers identified 93 potential drug-drug interactions. And among the 20 common medications, 15 interactions were classified as "potentially of major or life-threatening severity."

Much of the article was about the following and I find this interesting and conflicting at the same time as many doctors do ask for a complete list or bringing in all medications to their appointment. The most common reason for nondisclosure was lack of inquiry by physicians (57%), while 47% of patients said they didn't believe their physician needed to know about their use of CAM.

"Contrary to earlier findings, our results attribute most nondisclosure to physicians not asking about CAM use or to concerns about physician knowledge regarding CAM rather than to physician discouragement or negativity about the use of CAM," Jou and Johnson wrote.

Only 2% of patients said their physician had discouraged them from CAM use in the past, and 3% said they had received discouragement in the present.

"Physicians should consider more actively inquiring about patients' use of CAM, especially for modalities likely to be medically relevant," they wrote.

Public Health England Decries Low Carb Diet

Low carb diets were called out on Thursday, March 17 by Public Health England. The agency stated that carbohydrates are the backbone of a healthy diet and that meals low in carbohydrates do not provide vital nutrition because they lack the fiber crucial for digestion.

The agency doubled down on its healthy eating advice to urge Britons to consume more potatoes, pasta, bread, and other starchy carbohydrates to increased fiber intake by more than half, from 19g a day to 30g a day.

In addition to five portions of fruit and vegetables a day, people need the equivalent of two wholemeal breakfast cereal biscuits, two thick slices of wholemeal bread and a large jacket potato with its skin. The experts declared that it was important to choose wholegrain options to obtain the most nutrition from carbohydrates.

The Eatwell Guide increases the amount of starchy carbohydrates from 33 to 37 percent of recommended daily intake.

The officials also warned people not to rely on supposedly healthy “juicing” diets for their nutrition. Fruit juices and smoothies should be limited to a

single 150 ml glass per day because they are packed with sugar and rarely include fiber. An agency spokesperson said, “There seems to be a juicing trend, and low-carb diets are popular, but the scientific evidence is telling us otherwise."

Fiber helps the body digest food, as well as keeping people feeling fuller for longer. Fiber is also known to protect against certain cancers, heart disease, and diabetes. One in nine cases of bowel cancer is linked to eating too little fiber.

Sian Porter, of the British Dietetic Association, said: "You still need to watch your portion size, but starchy carbohydrates should form the basis of any diet."

The guide also urges Britons to eat less cake, biscuits, and sweets, red and processed meat, and dairy. However, Terry Jones, of the Provision Trade Federation, told Farmers Weekly this was a "kick in the teeth" for hard-pressed dairy farmers.

He added: "I find it staggering that, at a time when ministers are expressing support for the sector, an agency of government should not only encourage consumers to reduce consumption of dairy products, but also seemingly ignore the positive role they can play in public health."

Doubling down in their encouragement of eating carbohydrates is not the way to create healthy eating and will encourage more obesity and more diabetes in Great Britain.

Diabetes Forums in and out of Trouble

Yes, diabetes forums come and go. The good ones seem to be able to survive, but they do have ups and downs and many recently have created problems for themselves with the way they have changes their formats.

http://www.dlife.com/diabetes-forum/ This link will take you to dLife, but the forum no longer exists, at least I have not been able to find it. I don't know when the forum disappeared, but it did during 2015. There are many ads on the site and different pages and there are a few good bloggers still writing for the site. On a rating of 0 (lowest) to 10 (highest), I would rate this site as a 2.

http://www.tudiabetes.org/ This site is still very active and has many features appreciated in a diabetes forum website. There are ads, but not an unreasonable amount, but they still can be a distraction. Using the rating system above, I would rate this site a 7.

http://www.diabetesdaily.com/forum/ This site is still very active. It has a decent forum and an excellent blog site. Just beware of not using hyperlinks. Try not to create them accidentally as you will be warned and then on continued use, you will be banned. This is an area where this site has little or no tolerance. It does have a recipe area. David Mendosa does also post a monthly blog on this site. Because of the hyperlink problem, I can only rate this site a 4.

http://www.diabetesforums.com/forum/ Another decent forum, but be careful as they are not too tolerant of links and hyperlinks, but a little bit nicer about letting you know and explaining where you went wrong. I would rate this site a 6.

http://www.diabetesforum.com/forum.php I will be writing a separate blog on this site.

http://www.dailystrength.org/c/Diabetes-Type-2/forum I am not familiar with this site and most members are women. It is not as active as it was years ago, but does have daily activity.

http://forum.americandiabeteswholesale.com/ This is basically a dead forum with only posts of a newsletter that shows in November the most recent post since May 2015. Rating = 0

http://forums.joslin.org/ Another forum that I thought had been pulled, but it was just that my URL had been overwritten. The last post is in January 2016 with the previous post in October 2015. Rating = 0

http://www.diabetesnet.com/forum/forum.php This forum is active, but basically for people on pumps and it is good for that. Unrated.

http://www.diabeticconnect.com/ This site has discussions but no more forums and has mainly participation by people with type 1 diabetes. Type 1 people do need a place and this may fit their needs.

There are other forums, but they are closed to people from the United States and are in other countries. I am surprised by a couple of them as we have many of the people from their country as members in the forums here. Oh, well, such is life.

When Will Doctors Believe in Statin Damage?

Most doctors will continue to insist on prescribing statins, but more and more evidence is coming to light about the damage to our bodies being caused by statins. Increasing numbers of Americans are being prescribed statin drugs to lower their risk of heart attack or stroke. The risks of these drugs to muscles and kidneys may be greater than previously thought.

Statins are also associated with a higher risk of type 2 diabetes and with more rapid deterioration in patients with chronic kidney disease.

Duane Graveline, M.D., M.P.H., and Philip W. Blair, M.D. writing in the spring issue of the Journal of American Physicians and Surgeons say, “The risks of these drugs to muscles and kidneys may be greater than previously thought.” Graveline and Blair calculate that between 2005 and 2011 there may have been nearly 2,000 deaths from rhabdomyolysis due to statins, based on the FDA's MedWatch records.

Authors conclude that statin-associated muscle and kidney damage are both more common and more insidious than generally believed. The "collateral damage is probably higher than most clinicians would consider acceptable." They advocate restricting statin usage until more is known about these effects.

Damage may be occurring even if the patient's CPK levels are normal, authors state. CPK (creatine phosphokinase) is the blood test doctors monitor to check for muscle damage. Although rhabdomyolysis is generally considered to be an acute crisis, there is a chronic progressive form as in the case report in the article.

Some 24 percent of Americans have a gene called SNIPS, which causes blood levels of statins to be much higher than expected, authors warn.

Also read my blog about statins causing hardening of the arteries, which was not reported in this study.

With all the bad news being found in studies lately, it is hoped that doctors will slow their efforts to over prescribe statins, but the American Heart Association is not backing down in their efforts to prescribe statins to more people. They are even pushing for prescribing to people that have normal lipid panels and young people.

Those of us following the research know that people are abandoning statins in greater numbers and won't allow future prescriptions, even if they are labeled non-compliant.

Statins Receive Scrutiny They Deserve

I like what is happening in Great Britain. I can only hope that the United States can learn from them. The Queen's former doctor, Sir Richard Thompson has called for an inquiry into the safety and efficacy of statins. This was after a review into key trials concluded the pills were not effective in protecting against heart disease.

The former president of the Royal College of Physicians and personal doctor to the Queen for 21 years said: “The statin data needs to be urgently scrutinized. We are very worried about it and particularly side-effect data, which seems to have been swept under the carpet. We have to be very wary of the doubts about statins produced by this new research and if we are wrong about widespread prescribing of this drug we have to stand up and say sorry.”

This is very powerful and would be a first for doctors or their organizations to admit something and to say “sorry.” The cholesterol-busting drugs are given to up to 12 million patients in the UK, or around one in four adults.

Supporters, including the British Heart Foundation charity, say they save lives and UK health regulators insist they are safe. Yes, they still do not recognize the more severe side effects and like the American Heart Association will continue to promote statins even when they may be proven wrong. Please read my blog here about statins causing hardening of the arteries, a leading cause of heart problems.

Critics say the risks, such as severe muscle pain, depression, fatigue, impaired memory, and stroke, outweigh the benefits others claim exist. They also claim that much of the data could not be trusted as it relied on trials carried out before 2005/6 when new rules were brought in to make scientific studies more credible. It was later found by independent experts that the studies have no effect on death rates.

Another is the 4S study published 1994, which the new study claims should not be relied on as it was run and analyzed statistically by staff paid by a manufacturer of statins. This “would today be totally unacceptable” said the new report’s lead author Dr Michel De Logeril. His report concluded, “Statins are not effective for cardiovascular prevention”. Dr De Logeril, a cardiologist at the University of Grenoble in France, added: “We cannot trust these trials. I would warn people not to take statins.”

He was backed by eminent London-based cardiologist Dr Aseem Malhotra, who said: “These are truly disturbing findings and fit in with the concept that all industry-sponsored studies should be seen as marketing until proven otherwise.”

Dr Malcolm Kendrick, who has studied heart health extensively agreed. He said: “This review confirms my fears that research on statins is fatally biased.”

Experts have urged anyone with concerns about the use of statins to contact their GP

Moreover, Fiona Godlee, editor of the British Medical Journal, added: “This carefully done piece of work reinforces the need for a thorough review of the evidence base on statins.”

Lard Is Back!

Most of us have heard these offensive remarks, “lard ass, tub of lard, lardo.” I know I have and I still hear then occasionally. I am old enough to remember my parents butchering hogs and my mother always collected all the pork fat she could and rendering it for use in cooking. When she could, she also would obtain pork fat from a local locker when a person did not want it returned with the meat.

I know that even when margarine came into the stores, my mother was happy for all the extra lard she was able to obtain from the local locker. The locker, for those that are too young to know this, is a butcher shop that butchers beef and pork for people that did not know how and could not do it themselves. Until my father had a farm accident, we always did our own butchering and we always had a freezer full of meat, fruits, and vegetables.

Many people even today believe lard is bad for you. Recent studies have proved that saturated fats aren't that bad for you. I like lard because it doesn't change the flavor of foods like most cooking oils do. I do use some olive oils, but I prefer lard or butter depending on what I am cooking. Lard may be the newest, trendiest fat on the block.

Lard provides us with dietary cholesterol, which is, in fact, beneficial to the body and doesn’t contribute to blood cholesterol levels. Rather, it supports healthy hormone production and helps deal with inflammation.

While lists of heart-healthy foods don’t generally contain lard, it appears that they may want to consider adding it in the near future. The pervasive myth that animal fats increase the risk of heart disease is just that, a myth. Our great great grandparents consumed lard and butter and experienced extremely low rates of heart disease. Lard is part of a healthy diet and will not give you a heart attack.

Because of the way lard is chemically composed, it’s great to bake and to cook with. At around 40 percent saturated fat, 50 percent monounsaturated fat, and 10 percent polyunsaturated fat, its high saturated fat content prevents the other fat from oxidizing when introduced to heat.

After cod liver oil, lard ranks second on the list of foods highest in vitamin D.

It’s time to revitalize lard, a product that was in every American pantry and pan just mere decades ago. Rumors say that Upton Sinclair’s The Jungle may have played a big role in the killing of lard, but, regardless of who killed it, there’s no reason that lard can’t come back. Generations upon generations of cooks used this healthy fat.

Guidelines for Diabetic Foot Management

New evidence-based clinical-practiceguidelines on diabetic foot management cover five areas: ulcer prevention, off-loading, osteomyelitis diagnosis, wound care, and peripheral arterial disease. This is the first diabetic foot guideline developed by a multidisciplinary panel, which conducted separate systematic literature reviews for each of the five topics.

The document, sponsored jointly by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine, was published as a supplement to the February issue of the Journal of Vascular Surgery by Anil Hingorani, MD, of New York University Lutheran Medical Center, Brooklyn, and colleagues.

Asked to comment, endocrinologist and diabetic foot expert Jan S Ulbrecht, MD, of Pennsylvania State University, State College, told Medscape Medical News, "I think it's a hugely ambitious and comprehensive document, from a very distinguished group of authors." Dr. Ulbrecht added that although he takes issue with a few specific points, "There can be no doubt that if all care followed these guidelines, diabetic foot disease would be markedly diminished."

Five Recommendations: Examine Feet at Every Visit

The panel issued five recommendations for the care of the diabetic foot.

#1. For prevention of foot ulceration, the panel advises adequate glycemic control, periodic foot inspection, and patient and family education. For high-risk patients, including those with significant neuropathy, foot deformities, or previous amputation, custom therapeutic footwear is recommended.

#2. In patients with plantar diabetic foot ulcer, the panel recommends off-loading with a total contact cast or irremovable fixed-ankle walking boot. For those with nonplantar wounds or healed ulcers, specific types of pressure-relieving footwear are recommended.

#3. In patients with a new diabetic foot ulcer, the recommendation is a probe-to-bone test and plain films, followed by MRI if a soft-tissue abscess or osteomyelitis is still suspected following the probe-to-bone test.

#4. Debridement is recommended for all infected ulcers, with treatment of those infections based on the 2012 guidelines published by the Infectious Diseases Society of America. The current document provides detailed recommendations on comprehensive wound care and various debridement methods.

#5. The panel recommends measurement of ankle-brachial index (ABI) in all patients with diabetes starting at age 50. Those at high risk by virtue of foot ulcer history, prior abnormal vascular exam, or intervention for vascular disease or known cardiovascular disease should have an annual vascular examination of the lower extremities and feet.

The full text of the guidelines can be read here.

Metformin Does Cause B12 Deficiency

Allen called me shortly after he read this. I say shortly because he knows I sleep late and he does respect my sleep time. He was surprised that it has taken this long to publish something we have known for a long time. He knew that I would be busy for most of the afternoon and again the following day, but felt this was important enough to remind me of it and ask that I blog about it. Then he asked if I could meet with Ben, Barry, and him on Saturday. I agreed and was happy to do this.

When I arrived, they were waiting for me. Allen had printed a copy for me and asked if I had read it. I told him that I had and would be blogging about it after March 18. Barry said you already have posts that far out and I said yes. Plus, I have three other blogs ready to post and about 18 more topics I want to write in the weeks ahead. Ben said yes, there have been many topics of interest lately. I said I wish I had time to write about all the topics that interest me.

People taking metformin, one of the safest type 2 diabetes medications, for several years may be at heightened risk of vitamin B12 deficiency and anemia, according to a new analysis of long-term data. Allen knows this from first hand experience and others of us know this because our vitamin B12 levels were low and we cannot absorb what we need from the foods rich in B12.

Metformin helps to control the amount of sugar, or glucose, in the blood by reducing how much glucose is absorbed from food and produced by the liver, and by increasing the body’s response to the hormone insulin, according to the National Institutes of Health.

The study used blood samples and the researchers found that at year five, average B12 levels were lower in the metformin group than the placebo group, and B12 deficiency was more common, affecting 4 percent of those on metformin compared to 2 percent of those not taking the drug.

Borderline low B12 levels affected almost 20 percent of those on metformin and 10 percent of those taking placebo.

Average vitamin B12 levels were higher by year 13 than in year five, but B12 deficiency was also more common in both the metformin and placebo groups, as reported in the Journal of Clinical Endocrinology and Metabolism. The down side of being vitamin B12 deficient can mean nerve damage that is severe and may be irreversible. Severe and prolonged B12 deficiency has also been linked to impaired cognition and dementia. It can also cause anemia (low red blood cell count), but fortunately, this condition is reversible with treatment. Another finding of the study was more people in the metformin group were also anemic at year five than in the placebo group.

Humans do not make vitamin B12 and need to consume it from animal sources or supplements. Vegetarians may get enough from eating eggs and dairy products, but vegans need to rely on supplements or fortified grains.

Doctors who prescribe metformin to patients long-term for type 2 diabetes, gestational diabetes, polycystic ovarian syndrome or other indications should consider routine measurement of vitamin B12 levels, the authors conclude.

People who are taking metformin should ask their doctor about measuring their B12 level. Restoring healthy B12 levels is easy to accomplish with pills or monthly injections.

Finally, the study authors say, “The risk of B12 deficiency should not be considered a reason to avoid taking metformin.”