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Monday, April 22, 2013





SOME MORE DATA ON CALCIUM AND HEART DISEASE: In a recent issue I wept over the US Preventive Services Task recent statement on routine calcium and vitamin D supplementation. They went on record as against it. My assertion is that they were woefully premature as conclusive data just aren't there yet. This question from a subscriber is an example of the kind of agony they have caused for primary care doctors:

    My name is Bob and I'm a Vit D prescriber. I feel powerless in the face of
the USPFTF's recommendations. I enjoyed your wry comments. But what about
those concerns about increased heart disease from Ca supplementation?
That's what I worry about.

Here's my response:

     "You ask a good question about calcium supplementation, and I have concerns as well. In making a decision in cases like this I revert back to a basic set of principles of medical evidence.

1. Never change practice based on 1 study or just 1 evidence review. I reviewed the USPSTF statement, and it poses as many questions as they had answers (mostly wrong, in my opinion). The USPSTF clearly acknowledges that we need more data. I don't understand why they changed such a common, appropriate practice overnight. I just don't think the data are there yet. But the issue has been raised, and I will continue to search for more data. [See below.]

2. Whenever we've been doing something for 50 years or so with no reason to be concerned about, I fundamentally mistrust the new study that says STOP doing it. The methodologies of all these studies vary greatly, their level of significance varies, and they are not really homogeneous, so it is difficult to put them into meta-analyses. 

3. Look at the big picture. During this same time (last 50 years), cardiovascular disease has clearly and markedly declined (despite all the calcium we were recommending). I have not seen any one of my patients die of calcium-induced heart disease. (How would I know?) The recommendation seeks to have us remove a reputed agent of heart disease that we cannot see at work. This can lead to a lot of superstitious medicine. If I am going to be superstitious, it is going to be in the direction of encouraging nutritional adequacy across the board.

4. Apply common sense:  We know that the diets that most Americans eat these days are highly flawed. Significant rates of deficiency have been shown for vitamin C, D, folate, B12, and iron. It is absolutely counter-intuitive not to tell patients to get the recommended minimum amounts of calcium and vitamin D. Calcium is a much studied nutrient. We have studies showing the supplementation leads to reduced rates of obesity, colon cancer, and osteoporosis. How come the adverse cardiovascular effect never showed up in those studies? What is to say that the new studies are better and more definitive than the older studies. My expectation is that newer studies will show the USPSTF position irrelevant. [One example appears below.]

Finally, what I dislike most about this USPSTF recommendation is that it just so flies in the face of primary care physicians who have made a concerted effort to do the right thing, as it was previously recommended. When they come out with a new, different recommendation, the data need to be definitive. The worst thing they could do is to leave us in a no-man's land, which is what they have done. When we in primary care feel this upset about an issue, sometimes we're right.

Let's wait and see how the data unfold. In the meantime keep prescribing the minimum RDA of calcium and vitamin D."

The saga will continue.

IT DIDN'T TAKE LONG: "DIETARY AND SUPPLEMENTAL CALCIUM INTAKE AND CARDIOVASCULAR DISEASE MORTALITY: THE NATIONAL INSTITUTES OF HEALTH--AARP DIET AND HEALTH STUDY": This was a prospective study from 1995 through 1996 in California, Florida, Louisiana, New Jersey, North Carolina, and Pennsylvania and the two metropolitan areas of Atlanta, Georgia, and Detroit, Michigan.(1) There were a total of 388,229 men and women aged 50 to 71 years included in the study. Dietary and supplemental calcium intake was assessed at baseline. Supplemental calcium intake included calcium from multivitamins and individual calcium supplements. During a mean of 12 years of follow-up, 7904 and 3874 cardiovascular deaths occurred in men and women, respectively. Supplements containing calcium were used by 51% of men and 70% of women. In men, supplemental calcium intake was associated with an elevated risk of CVD death (RR 1.20), more specifically with heart disease death (RR, 1.19), but not significantly with cerebrovascular disease death (RR, 1.14). In women, supplemental calcium intake was not associated with CVD death (RR, 1.06), heat disease death (1.05), or cerebrovascular disease death (1.08). Dietary calcium intake was unrelated to CVD death in either men or women. The authors conclude simply that more studies are needed. COMMENT: So what is all the fuss about? Most of the supplements we prescribe are to older women who do not appeared to be harmed at all by this.
AND, YES, VIRGINIA, COUNSELING ABOUT DIET IS GOOD FOR REDUCING CARDIOVASCULAR RISK:  Notwithstanding the misguided opinion of the USPSTF, the Cochrane Collaboration does indeed find dietary counseling to be a good thing.(2) These Cochrane collaborators analyzed randomized studies with no more than 20% loss to follow-up, which lasted at least 3 months, and involved healthy adults comparing dietary advice with no advice or minimal advice. Trials involving children, trials to reduce weight, and trials involving supplementation were excluded. The investigators found 42 trials with 52 intervention arms (comparisons) comparing dietary advice with no advice. There were 18,175 participants or clusters randomized. 29 of the 44 included trials were conducted in the US. Dietary advice reduced total serum cholesterol by 0.15 mmol/L and LDL cholesterol by 0.16 mmol/L after 3 to 24 months. Mean HDL cholesterol levels and triglyceride levels were unchanged. Dietary advice reduced blood pressure by 2.61 mm Hg systolic and 1.45 mm Hg diastolic and 24-hour urinary sodium excretion by 40.9 mmol after 3 to 36 months. Compared to no advice, dietary advice increased fruit and vegetable intake by 1.18 servings a day. Dietary fiber intake increased with advice by 6.5 g/day, while total dietary fat as a percentage of total energy intake fell by 4.48% with dietary advice, and saturated fat intake fell by 2.39%. The authors conclude: "Dietary advice appears to be effective in bringing about modest beneficial changes in diet and cardiovascular risk factors over approximately 12 months, but longer-term effects are not known." COMMENT: It should be no discouragement that the benefits are in relatively small percentages because we are talking about brief, simple interventions across the entire population. Just as every 1-2 mm Hg and 1-2 mg of cholesterol make a difference, so does every extra serving of fruits and vegetables. The goal is only 5. We can get there. It will make a difference!


Xiao Q et al. Dietary and supplemental calcium intake and cardiovascular disease mortality: The National Institutes of Health-AARP Diet and Health Study. JAMA Intern Med 2013; 173(8): 639-46.

Rees K et al. Dietary advice for reducing cardiovascular risk. Cochrane Database Syst Rev. 2013 Mar 28:3: CD002128. doi: 10.1002/14651858. CD002128.pub4. PMID: 23543514.

Thursday, April 4, 2013


THE BEST WHAT-NOT-TO-DO's IN MEDICINE:  We are at the threshold of a new era in medicine that really began with an article in Annals of Internal Medicine(1), which I reviewed in the Jan 12th issue of the Journal of the FP Revolution in 2012. This started a brand new movement in medicine which has now gained substantial momentum. A large number of generalist and specialist societies have now identified and endorse a core set of test, evaluations, and practices that no longer ought to be done. [Actually we should never have been doing them, but we're slow learners making progress.] Since they are posted in the Internet in obscure locations (2), many of us have never seen them. Therefore, I am going to just provide a graphic to illustrate each of them with no other commentary in this issue. Read 'em and learn 'em. They're great!

Here's the main point: There is almost universal consensus among medical experts (including myself) that the medical procedures listed below SHOULD NOT BE DONE. If your doctor is recommending any of them, ask him/her, "Why?"  Or, equally acceptable, just say NO!

      Also very valuable for consumers are the consumer information sheets that accompany each one of these guidelines. There is a sample at the bottom of this page. The whole set can be found at this link:
        My favorites are (a Baker's Dozen):
  1. No routine pre-operative lab tests in average risk patients: not chest x-rays, ECGs, or chemistries or coagulation tests. Let's face it. Hospitals and surgicenters want these only for revenue production.
  2. No DEXA scanning for bone mineral density until age 65 in women, one-time only, and age 70 in men.
  3. No routine annual cholesterol panel in patients not on a special diet or drug therapy. [Note: This puts us at odds with many so-called expert guidelines that govern organizations like Kaiser, Community Health Centers, etc. Once every 5 years is enough for people without risk factors or disease.]
  4. Don't perform Pap smears on women younger than 21.
  5. Don't order HPV (human papilloma virus) testing on women younger than 30.
  6. Don't order carotid ultrasounds as screening for asymptomatic patients. [The corollary of this is, Don't auscultate for bruits (a harsh sound from irregular blood flow) on routine exams. A finding of a bruit will make your doctor really, really want to order an ultrasound. Don't let him/her! The USPSTF specifically 'recommends against' it because known harms exceed known benefits.
  7. Don't repeat colon cancer screening by any method (including stool blood testing) for 10 years after a negative colonoscopy in average-risk individuals.
  8. In the hospital don't order daily blood counts and chemistry panels in the face of clinical and lab stability.
  9. No echocardiograms or carotid ultrasounds for patients with simple syncope (faint).
  10. Don't order nuclear thyroid scans to evaluate thyroid nodules if thyroid function is normal.
  11. Don't prescribe cough and cold medications for children < 4 years of age. [Their parents can always do this, but physicians shouldn't be doing it.]
  12. Don't perform ultrasound testing for boys with undescended testicles. [This is a new one for me.]
  13. Don't order special testing for clotting disorders when patient presents with a first episode of a venous leg clot with a known cause (such as a recent fall, fracture, surgery, or other trauma). Don't re-image a venous leg clot in the absence of a clinical change.
    Go ahead and pick your own favorites from the lists below. [...and let your friends know!]

        The Choosing Wisely website also has nice accompany patient education handouts for consumers. A sample for GERD appears below.

parts per million of atmospheric carbon compatible with a familiar, sustainable planet Earth
1. Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med 2012; 156: 147-9. EDITORIAL: Laine C. High-value testing begins with a few simple questions. Ann Intern Med 2012; 156: 162-3.
2. The ABIM Choosing Wisely website:
Article retrieval tips: To find an article in PubMed simply enter the PMID number into the search field. Where a 'doi' heading is listed, you can insert the doi information into a Google search and retrieve the article.