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DR. C’S MEDICINE CABINET: “FOLIC ACID” SUPPLEMENTS

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Folic acid has a secure place in my medicine cabinet, and is there for one of the best reasons. In screening for possible causes for heart disease, my doctor ordered a HOMOCYSTEINE LEVEL. The Laboratory value came back elevated.

The treatment given was folic acid. Some background is necessary. Homocysteine is a rather toxic amino acid that can cause heart disease and neurological problems, among other things. If you do not get enough folic acid in your diet with green vegetables, legumes, nuts, eggs and the like (it is hard to be deficient with a good diet), your Homocysteine may become elevated.

You need folic acid to convert Homocysteine to the essential amino acid, Methionine. 10-15% of the population, and up to 30% of older people have elevated Homocysteine levels. Stiffness, slow gait, and heart disease can be related to these elevated levels.

Since I have a good diet, I assume that I have a weak form of an enzyme called Tetrahydrofolate Reductase, which is the rate limiting enzyme in converting Homocysteine to Methionine. A weak enzyme needs more folic acid to do its job. The MDR of Folic acid is 0.4 mg./day. I started supplementing with 1 mg. Daily, without effect on the Homocysteine level. I doubled the dose to 2 mg., and my blood level was still above the upper limits of normal, 15 micromoles/L.. I doubled it again to 4 mg., 2 mg. Twice daily.

Finally my level became normal at 10, This was a decade ago. Recently, I have been doing some research on Alzheimer’s Disease, because a Friend is losing her short term memory. I talked to a neurologist to see if a medical evaluation was mandatory, and found that he has recently BEEN GIVING FOLIC ACID supplements to his AD Patients.

Folic acid deficiency is now being suspected as being a factor in AD! This story is similar to the Vitamin D conundrum. Should I take Vitamin D or not? Am I a “believer” or not. The resolution is easy. You get a Vitamin D blood level.

The lab test will report “normal” if your level is above 20 ng,/ml. I prefer 50, which I achieve with 4000 i.u. Daily supplement. The NFL likes their players to be above 50 to be in best shape. The point is, take a measurement, and then decide.

If you chose to take a Folic acid supplement, I would suggest checking both your Folic acid blood level, and Homocysteine blood level as a reference.

Also, if you take folic (B9) supplements, you should also take extra B12, and B6, since they are involved in the same metabolic pathways. Balance is necessary in metabolism.

–Dr. C

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DIABETES MANAGEMENT: “SMART INSULIN PUMPS”

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Technology is finally innovating diabetes management. With the advancement in technologies like continuous glucose monitors, traditional insulin pumps are evolving into smarter devices that can automate insulin delivery.

Medtronic and Tandem Diabetes are the only two companies to offer hybrid closed loop systems. A community of diabetics are also hacking pumps to do the same thing. CNBC’s Erin Black just switched from the hacked system to Tandem’s Control-IQ and takes a look at how insulin pumps are getting smarter.

Dr. C's Journal, Medicine, Men's Health

BLOOD VESSELS: HUMAN “PULMONARY CIRCULATION”

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Humans have a high energy requirement. Like a sports car we need to be turbosupercharged. We need an entirely separate Pulmonary circulation to handle our great oxygen demand.

Fish can get by on a single heart and circulation. They are “cold-blooded” and have no elevation of temperature above that in the environment. The water buoys them up, and they don’t need to constantly fight gravity.

Birds, and by extension, therapod dinosaurs, need more efficiency, and have a separate pulmonary circulation, just like we do. They share with us a DOUBLE CIRCULATION, a 4-chambered heart, with 2 entirely separate circuits.

In my residency, I saw a lot of congenital heart disease. In the process of development, the very early human embryo has a single circulation, just like “early” vertebrates, like fish.

In the process of development, the Systemic and Pulmonary circulations divide the previously unitary system into 2 separate systems, by a continuous spiral of partitions, or “septae”.

Ontogeny recapitulates Phylogeny: Development recaps Evolution. If this process of separation fails to happen in a given child, Congenital Heart Disease is the result:

  • IASD. Interatrial Septal Defect is failure to separate the Atria, the upper chambers of the heart;
  • IVSD, Interventricular Septal Defect, is failure to separate the Ventricles, the lower chambers of the heart;
  • AV Communis is both of the above, plus failure of Atria and Ventricles, the upper and lower chambers, to separate, giving one big inefficient chamber.

When you listen to the hearts of these children, there are prominent murmurs, or noises, which betray the presence of turbulence and inefficiency, the very thing that evolution “tried” to prevent.

In the normal Human Heart, the blood returns from it’s systemic circuit through the capillaries, depleted of oxygen, into the vena cava. It passes to the Right Atrium, through the tricuspid valves, to the right ventricle.

With the contraction of the heart, the blood goes through the pulmonary artery, into the pulmonary capillaries, into close contact with air-containing alveoli. The oxygen passes through the alveolar membrane into the capillary blood, which becomes red. The oxygenated blood then passes into the pulmonary veins and on into the left atrium, and the systemic circulation.

It is interesting, and essential that the systemic arteries contain red, oxygenated blood, and the Pulmonary artery contains blue, oxygen-depleted blood. The “tired” blood, returning from the body must be “pepped up” by passing through the pulmonary circuit, picking up oxygen in the process.

Similarly a clot, originating in a quiet vein, perhaps a dilated, or varicose vein, is pumped into the Pulmonary circuit, where it lodges in the tiny capillaries and produces a PULMONARY EMBOLISM.

The embolus clogs the pulmonary circuit, increasing resistance, raises the normally-low pulmonary artery pressure and produces PULMONARY HYPERTENSION, placing more load and strain on the Right Ventricle.

Pulmonary Hypertension is also caused by a variety of Lung, heart, inherited and kidney diseases, as well as by certain drugs, high altitude, and Obstructive Sleep Apnea.

Please check the Mayo Clinic discussion that follows.

–Dr. C

Pulmonary Hypertension Article

Dr. C's Journal, Medicine, Men's Health, Women's Health

BLOOD VESSELS: THE “SYSTEMIC ARTERIAL SYSTEM”

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BLOOD VESSELS; it is hard to overestimate their importance. They are literally our lifelines, delivering the oxygen and nutrition necessary for life. We are as old as our blood vessels.

I will divide blood vessels into 4 components with rather separate domains: The Systemic Arterial system, the Pulmonary circulation, the Venous system, and the Lymphatic system, and will discuss these separately.

SYSTEMIC ARTERIAL SYSTEM

The Boy Scouts taught me the pressure points; The radial, at the thumb-side of the wrist, the brachial, on the inside of the upper arm, and the inguinal in the groin area. Pressure on these sites will stop arterial bleeding distally.

You should be able to locate the radial artery pulse, and begin to appreciate its strength and regularity. Strength in case you encounter a person who isn’t moving, and regularity for yourself; many older people develop an irregularity called Atrial Fibrillation, and you might be the first to discover it..

ANEURISMS are swelling of the arteries, and the swelling may thin the arterial wall so that it can burst. A Cerebral aneurysm can burst and cause a stroke-like problem. If an aortic aneurism bursts, the internal blood loss can be fatal.

RAYNAUD’S Phenomenon is fairly common, and consists of an over-reaction to cold, where arteries of the hands constrict, and the fingers get white and cold. Burger’s disease involves small arteries, and often is associated with Raynaud’s. The arteries carry the blood distally (away from the heart), continuing to divide into ever smaller arterioles which terminate in capillaries, which branch out in such an arborization as to supply all cells except cartilage and parts of the eye.

HYPERTENSION develops when the arterioles, under hormonal or neural influence, constrict, increasing the resistance to blood flow, and so the pressure. Increase in sodium retention and therefore the blood volume can also increase pressure.

ATHEROSCLEROSIS is the common disease of western life style. Excessive calories and sedentary life style combined with genetic defects in fatty metabolism produce cholesterol plaques which narrow and stiffen the arteries, often leading to BLOCKAGE of blood flow. Blockage of flow to the HEART, BRAIN, KIDNEYS, BOWEL, or EXTREMITIES each produce their separate disorders of Myocardial Infarction, Stroke, Renal artery Disease. Intestinal ischemic syndrome, and Claudication.

Atherosclerosis

These disorders will each be separately discussed. I have always thought of vascular disease as a special class of CAUSATIVE MECHANISMS when trying to develop a DIFFERENTIAL DIAGNOSIS of a patient’s problems. Blockage to an area results in PAIN or LOSS OF FUNCTION.

Stroke is usually painless with blockage, since the brain has no pain sensors. Blockage of the renal artery often causes complex difficulties including Hypertension, because the kidney is an endocrine organ in addition to its excretory function.

A good Friend and patient showed what careful self-care can accomplish. It all started with a myocardial infarction, the first sign of his blood vessel disease. He had a complication in his workup, and had to have emergency bypass surgery. There had been damage to the heart muscle, with a large reduction in his EJECTION FRACTION.

His cardiologist gave him at most 5 years to live. That was 25 years ago, before the development of the statin drugs. He was given a draconian low cholesterol diet, which he followed exactly. One one visit to the cardiologist, he inquired whether he could have other areas of arterial blockage. His doctor then listened to his neck and discovered a bruit (noise) in the carotid artery, after which he had a Carotid endarterectomy.

In an orthopedist office for back pain, the orthopedist left the room, and my friend noticed in the CT scan report mention of cysts in the kidneys.

The Orthopedist cared mainly about his bones, and had overlooked the “incidental finding”. His brother had died of mesenteric artery blockage from atherosclerosis, he had stomach symptoms, and sure enough he also had arterial blockage to the intestines.

Bottom line: it pays to be an ACTIVE PARTICIPANT in our medical treatment, and even though we all have genetic determinants, we can make our health BETTER with attention to our health, especially SLEEP, DIET and EXERCISE.

–DR. C

Dr. C "Comments", Medicine, Men's Health, Women's Health

INFOGRAPHIC: A LOOK AT “CANCERS ASSOCIATED WITH OVERWEIGHT & OBESITY

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There is consistent evidence that higher amounts of body fat are associated with increased risks of a number of cancers (6), including:

  • Endometrial cancer: Obese and overweight women are two to about four times as likely as normal-weight women to develop endometrial cancer (cancer of the lining of the uterus), and extremely obese women are about seven times as likely to develop the more common of the two main types of this cancer (7). The risk of endometrial cancer increases with increasing weight gain in adulthood, particularly among women who have never used menopausal hormone therapy (8).
  • Esophageal adenocarcinoma: People who are overweight or obese are about twice as likely as normal-weight people to develop a type of esophageal cancer called esophageal adenocarcinoma, and people who are extremely obese are more than four times as likely (9).
  • Gastric cardia cancer: People who are obese are nearly twice as likely as normal-weight people to develop cancer in the upper part of the stomach, that is, the part that is closest to the esophagus (10).
  • Liver cancer: People who are overweight or obese are up to twice as likely as normal-weight people to develop liver cancer. The association between overweight/obesity and liver cancer is stronger in men than women (11, 12).
  • Kidney cancer: People who are overweight or obese are nearly twice as likely as normal-weight people to develop renal cell cancer, the most common form of kidney cancer (13). The association of renal cell cancer with obesity is independent of its association with high blood pressure, a known risk factor for kidney cancer (14).
  • Multiple myeloma: Compared with normal-weight individuals, overweight and obese individuals have a slight (10% to 20%) increase in the risk of developing multiple myeloma (15).
  • Meningioma: The risk of this slow-growing brain tumor that arises in the membranes surrounding the brain and the spinal cord is increased by about 50% in people who are obese and about 20% in people who are overweight (16).
  • Pancreatic cancer: People who are overweight or obese are about 1.5 times as likely to develop pancreatic cancer as normal-weight people (17).
  • Colorectal cancer: People who are obese are slightly (about 30%) more likely to develop colorectal cancer than normal-weight people (18).A higher BMI is associated with increased risks of colon and rectal cancers in both men and in women, but the increases are higher in men than in women (18).
  • Gallbladder cancer: Compared with normal-weight people, people who are overweight have a slight (about 20%) increase in risk of gallbladder cancer, and people who are obese have a 60% increase in risk of gallbladder cancer (19, 20). The risk increase is greater in women than men.
  • Breast cancer: Many studies have shown that, in postmenopausal women, a higher BMI is associated with a modest increase in risk of breast cancer. For example, a 5-unit increase in BMI is associated with a 12% increase in risk (21). Among postmenopausal women, those who are obese have a 20% to 40% increase in risk of developing breast cancer compared with normal-weight women (22). The higher risks are seen mainly in women who have never used menopausal hormone therapy and for tumors that express hormone receptors. Obesity is also a risk factor for breast cancer in men (23).In premenopausal women, by contrast, overweight and obesity have been found to be associated with a 20% decreased risk of breast tumors that express hormone receptors (22).
  • Ovarian cancer: Higher BMI is associated with a slight increase in the risk of ovarian cancer, particularly in women who have never used menopausal hormone therapy (24). For example, a 5-unit increase in BMI is associated with a 10% increase in risk among women who have never used menopausal hormone therapy (24).
  • Thyroid cancer: Higher BMI (specifically, a 5-unit increase in BMI) is associated with a slight (10%) increase in the risk of thyroid cancer (25).

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COMMENTARY

Obesity increases the incidence of cancer, and complicates its treatment.
A healthy life style.,’including good sleep, diet and exercise, should prevent obesity in all but extreme genetic aberrations.

It is better to prevent problems than to grapple with them.
Stay healthy!

—Dr. C.