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Fall 2009 - Vol.4, No.3

Updates of Past Top Tips From Family Practice
Alan S. Peterson, M.D.

Associate Director Family Practice Residency Program

Director of Environmental and Community Medicine

Since the Spring Edition of 2006, we have now published 14 issues of this Journal. I thought it would be appropriate to update some of the topics that I have written about over that time.

Vitamin D – The first update concerns vitamin D, which was the subject of nearly the entire issue of Winter 2006-2007 (Volume 1 #3). Research on this vitamin has flourished since then. Some of the studies reported severe deficiency of vitamin D in critically ill patients (NEJM 360; 18:1912-1914) , in patients with bacterial vaginosis (J. Nutr. 2009;139:1157-1161), and in one third of Canadian toddlers (presented at the Pediatric Academic Society's 2009 Annual Meeting: Abstract 4545.2 May 4, 2009). Higher dosages of vitamin D have been shown to prevent fractures (Arch Intern Med 2009; 169(6):551-561), and there is further evidence supporting the linkage between vitamin D deficiency and coronary disease (Arch Intern Med 2008; 168:1174-1180).

Dr. Michael Holick of Boston University, a foremost authority on vitamin D, suggests that all adults take 1000 units of vitamin D daily in addition to a vitamin D-containing multivitamin. (Be careful in patients who have significant renal failure and/or hypercalcemia.) The two fold increase in risk of myocardial infarction as well as a higher incidence of statin-induced myalgias in those deficient in vitamin D has prompted The Heart Group here in Lancaster to adopt a vitamin D protocol in its patients. Vitamin D deficiency is truly an epidemic in the United States and is associated with or causes multiple medical and surgical disorders.

Conflict of Interest – In the December 2008 JLGH, I wrote about the drug industry and how they can and have manipulated and misinformed us. Since then more articles have been published. In May 2009, in an Australian Federal Court, prosecutors claimed that a prominent cardiologist, Marvin Konstam MD, was the lead author of a 2001 Circulation paper about Vioxx that was actually written in-house by Merck scientists. This "ghostwriting" allegation came just as the Pharmaceutical Research and Manufacturers of America (PhRMA) issued "revised principles" on the communication of clinical trial results, including restricting authorship on medical manuscripts to individuals who have made "substantial contributions." In another article that highlights industry funding of research, the May 11, 2009 (on-line) issue of Cancer stated that nearly 1 in 5 oncology research articles were funded by the pharmaceutical industry, raising questions about the "industrialization of clinical research." Some kind of conflict of interest was found in 29% of 1,534 cancer clinical-research studies published in 2006 in 8 prestigious medical journals.

An on-line April 29, 2009 NEJM Perspective article critiqued an April 2009 report from The Institute of Medicine (IOM) which contained recommendations designed to reduce conflicts of interest in medical research, education and practice. The author, Dr. Robert Steinbrook, a NEJM national correspondent, states "although specific recommendations may be criticized as either too strong or too weak, the IOM's overall proposals are comprehensive and – if adopted – would most likely have substantial effects on individual physicians and medical institutions."

Fructose – The JLGH Winter 2008 issue (Vol 3 #4) included my concerns about fructose and its negative impact on our diet and health. Since then, the Obesity Society's October 2008 meeting included a study from Temple University in which three fourths of 42 schools in the study had vending machines, and 28% of those machines offered drinks with added sugar (averaging 280 calories per drink). Other common snacks included 100% fruit drinks (often containing extra-large servings), "reduced-fat" chips, "low-fat" ice cream, and baked goods which contained an average of 480 calories per package. Their goal is to ultimately remove all juice and sugar-added beverages, offer water instead, and eliminate candy from vending machines.

A January 2009 report from the Institute for Agriculture and Trade Policy (IATP) showed that 31% of foods and drinks rich in high-fructose corn syrup contain detectable levels of total mercury. Many of the implicated food companies said they felt their products were safe, but I don't know of any "plus" for any added mercury in our diet.

The NEJM Perspective article (360; 18:1805-1808) entitled "Ounces of Prevention – The Public policy Case for Taxes on Sugared Beverages" gives excellent health reasons why we should heed Adam Smith's quote from The Wealth of Nations in 1776 – "Sugar, rum, and tobacco are commodities which are nowhere necessities of life, which are become objects of almost universal consumption, and which are therefore extremely proper subjects of taxation." Although a tax on beverages with sugar would have medical benefits regardless of how the money is used, studies show the populace would increase its support of the tax if it would be used for programs focused on childhood obesity, physical activity, and healthier food in schools.

Speaking of childhood obesity programs in PA, I recently learned of an excellent one promoted by the PA Advocates for Nutrition and Activity. Go to the web site for their obesity handouts and program. It can be of great help in the doctor's office and the patient's home.

Finally, stand by for the next issue of JLGH, devoted entirely to the subject of obesity.

Alan S. Peterson, M.D.
Associate Director, Family 7 Community Medicine
Walter L. Aument Family Health Center
317 South Chestnut Street
Quarryville, PA 17566