Vitamins & Supplements

There's lots of information available about the role of vitamins, minerals and supplements and also questions that frequently arise about them.

Part of the complexity stems from the fact that they are sold as dietary supplements and not as medicines or pharmaceuticals. This means that there is little requirement around them for large scale testing of effectiveness and safety, testing for side-effects and interactions with other agents or even for truth in advertising. Whatever may be said about prescription medications and pharmaceutical companies, they are sold under very cautious regulations. In other words, consider vitamins and supplements with the same care as you would for a prescription medicine.

Keeping my comments and recommendations here only to the findings of medical research and studies then:

• CALCIUM: Calcium improves bone density up to 35 years of age. It is especially important in the high school ages. After 35 years old, supplementing calcium does not increase bone density, but it does assure adequate dietary calcium which otherwise is found in dairy products.
• Calcium carbonate (such as TUMS) is the cheapest, and most bio-available. This means that it is not necessarily the fastest into bloodstream, but it is the fastest into bone.
• Dose should be 600 mg, twice a day (up to three times a day in high school aged women).
• I do not recommend oyster shell or coral calcium. If the oyster shell or coral happens to come from a polluted area of ocean, you may be eating the pollutants.

• VITAMIN D: Vitamin D is crucial for normal bone growth, and also nerve growth. Several medical studies link low vitamin D levels to osteoporosis, higher risk of falls and higher risks of all types of cancers. Because vitamin D is mainly found in sardines, mackeral and artificially in milk having low levels is not unusual. This may also be because folks are using more sunscreen and avoiding over-exposure to sun to avoid skin damage and skin cancers!
• Doses of 200-400 I.U. per day are beneficial.
  
• This can often be found combined with calcium, for convenience.

• MULTIVITAMINS WITH MINERALS: You know; like Centrum, One-a-Day, and the generic brands for these. If you have a well balanced diet, you are not likely to be low in vitamins and minerals. Vitamin B12 deficiency can occur in strict vegans, but it isn't common. The trace mineral supplements are helpful in maintaining normal bone health.
• One a day of any inexpensive vitamin supplement may be helpful and isn't harmful.

• ANTIOXIDANTS: In theory, anti-oxidants should prevent cancers and promote longevity since oxidant molecules (so-called oxygen radicals) are a key factor in chromosomal damage which is the underlying cause of cancers and aging. Unfortunately, many studies have been done looking for this effect and it doesn't seem to bear out. If anything, antioxidant supplements may increase risk of heart attacks!
• One exception to this is the use of antioxidant vitamins and minerals in preventing and treating macular degeneration, which is a serious vision problem.
• Over-the-counter preparations such as OcuVite are helpful.

• VITAMIN C AND ZINC:
• Sorry, they really don't seem to prevent or treat colds and flus.
• They do help to promote wound healing, so taking some after surgery, a wound repair or an injury can be helpful. 500 mg a day of Vitamin C plus 200 mg of zinc are common doses for this.

• ASPIRIN: Aspirin reduces the risk of having a stroke or heart attack by making it harder for clots to rapidly form at cholesterol plaques in your blood vessels.
• An 81 mg "baby" aspirin a day is just as good as higher doses, and causes less bleeding problems.

• GLUCOSAMINE: This a precursor to cartilage which buffers joint surfaces. Swallowing it might not necessarily increase cartilage in joints and treat arthritis pain, but it seems to do just that.
• 1,500 mg a day of glucosamine is the normal dose. It can be taken all at once, or in 2-3 smaller doses a day if it upsets your stomach.
• It is not a "pain pill" in the usual sense, so take it for 3-4 months before you decide whether it's helping you or not.
• Chondroitin, MSM and magnesium don't seem to be helpful or add anything so don't bother paying more for these.

There is a lot of exciting research and study on vitamins and supplements, and plenty of it is to be found on-line or on TV and in magazines. Just review it with a critical eye, the same way you would with prescription pills.

School Immunizations

Back in the day when there were school nurses and they actually were registered nurses, 11-12 year olds were offered shots and boosters for diseases like tetanus. That went by the wayside for reasons probably related to funding and concerns about liability.

Unfortunately, that meant a lot of middle schoolers weren't getting them at all (most middle schoolers are quite healthy, and not at all interested in coming to the doctor for some shots).

The El Dorado County Public Health Department has really stepped up to the plate, and is offering routine immunizations to 11 and 12 year olds free of charge and on a completely voluntary basis. I encourage everyone who has received the packet sent home from school to look it over thoroughly. The information is complete, accurate and helpful.

And yes, I signed up my middle schooler for all of them.

CalPERS Open Enrollment- The Short Answers

Those of you who are State of California employees, or public employees who use CalPERS for health insurance (such as City of Placerville, Garden Valley Fire Department, El Dorado Irrigation District) have by now received the thick stack of glossy paper presentations on your options for health insurance for 2008.

I've already posted on this several times, and have discussed this with lots of patients, many of whom I have known for up to 10 years. I'm definitely getting the idea that any lengthy discussion larded over with HMO-PPO-EPO-IPA-blah-blah-blah is simply confusing, and that the big package from CalPERS can be overwhelming.

So, in a nutshell, here are the Short Answers to the Frequently Asked Questions:

• How do I keep you as my doctor?
• Choose one of the Blue Cross administered PPO choices: PERS Care, PERS Select, or PERS Choice.

• Are you with PERS Select?
• Yes.

• What is PERS Select?
• It's basically the same benefits as the PERS Choice plan, but where the 20% tier of personal costs goes with seeing doctors who are PERS Select doctors.
• I think these are doctors who Blue Cross feels meet some selective criteria for higher quality of preventive care and treatment of chronic illnesses.

• What are PERS Care and PERS Choice?
• These are brand names for two PPO plans through Blue Cross.

• What's a PPO?
• This is health insurance where you can choose your own doctors and see specialists whenever you want.
  
• Annual physicals are covered.
  
• Coverage of medications is typically better.
  
• There is an annual $500 deductible (this is very low compared to most other people's insurance).
  
• After this, you pay 10% (for PERS Care) or 20% (for PERS Choice or PERS Select) up to the annual max. After that, Blue Cross picks up 100% of medical costs.
• Please notice the annual max: you won't be getting a bill for 10-20% of a million dollars in medical care for a medical catastrophe!
  
• This is basically like the insurance plans that employees of smaller employers (like Intel, Bank of America, Microsoft...) get to pick from only with lower deductibles and lower max. In other words, you are on the hook for less money than most folks.

• Will it be hard to see primary care doctors or specialists?
• No.
• Most doctors take Blue Cross.
• Referrals are not required by the insurance.
  

• Should I pick PERS Care or PERS Choice? What's the difference?
  
• PERS Care has higher premiums every month, but it pays for more of your medical care.
• Most folks with chronic medical problems pick this because they know they're going to fully use it.

• PERS Choice and PERS Select have lower premiums, but pay a lower percentage of costs.
• Most folks who pick these are pretty healthy and don't use their health insurance a lot.
• These can also be a good choice for folks who save money well and want to spend less a month on the premiums since they know that if there's a need, they can manage the annual cap, after which point the insurance picks up everything.

• Can I still be on Blue Shield?
• Yes, but only as an HMO which means all your medical care will be down the hill just like with Kaiser.

• I was told that the Blue Shield EPO will still be available in "certain parts of El Dorado county". Is that true?
• No.
• CalPERS press releases state that your EPO has been dropped completely.
• Blue Shield as an HMO may be available in areas close to the border with Sacramento County.

• What if my employer switches to some other insurance?
• Fine by me.
• Most local large employers are very upset with CalPERS, and looking for insurance that most doctors up here already take. They already have stated at meetings that they don't want people to go to Kaiser because it's far and will result in a lot more missed work because of the drive time involved just to get seen.
• For example, EID is looking at benefits through the Association of California Water Agencies which offers Blue Cross.

• What if I am retired or retiring soon?
• Look closely at what you want to have beyond Medicare Part A and Part B (these cover ER, hospital, doctor visits, labs and X-Rays).
• You could easily be better off choosing PERS Choice because it has the lowest premiums, or even dropping CalPERS altogether.
• Medicare Part D (the drug plan) has an average premium of about $40/month.
• The most expensive Medicare supplement (for additional coverage of things like long-term care) is about $80/month.
  

• I have decided to switch to Kaiser.
• I am very sorry to hear that. You will be missed!

Will you see my child, too?

Short answer: Why, sure!

Family physicians are specifically trained to see patients of all ages and this includes delivering babies, and caring for newborns, infants, toddlers, adolescents and teens. (I confess: I stopped doing pre-natal care and delivering babies after the first 500 or so deliveries, in the interest of sleeping all night from time to time.)

Mind you, if your child has a rare and complex chronic medical problem, I am very likely to want to share their care with pediatric sub-specialists (down the hill since there aren't any up here).

I also get asked this question a lot about children who already see a pediatrician. Most of the time the question comes up in the sense that the child is a teen or pre-teen who is feeling a bit old to be seeing a pediatrician. Changing to an "adult doctor" seems reasonable to me, assuming that there are no ongoing concerns or medical problems that might make that a bad idea. Feel free to ask!