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Frequently Asked Questions

 
Ted A. Tobey, M.D., Inc.
505 Central Ave., Suite #301
Pacific Grove , CA . 93950
Telephone (831) 655-9578
FAX (831) 655-4628
 
Diabetes
How does one handle diabetic medications when traveling across time zones?

Diet and Weight Loss
Summary of Weight Loss Plans
Why do some people seem to have much more difficulty losing weight and keeping the weight off than others?
Lipids and Atherosclerosis:
Should I Stop My Zetia (or Vytorin) Because of the Recently Publicized Results of the ENHANCE Study?
 
Thyroid:

Other
How can I reduce the cost of my prescription medications?



Articles
Listed Articles


Diabetes
How does one handle diabetic medications when traveling across time zones?

  If you pack your medications (or insulin) in your checked luggage, pack a secondary duplicate supply in you carry-on luggage, in case luggage gets lost or delayed. Don’t assume that you can get the same supplies abroad as you get at home. In going West to East, your day becomes shorter. That means that meals will be spaced more closely together. Generally nothing needs to be done with regard to adjusting medications in this situation. Simply check your blood sugars and take the medications in relation to meals as you normally would. In going from East to West, your day becomes longer. Carry one or more extra snacks to have between meals, and be prepared to check a couple of extra blood sugars. Generally speaking you should plan to take your medications in relation to breakfast, lunch and dinner meals as you normally would. Due to heightened security, keep your medications in their original containers and carry medical identification for your condition.

Health & Wellness
How can I reduce the cost of my prescription medications?

  First of all, check with your insurance company to see if they sponsor a mail-order prescription service. Prescriptions through these services are usually filled in 2- or 3-month increments, so you will have fewer co-pays to make than going to a local pharmacy once a month. I usually write prescriptions for 90 days at a time. If you are getting a lesser quantity than that, it typically is your insurance company that is imposing that limitation.

  Depending on your income, you may be eligible for some prescription medications for free, or at a significantly reduced rate. Many drug companies have programs to provide medications to patients on limited incomes (less than $25,000-$30,000 or so per year). You can check with the receptionist at our front office to see if any of your medications we prescribe may be covered under these programs. We are happy to help with these forms and send them in for our patients, but our patients must take responsibility to accurately fill out your information and provide the appropriate financial documents if and when requested. Our office cannot be responsible for patients not fulfilling their obligation to provide information under these programs.

  When you get a prescription filled, you can ask for any amount of pills less than or equal to the maximum number of pills listed on the prescription. If you’re just starting a new medication and it is expensive, ask for a limited number of pills. You will have to make another prescription co-payment when you pick up the rest of the pills, but it will save you the full cost of the medication if it does not agree with you and you have to stop it. If you can’t afford a medication, let us know immediately, so we can start working on a solution. The Important Links section of this website has Internet links to some sources of discounted medications.

 

Both Walmart and Target now sponser generic drug programs.  There are about 300 generic drugs you can now purchase through Walmart for $4 per month or $10 to $24 for a 3 month supply.  Target has also recently started a generic drug program and has similar charges for about 200 generic drugs.  A listing of these drugs is available on line.  Look at Important Links - Other Links of Interest - Prescription Drugs on this website.  These programs are really unbeatable for price and many non-generic drugs have good generic drug equivalents.  Ask your doctor.

  Medications can be ordered from Canada (see Important Links in this website). Technically this is still illegal, and you should be aware of important issues around this procedure, but it does typically save individuals ~40% of the cost of their medications.

What alternative therapies are useful for treating elevated cholesterol (lipids)?
  Lifestyle modifications are an important means to address adverse effects of elevated cholesterol or a bad lipid (blood fats) profile. Smoking dramatically increases the risk of cardiovascular disease(CVD) caused by lipid problems. After stopping smoking for just 1 year, the risk of cardiovascular disease drops by 50%, and the smoking-related risk almost disappears after 3 years.

  Alcohol consumption confers both health benefits and risks. One drink per day seems to be protective of CVD in women because it is associated with an increase in high-density cholesterol (so-called “good” cholesterol). However, drinking 2 or more alcoholic beverages per day may increase CVD because that is associated with an increase in blood pressure.

  Weight loss and increased physical activity both help to improve bad lipid profiles and reduce the risk of CVD. Obesity is associated with high triglycerides (blood fats) and low high-density cholesterol, both of which are associated with an increased risk of CVD. In particular, further weight gain after attaining adulthood will significantly increase the risk of atherosclerosis (fat and cholesterol build-up on the inside of arteries leading to CVD). A sedentary lifestyle is also an independent risk factor for CVD. A regular aerobic exercise program, either walking or doing more vigorous activity, will significantly reduce the risk of CVD. Current federal guidelines recommend moderate activity such as walking 30 minutes a day five times weekly.

  A healthy diet is of primary importance in reducing the risk of CVD. It should follow federal guidelines, emphasizing fresh fruits and vegetables, be low in saturated fat, and utilize moderate amounts of fish, poultry and lean meats, with generous amounts of whole grains, legumes, nuts, seeds, and soluble fiber such as pectin, oats and psyllium. In addition, the consumption of trans-fatty acids should be replaced with mono- or polyunsaturated fats. Soy-based foods are rich in isoflavones, low in saturated fat and quite healthy for the heart. Soy based diets with the consumption of 45-50 grams/day will lower total cholesterol levels by about 9%, low-density cholesterol (LDL -“bad” cholesterol) by about 13% and triglycerides (blood fats) by 10%. Plant sterols, called phytosterols, are also able to lower cholesterol levels. They accomplish this by impairing the absorption of cholesterol from the gut. Consuming 2-3 grams of phytosterols/day may lower cholesterol levels by as much as 10-15% (However, these agents may also impair the absorption of ß-carotine, a-tocopheral, and lycopene, requiring supplementation.

  Supplements such as niacin (nicotinic acid) will favorably affect lipid levels. Niacin acts by inhibiting the peripheral mobilization of free fatty acids and thereby reduces the production of lipids from the liver. Therapeutic doses of niacin can reduce the risk of recurrent heart disease over a 5-year period by more than 25%. Niacin is currently the best treatment available to raise high-density cholesterol (HDL – “good” cholesterol). Therapeutic doses of niacin can raise HDL cholesterol by 15-35%. The major problems with these large doses (1.5-3.0 grams/day) are flushing, and at times liver inflammation. Immediate release niacin is recommended, as the sustained-release preparations seem to be associated with a higher risk of liver disease. Niacin, especially in larger doses, can also exacerbate blood sugar levels in people with diabetes. Therapeutic doses of niacin are best monitored by a physician.

  Policosanols are mixtures of alcohols extracted from sugar cane wax or beeswax. Twenty mg/day of policosanols will lower total cholesterol and LDL levels by about 20%, while raising HDL levels by about 15%, with little effect on triglycerides.

  Fish oil is another dietary supplement associated with a lowered risk of CVD. Fish oil is composed of omega-3 fatty acids (another rich source of omega-3 fatty acids is flax seed oil), and will favorably alter lipid levels. The recommended doses for fish oil supplementation are 200 mg/day of EPA and 120 mg/day of DHA.

  Herbal supplements include red yeast rice, garlic, guggul and globe artichokes. Red yeast rice contains small amounts of lovastatin (known by the drug name Mevacor) which inhibits cholesterol production from the liver. The amount of lovastatin in red yeast rice is very small, and other agents in red yeast rice such as omega-3 fatty acids, isoflavones and plant sterols probably also have some positive lipid effects. Because earlier preparations of red yeast rice contained significant amounts of lovastatin, the use of these agents was considered a patent infringement by the FDA and red yeast rice preparations with higher lovastatin concentrations were banned in this country. Although garlic is a popular lipid-lowering agent, its effect is at best slight. Garlic contains allicin, which will be inactivated by stomach acid, and therefore these agents must be protected from stomach acid breakdown to have any effect on lipids. Furthermore this effect is quite transient and appears only to lower cholesterol levels by 5-10%. Guggul is a medicinal herb from the guggul tree of the middle east. Guggulsterones help to prevent deposits of LDL cholesterol on vessel walls, and help the body to excrete cholesterol. Guggul 500 mg three times per day (25 mg of guggulsterones three times per day) will decrease total cholesterol by about 12%, LDL cholesterol by about 12%, triglycerides by about 12% with little effect on HDL cholesterol. Globe artichoke leaf extract has lipid-lowering activity. Eighteen hundred mg per day will lower cholesterol levels by about 18%, and LDL levels by about 23%. However globe artichoke leaf extract may induce gallstone or gallbladder attacks.

Should I Stop My Zetia (or Vytorin) Because of the Recently Publicized Results of the ENHANCE Study?
The ENHANCE Study is a medical trial study done in 720 patients with Heterozygous Familial Hypercholesterolemia (HeFH).  This is a relatively rare form of disease in which cholesterol levels are extremely high due to LDL-cholesterol (“Bad” cholesterol) receptor abnormalities.  These patients have very high rates of atherosclerosis leading to heart disease and strokes.  This study was conducted by the manufacturers of Zetia (Merck & Schering-Plough Pharmaceuticals) in an attempt to show that atherosclerotic plaque buildup (cholesterol, fats, and calcium) on the inside of arteries in the neck would be slowed down in these high-risk patients who took Zetia + simvastatin as opposed to simvastatin alone after a period of 2 years. 

Merck and Schering-Plough did the study and then sat on the results without publishing them for 20 months.  The results were finally released January 14, 2008 and showed a negative result (there was no difference in the 2 study groups of patients).  There was no evidence the patients taking the Zetia + simvastatin had any adverse outcomes or side effects from taking the Zetia.  Their cholesterol levels in fact declined MORE than those of the patients who didn’t take the Zetia.  They just didn’t do any better with regard to the primary endpoint of the study (atherosclerotic plaque buildup on the inside of arteries in the neck was NOT slowed down).  Now there are calls from some physicians to stop prescribing Zetia for patients with hypercholesterolemia because they interpret this study to mean that Zetia is ineffective in reducing the risk of coronary artery disease and stroke.

My opinion on this is that at the moment we do not have enough good information to tell us that Zetia really is ineffective.  My conclusion is that for all the patients currently taking Zetia or Vytorin they should continue taking it.  The reasons for this include the following:

  1. The group of patients in the ENHANCE study is a uniform group of people with a rare disorder, that probably is NOT applicable to the general population.  Their cholesterol levels were NEVER brought down to GOAL levels in either the study group of patients or the control group of patients.  The study was NOT designed to look at outcomes such as heart attack or stroke, and it should not be surprising that we did not see differences in those outcomes.  It is not clear that the study primary endpoint (vessel plaque buildup) is the best marker for progression of atherosclerosis in this group of patients.
  2. Zetia DID in fact lower cholesterol levels significantly further in those patients in the study who took it.  This is in keeping with Zetia’s mechanism of action and other studies of its action.  What didn’t happen (and what the ENHANCE study was NOT designed to measure) was a difference in heart attack or stroke outcomes.
  3. Our global knowledge of cholesterol problems and atherosclerosis supports the notion that lowering cholesterol levels will reduce the risk of heart attack and stroke.  Unless that fundamental relationship is wrong, lowering the cholesterol level with drugs such as Zetia will in fact, given the proper study circumstances, show a decreased risk for stroke and heart attack over time.  Zetia was approved by the FDA because in fact it does lower cholesterol levels effectively.
  4. There are several other much larger studies currently underway that ARE testing Zetia with regard to heart attack and stroke outcomes.  These studies should give us a much better indication of whether Zetia will reduce heart attack and stroke as we all up until this point have presumed it will.  It makes good sense to wait at least until these new studies are published in the next 1-2 years before abandoning Zetia.
  5. At this point in time, if we were just to abandon the use of Zetia, we would have no drug to replace it.  Almost all patients who are taking Zetia are already taking a statin drug (or are totally intolerant of statin drugs and can’t take them at all), and are not at lipid level GOALs.  If we stop using Zetia, those patients would never be able to get to their lipid level goals.  And we know that unless we get patients to lipid level goals, that their burden of atherosclerotic plaque will continue to rise.

The fact that Merck and Schering-Plough have suppressed the publication of this information for 20 months while they continue to make several BILLION dollars annually on Zetia is reprehensible.  The system of drug approval, drug supervision, and drug studies in the United States needs reform.  Those issues, however, should not taint a careful, balanced decision-making process about the real long-term usefulness of this medication.  We need free and timely access to more information as soon as it becomes available. 

 


Why do some people seem to have much more difficulty losing weight and keeping the weight off than others?
For years physicians, including myself, have heard that some people can’t lose weight no matter how much they diet. We know that when people start a calorie-restricted diet over some days time their metabolic rate declines so as not to burn calories so fast— a form of weight conservation genetically programmed into us. Now we also have data that suggests some people routinely burn fewer calories than others, and these differences correlate with excess body weight.

Self-described couch potatoes who are overweight have a lower metabolic rate in part because of lower levels of non-exercise activity thermogenesis, or NEAT.

Non-exercise activity thermogenesis refers to daily low-key activities that are not routinely considered exercise per se, but do in fact burn calories. Such activities include extra walking, standing, “figeting”, shopping, cleaning, moving things about, etc. In a published study (Science 2005, authors JA Levine et. Al), NEAT appears to have a stronger correlation with lower body weight than formal exercise programs. Not previously fully appreciated, large differences exist in NEAT among individuals. Even in self-described sedentary people, it’s easy to see NEAT calorie expenditure differences of 350-500 calories/day between individuals. That’s enough to explain a loss (or gain) of 1 pound or more a week. Some of these differences may be genetically programmed, for instance, by brain chemicals such as the arousal neuropeptide orexin. But its likely that environmental factors and motivation also play significant roles.

The study. found that on average obese people sit 2 hours more per day than their lean counterparts. This difference translates into 350 fewer calories burned per day in the more sedentary group.

The researchers recruited 20 healthy but self-described “couch potatoes” - 10 of whom were lean and 10 of whom were overweight—for this pilot study. Each was outfitted with special undergarments embedded with sensors that recorded movement. Subject movement was monitored every 1/2 second for the 10 day study. Dietary intake and formal exercise were controlled, and patients were instructed to go about their usual daily activities.

Overweight individuals sat an average of 164 minutes more/day than their lean counterparts. Total body movement was correlated with lean body mass. The non-exercise activity thermogenesis (NEAT) differed between individuals by a factor of 10, and higher NEAT strongly correlated with leanness. When participants were next forced to gain or lose weight, and then re-monitored, their NEAT scores remained unchanged. This means that although NEAT may affect your weight, your weight does not affect your NEAT score.

The implications of this study are important. If you’re overweight, think about adding NEAT activities to your routine. Don’t relax by sitting in front of the TV (put a treadmill or exercise piece in front of your TV!). Use your lunch break for a walk. Play with the kids. Fire your cleaning person. Celebrate birthdays with activities. Meet friends for outings. Walk more. Use the stairs.

 

Diet
Summary of Weight Loss Plans (adapted from Diabetes, Obesity and Cardiovascular Disease News, February 2005):
Note: “Carbohydrate” is abbreviated as “CHO”
Diet & Type Suggested Foods Restricted Foods Exercise Behavior Changes Long-term Plan
The Abs Diet

Low-refined CHO, high-fiber & protein diet
Nuts, legumes, green vegetables, berries, low-fat dairy, oatmeal, lean meats, eggs, olive oil, whole-grain bread & cereal, protein whey powder Fatty meats, processed & refined CHO, high-sugar foods Total body strength training workout designed to build muscle Only to participate in the program Lifelong diet & exercise program
Atkins Diet

High-protein, low CHO diet
Meats, shellfish, eggs, cheese, some salad and low-CHO vegetables, butter, vegetable oils, official Atkins food products Fruit, bread, grains, starchy vegetables, pasta, alcohol, & dairy for 14 days, minimal CHO increase thereafter Suggests daily exercise Only diet and exercise program Phased for ongoing weight loss & maintenance
DASH Diet

Balanced low-sodium diet
High intake of grains, fruit, vegetables; moderate intake of fat-free dairy & vegetable oils, nuts, legumes Limit meat, fish, poultry to 2 servings per day, sweets to 1/day, limited salt & alcohol Suggests physical activity Tracks before & after dietary habits Lifelong dietary program
Dean Ornish Low-fat, high-CHO diet, exercise, relaxation Vegetables, fruit, whole-grains, dried beans, legumes; very lean poultry, fish, red meat & dairy, vitamin & mineral supplements Most processed & high-fat foods, caffeine, alcohol, sugar, salt, dietary fats & oils Suggests moderate aerobic exercise Stress reduction & management techniques Lifelong dietary program
Jenny Craig

Calorie & portion control, balanced diet
Proprietary meals & supple-ments plus fruits, vegetables, dairy, whole-grain foods Most foods other than proprietary foods & supple-ments Suggests regular exercise One-on-one counseling As long as a program participant
Pritikin Eating Plan

Very low-fat & low sodium, high CHO, moderate protein diet
High daily intake of whole grains & starches, plus green, yellow & orange vegetables, fruits, moderate low-fat dairy, one lean poultry, meat or fish No whole-fat dairy, egg yolks, processed animal fats, tropical oils. Limited refined grains, caffeine, oils, salt Suggests regular exercise Promotes stress avoidance & lifestyle education Lifelong program
South Beach Diet

Initial low-CHO & balanced protein diet, then balanced CHO & protein phases
Lean meats, poultry, seafood, low-fat dairy, eggs, nuts, non-starchy vegetables, low-calorie sweets during 1st phase. Then fruits, whole-grains, CHO introduced during phase 2 No high-fat meat or dairy, bread, rice, pasta, or starchy vegetables, fruit, alcohol for 14 days. Continued limits on refined breads, cereals, pasta, beets, carrots, white potatoes, corn, some fruits Daily vigorous walk or substitute exercise & daily stretching. Regular weight training None beyond diet & exercise program Phase –3 diet & menus for weight maintenance
The Ultimate Weight Solution

High-protein, portion control diet & behavior modification
Daily servings of 3 proteins, 2-3 CHO, 4 vegetable, 2 dairy & 1 fat plus proprietary supplements & nutritional bars Whole-fat cheese & dairy, pizza, white pasta, tortilla chips & other “foods you grab & eat on the run.” Regular walking or aerobics & weight training Behavior modification & support groups are main focus of the plan Lifelong behavior modification program
Weight Watchers

Calorie-controlled balanced diet & support group
Point system based on fat, fiber & calorie content of foods. Food intake based upon individual’s recommended points Based upon individual point recommendations Suggests increased physical activity levels Weekly group or on-line meetings to identify lifestyle changes & set goals Encourages lifestyle changes for weight maintenance
The Zone Diet

Low-CHO balanced protein & fat diet based upon body mass & activity
Offers food & recipes based on balanced “blocks” of protein, fat and CHO High-fat & high-CHO foods Suggests regular exercise Not specified beyond diet & exercise program Lifelong program

 

Prevalence of diabetes and impaired glucose tolerance and plasma glucose levels in U.S. population aged 20-74 yr.
Diabetes. 1987 Apr;36(4):523-34.
PMID: 3817306 [PubMed - indexed for MEDLINE]
 
The Diabetes Prevention Program: baseline characteristics of the randomized cohort. The Diabetes Prevention Program Research Group.
Diabetes Care. 2000 Nov;23(11):1619-29.
PMID: 11092283 [PubMed - indexed for MEDLINE]
 
Strategies to Identify Adults at High Risk for Type 2 Diabetes: The Diabetes Prevention Program.
Diabetes Care. 2005 Jan;28(1):138-144.
PMID: 15616247 [PubMed - as supplied by publisher]
 
Achieving weight and activity goals among diabetes prevention program lifestyle participants.
Obes Res. 2004 Sep;12(9):1426-34.
PMID: 15483207 [PubMed - in process]
 
Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
N Engl J Med. 2002 Feb 7;346(6):393-403.
PMID: 11832527 [PubMed - indexed for MEDLINE]
 
Projected impact of implementing the results of the diabetes prevention program in the U.S. population.
Diabetes Care. 2002 Nov;25(11):1940-5.
PMID: 12401736 [PubMed - indexed for MEDLINE]
 
The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity.
Diabetes Care. 2003 Dec;26(12):3230-6.
PMID: 14633807 [PubMed - indexed for MEDLINE]
 
Meeting recommendations for multiple healthy lifestyle factors. Prevalence, clustering, and predictors among adolescent, adult, and senior health plan members.
Am J Prev Med. 2004 Aug;27(2 Suppl):25-33.
PMID: 15275671 [PubMed - indexed for MEDLINE]
 
Leisure-time activity is an important determinant of long-term weight maintenance after weight loss in the Sibutramine Trial on Obesity Reduction and Maintenance (STORM trial).
Am J Clin Nutr. 2003 Aug;78(2):209-14.
PMID: 12885699 [PubMed - indexed for MEDLINE]
 
Long-term weight loss and changes in blood pressure: results of the Trials of Hypertension Prevention, phase II.
Ann Intern Med. 2001 Jan 2;134(1):1-11.
PMID: 11187414 [PubMed - indexed for MEDLINE]
 

Revised 8/08

 


©Ted A. Tobey, M.D., Inc. ~ All Rights Reserved