A pharmacist's look at the supermarket and beyond

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Health Care Extremism

The latest attempt to repeal and replace “Obamacare” has failed, despite a Republican controlled Congress and a president that ran as a Republican, but is demonstrably a party of one. The Ryan plan, dubbed the American Health Care Plan, remained too socialist and liberal for the conservatives, too generous to the wealthy for the Democrats, and too weak to be a meaningful replacement for the more robust ACA. I’m glad it failed. It was an extreme and poorly crafted alternative. This is the best they could come up with in seven friggin’ years??!! And then they were willing to bend over for the “Freedom” Caucus and demolish women’s health care. Spineless tools.

Not that I am all that happy with the ACA. Most folks agree that certain aspects of Obamacare are winners,the pre-existing condition requirement, the age 26 coverage as a dependent, and the expansion of Medicaid, seem to be the top three. Major mis-steps are the pricing structure that allows healthy individuals to forego coverage unless they pay a penalty, and the mandated coverage of certain items that are not universally needed. Either way, a person starting out in the workforce has a new expense that will delay many desirable milestones as a contributing citizen. It makes it more difficult to buy that first home, start a family or own a business, and erodes any attempt to plan for the future. Insurers were left offering policies with unneeded coverage line items that inflated premiums and made plans unattractive to potential buyers. That whole pricing/minimum coverage strategy coupled with tax implications are the biggest flaws of the ACA.

My question is: Why must we repeal and replace the entire Act? That’s extreme! Shouldn’t we be gathering our experts and stakeholders to work with Congress and find a workable solution? Congress should be representing the best interests of its constituencies, not special interests such as Big Pharma, behemoth insurance companies and their CEOs, or other members of the oligarchy.

Medicare has worked relatively well for decades. This despite the government “borrowing” all of the money that we have paid into the trust fund itself. The funding strategy is not as convoluted as the ACA and with proper changes in design, intelligent limits on coverage, and aggressive fraud deterrence, a national health care plan is possible. We should cover every American with a basic level of coverage starting with first breath. A balanced fee structure could be designed using a person’s age and income (ability to pay) to determine a reasonable premium. Note that I said basic coverage, you can read that as catastrophic coverage if you like. The main point is to provide federal coverage for all. Once we agree on that we can start to discuss incentives for healthy behavior and limits to care for self-inflicted conditions. We can balance payments according to age and ability to pay. We could even consider levels of coverage above the basic as people entered the workforce while creating incentives for people to seek gainful employment. States could take action to help those at greater risk and lower abilities. I’d still like to see everyone contribute to match their abilities.

This would not mean the end of more robust plans, which could be offered by employers as part of an attractive benefit package. HSAs could easily survive.Once the baseline coverage foundation is established, building on it in the marketplace, either through private purchase or as part of a group (be it employer or other groups), can fulfill that burning Republican desire for capitalism in health care. Although we need to be very careful how this is crafted.

I wonder if we see this extreme behavior to completely destroy Obamacare as a reactionary dislike for our first Black president simply because he is Black. I’ve told my Senators and Representatives that I want the ACA made better, not destroyed. That is how we made America great, by building on our successes and revising and improving on ideas that didn’t meet expectations. Not by the extreme politics that we are seeing now.

And while we are at it: One of the components of the ACA was to limit health insurance executives to $500,000 in tax deductions. HHS Secretary, Tom Price stated that it is unAmerican to single out these individuals.
I agree! Why not have that $500,000 limit on everyone? We could exclude charitable donations to true charities (NOT PACs!). No one is singled out. Problem solved!
Who the Hell needs more than half a million in tax deductions??? Yeah, I can think of one guy too.

Finally, no matter what we do, the end result should be something that can be easily understood by the average Joe. No more of the coverage gap, you pay this % we pay that %, Big Pharma gives you a discount (wink, wink), spend this much, we match, check out of pocket, cover this today, not tomorrow, authoritarian health rules. I must be able to explain coverage to my patients! Preferably in two sentences! That would be Great!

Suggested Executive Orders for DJT

I thought I should expand on a brief note that I have sent to the White House and posted on Facebook. Maybe, though, rather than expand it, I would be better off trying to get it down to tweet size! (Added text in italics)

President Trump,
I am not a lobbyist. I am a practicing pharmacist with a few suggestions for my professional arena that I think will help make America greater.
1. Immediately make all pharmaceutical manufacturer’s discount cards eligible to be used by patients with Medicare. This exclusion is just a lobbyist-fueled, mean-spirited obstacle for those patients most in need of our help with exorbitant drug costs. This is an apparent attempt to avoid violating the Medicare Anti Kickback statute. Congress enacted the Anti Kickback Statute as Amendments to the Social Security Act in 1972. It was more recently revised in 2010 as part of ACA. In pharmacy, one notable case involved Walgreens in a 2012 settlement of $7.9 million. Walgreens, of course, denied any fault. They had simply offered gift cards Medicare and Medicaid beneficiaries in exchange for transferring their prescriptions to Walgreens. I suppose this is similar in concept to a drug company offering to reduce a copay for a Medicare patient’s brand name med. The difference is that patients are given an Rx for a specific drug. It’s not like they can simply go across the street to a competitor. Too often, a patient struggles, trying to decide where the money will come from to pay for their fancy post-op blood thinner or the latest and greatest diabetes med that may lower their A1C by half a point. It’s OK if you are privately insured though! This distinction helps to contribute to the high cost of brand name medications and should be modified as soon as possible. Easily remedied with an executive order! Notice these cards not only exempt Medicare patients but also our veterans covered by TriCare or other DOD plans!

2. Create a third category of pharmaceuticals that could be ordered by pharmacists for the benefit of their patients. Drugs to be included in this category can be selected by a small pro-tem committee of a practicing pharmacist, an academic pharmacist, a physician, a representative of PHRMA, and a consumer. This idea has been in various stages of discussion for as long as I can remember. There seems to be a concerted among powerful lobbying groups to prevent it from ever happening. As always, the reason is money. I’m sure the AMA sees it as an attack on their rice bowl as does the insurance industry. As a colleague of mine pointed out (thanks, Andrea!) Big Pharma should be with us on this after seeing what pharmacy has done to increase sales of immunizations. Easily remedied with an executive order!

3. Immediately grant pharmacists provider status. Congress has dithered with this long enough. Make it so. The latest iteration is a proposed statute granting provider status in rural, under-served areas ONLY. That’s a bunch of crap. The value of pharmacists in the delivery of health care and the resulting improvement in outcomes and cost and been well documented many times. Easily remedied with an executive order!

I tried to keep this message brief and would be happy to discuss or answer any questions that you may have.

Let’s make pharmacy greater!

Who Wants to Live Forever?

I was looking over my Social Security statement today and noticed a few things. Most obvious was the impact of my professional education. My annual income increased ten-fold in my graduation year. Granted that compares a student’s wages (working full time during summers and other breaks, with some part time work during school), against six months as a pharmacist. Suddenly, I had money and I learned to spend it, usually unwisely, but that’s another story.
I also calculated that the amounts paid in by myself and my employers would fund my retirement for ten years, even if that money did not earn any interest or other dividends. With only modest compounded interest, it is obvious that my retirement could and should be well funded, even beyond my death. My employers and I have paid a mere $81,000 into Medicare, however. That could buy a health insurance policy for about $350 per monthly premium for ten years. How much does health insurance cost? I checked:
Average monthly premiums for individual plans by age group were: (The figures are from eHealth’s Health Insurance Price Index Report for 2016)
$152 for people under age 18
$177 for people age 18-24
$239 for people age 25-34
$303 for people age 35-44
$400 for people age 45-54
$580 for people age 55-64
So if I were in my forties, I might be OK, but really I could last about 12 years, again assuming no earnings on my contributions.

With careful planning and a frugal lifestyle, I could probably make it to 90 without either of these government programs, assuming I invested similar amounts. Fortunately, I have made additional investments for my future, as well as my children, so I’m good to go indefinitely! Unless immortality is very expensive, of course. Kidding. I am lucky to have made it this far!

One of the proposed suggestions for revising American health care is Medicare for all. It is apparent to me that after paying into Medicare for over 40 years that I could barely take care of my own health needs, and I’m pretty damned healthy. There are millions that have exhausted any funding that they may have personally contributed and are now dependent on folks like me. If we are to keep Medicare solvent and/or cover everyone then we face some huge financial hurdles. Like any other type of insurance, we will have to make sure that the money coming in is sufficient to pay the claims to be paid. Right now, we do not have that balanced equation and that must change.

First of all, we cannot pay for everything. I’ve blogged about incredibly expensive, yet hardly effective treatments, and those must be forsaken. End of life planning is essential and you may call them death panels hoping to scare people away but the costs of an unplanned, undignified death are simply unreasonable. Our efforts to eliminate fraud have met with modest success and our payment system must be rigorously reviewed and strengthened. If everyone had the same baseline coverage, the incentive to have a cohesive system would be strong and we would all be invested in seeing it succeed.

My employers and I have each paid 1.45% of my wages into Medicare. If self-employed you pay 2.9% of your net earnings. That may not be enough to sustain Medicare for all. Do we raise this contribution? Now that Citizens United has declared corporations to be people, perhaps they should start paying into Medicare and Social Security too. How should we fund the new health care model? What we will find is that our entire taxation model has been corrupted and will require overhaul also. I’d be a lot more comfortable with taxes that are encumbered for specific uses, elimination of loopholes and subsidies that are essentially corporate welfare, elimination of unnecessary redundancy in our government agencies, and finally, most importantly, a balanced budget. We must have fairness, truth and justice. When the accumulation of wealth depends on the immoral strategies of deception, corruption, conspired laws, and outright cheating, there must be a reckoning.

Get out there and make a difference!

Contact your elected representatives!


Oh Those Golden Grahams!

My supermarket had the Valentine’s Day candy out on the shelves before the Christmas clearance had been fully marked down. I always recall the son of one of my ASU technicians whom I met while he would visit us back in the time he was taking classes. He is now married with kids, but back then he was very single. I used to tease him that he always got confused this time of year because he couldn’t tell the difference between Valentine’s Day and Palm Sunday. Perhaps he should have been eating more graham crackers.

Minister Sylvester Graham, a married man and a member of the Pennsylvania Temperance Society in the early 1800s, who became a big believer in abstinence and vegetarianism, is usually credited with the invention of the graham cracker. He was ahead of his time in his recommendation for the use of whole wheat in bread-making and his disdain for branless, additive-laden white flour. He even published a Treatise on Bread and Bread-Making and during a cholera outbreak in the 1830 began lecturing on whole foods and healthy habits. These healthy habits most certainly did NOT include masturbation. In fact, his rigorous plan included cold baths, loose clothing (but not loose women), and a meatless diet in order to keep the libido in check. It’s not clear if he or one of his acolytes developed the Graham cracker which was touted as an essential part of the diet for those wishing to avoid masturbation or excess sexual activity.

His lectures targeted at young men spoke of the evils of spices and hot food. His ideas were not all crazy. He may have liked talking about sexuality, which was a part of his lectures. In my home state of Maine, one of his lectures was aborted by a mob of citizens too shocked to allow him to discuss sex in front of a mixed audience.

Remember, this was the early 19th century, when society was becoming more urban (and urbane?) and religions still tended toward severe chastity and restraint, proclaiming sex was only for procreation. I imagine many people found the crackers helpful if only as a placebo to curb their lustful urges and activities. Of course, combining graham crackers with chocolate and marshmallow and heating it up over a fire is far different than the pastor’s intention. Some might even say that s’mores are an aphrodisiac. Maybe Sylvester was on to something after all.

Almost a hundred years later, Nabisco, mass produced graham crackers with a different formula and even highlighted the “graham” taste with the addition of honey. You can see here that today’s honey grahams contain a mixed of enriched white flour and whole grain (graham) flour.
Sylvester Graham would not approve.

Today we have a multitude of graham crackers on our shelves and I don’t think any of them would meet Pastor Graham’s standards.

(Somehow I cut off the last couple paragraphs and pics in the first upload. Sorry)

End of Year Hijinks

The end of the year is always an interesting time in the pharmacy. Some patients are trying to hold off until the next calendar year when they will be out of the coverage gap while others are trying to squeeze in every refill possible because they are beyond the gap or their insurance is changing or co-pays are going up next year.The ones that are trying to hold off are a particular challenge because they often put their health at risk by skipping doses or even entire weeks of medication. We strive to find solutions for these folks, but I fear that much of this behavior flies under the radar and we simply don’t know it is happening. We use partial fills when possible and try to find manufacturers’ discount cards for the more expensive brand name drugs. (see several previous blog posts) Unfortunately, our tool of a Congress has made it illegal to offer these discounts to people that are Medicare eligible. Not even enrolled patients, mind you, “eligible” patients. So even if you opted out of coverage you still cannot take advantage of these discounts! Our Senators and Representatives have no such restrictions, of course, enjoying the best health care coverage possible, on our dime.

So, yes, we have found some of our patients reducing their insulin dosage or simply doing without. Scary. Others forego blood pressure drugs, or even heart meds. It is quite common for people to use a variety of ill-conceived strategies to stretch their supply of medication. Their interactions with their insurance companies must be quite interesting.

One of our patients was recently approved for Enbrel and since he was past the coverage gap and into “catastrophic” coverage his co-pay was only $200. This persuasive and persistent patient was able to convince his Medicare part D plan that he was going on vacation in early January and got approved for a “vacation override” for another 4 weeks of Enbrel. Score! Most patients are not so lucky, each claim that we try to squeeze in before the end of the year is often rejected with a “refill too soon” message that indicates the date it may be filled. There is no easy way around this.

Another patient, with a Health Savings Account (HSA) thought it would be clever to refill all his inhalers, nasal sprays, and anything dispensed in its original container so that he could charge it to his HSA and then return them all for cash. Dude, that’s genius! Luckily, he asked about our return policy before actually proceeding with this scam. Federal law does not allow returns of medication, regardless of packaging, nor would we participate in this attempt at fraud. Dude, you’re busted!

Most of our chronic pain patients understand our guidelines and will not even ask about early fills. We did get a few however who questioned our calendar math, trying to get a fresh supply of oxycodone before the New Year. We are merciless and will not fill schedule 2 Rxs until there is 90% utilization of the previous Rx from the date picked up (not date filled, that may differ). We only had a handful that tried to push the issue. Being closed on Christmas and New Year’s day we often had to point out that even if Christmas was day 27 of 30 (90%), on the day after they should still have 2 days of medication remaining. Patients that continue press this issue end up with us taking a closer look at their utilization over a longer span of time than one month. We cannot be too careful when close to 100 people per day are dying from opioid overdose! Patient education and counseling becomes critical in these situations.

There are also a number of patients that have prescriptions that can be filled before the end of the year that will wait in our “ready” bins until the new year because the patients do not have the funds to pay their co-pays. This gives them about two weeks to come and pick up their meds.

I write this on New Year’s eve and I will tell you that next week will be even more fun as we deal with huge (or is that “yuge” now?) numbers of our patients having new insurance coverage and a fair number of them with no new insurance card, or changes in coverage and co-pays that they did not expect. It is one of the most challenging weeks in a retail pharmacy. Believe me!

Here is a chart from Kaiser that illustrates 2017 Medicare part D coverage:

Mind Games

Here’s a little mental exercise to play with:

We do a huge part of our prescription business in mental health medications. Some of these brand name meds are quite expensive and I would like to focus on aripiprazole, aka Abilify, for this thought experiment. Abilify is indicated as an adjunct or “add-on” therapy in the treatment of depression. There are a couple studies showing that it is more effective than placebo when added to existing SSRI, such as Zoloft or Paxil) or other therapies such as bupropion. Patients report both success stories and miserable failures when taking Abilify. Half of the package insert is a discussion of side effects and adverse reactions. In my opinion this is a drug of some moderate usefulness, high cost, and very significant risks.

One of the state behavioral health plans covers Abilify, and interestingly insists on brand name. I can only assume that some sort of rebate to the plan is in place. Otherwise, why spend more of the taxpayers’ money than is necessary? The monthly cost of Abilify is about $1,000 per month. Abilify is often used to boost the therapy of a depressed patient. So I postulate: If we have a depressed patient, being treated with moderate success with one or two generic agents, and we are considering adding Abilify, why wouldn’t we consider another choice? I would suggest that the taxpayers could be well-served by simply giving the patient $500 cash each month! If I were moderately depressed and on a state welfare plan, $500 per month might be a huge factor in changing my life and lifting my depression. An extra $500, with continued counseling, could change my life in ways far beyond the power of a pill like Abilify. I doubt the plan is getting a 50% rebate, so $500 likely saves the taxpayers plenty of money. Even if the stipend was $300, there would be a noticeable and positive on that patient’s life and lowered taxpayer cost.

I, for one, would rather see my cost reduced and my taxes dollars be used in more insightful and innovative ways. Obviously this is just the nugget of an idea and needs refinement but don’t be afraid to consider this kind of out of the box thinking when it comes to recreating health care.

Think about it.

the wall

Drugs and US

Many of the shady practices of our healthcare system are getting lit up as we continue to question exponentially increasing drug prices, the legalized creation of millions of opioid addicts, exorbitantly paid health insurance and pharmaceutical executives, and cancer doctors that benefit from expensive drug treatments that may or may not work. This is what happens when we let free-reign capitalism takes over our health care. Greed rules, patients pay, suffer, and die.

Once upon a time, I thought Mylan was a pretty good generic company. They produced a good product and had fair pricing. Then they got greedy. Heather Bresch has been CEO of Mylan since 2012 and with the help of her family pushed profits and her salary to the point where we started to notice. The $608 price tag for Epi-Pen has garnered headlines and congressional hearings. Plenty came to light in these hearings, including that Heather thought her $18.9 million salary was fairly normal for her industry. Last year, Mylan incorporated in the Netherlands, dodging millions in US taxes.

It turns out that Heather’s dad is a US Senator (since 2010) who was instrumental in landing Heather a job at Mylan. Daddy Joe Manchin is known as a “bipartisan” senator by many and as a “DINO” (Democrat In Name Only) in other circles, because of his breaks with Democratic leadership in voting to defund Planned Parenthood, support of coal, and not endorsing Obama in the 2012 election. To be fair, Sen. Manchin did co-sponsor a balanced budget amendment, introduced the Silver Alert Act, and helped put hydrocodone into schedule II.

Mom got into this act also. In 2013 Gayle Manchin became president of the National Association of State Boards of Education. This followed her appointment to the West Virginia Board of Education by her husband, who was at the time, governor of West Virginia. Momma Gayle thought that Epi-Pens were the coolest thing around and that every school in the nation should have several on hand. She was quite successful in her campaign and Epi-Pen popularity skyrocketed right along with its price.

We call all that shenanigans. Congress calls for a possible anti-trust investigation. A few politicians even dared to mention that we end the ban on Medicare being able to negotiate drug prices! Why the Hell not??!!?? We are being exploited by these greedy corporate weasels and their tools in Congress! There are over 10,000 congressional lobbyists, 100 Senators and 435 Representatives. That’s almost 20 lobbysits for each of our elected “representatives” and I use that term loosely. Look here for the top 20 BIG spenders! OpenSecrets.Org has some good info, including looking at the new phenomenon of “almost a lobbyist, a la John Boehner. As I said, tools, bought and paid for! Be very careful who you re-elect!

We discussed health insurance CEO salaries last year in this very blog. What about pharmaceutical manufacturers? Well, Johnson & Johnson’s William Weldon, took in $29.8 million, and Pfizer’s Ian Read, received $25.6 million. Abbott was right up there in the $25 million range and we know that even a generic company like Mylan paid its CEO close to $20 milllion. Is that really necessary? Even more unnecessary is that over the last ten years Big Pharma has plundered over $700 Billion in profits from the sick and the dying.

Speaking of the sick and dying…
A fairly meticulous study based on an analysis of the results of all the randomized, controlled clinical trials (RCTs) performed in Australia and the US, reported a statistically significant increase in 5-year survival due to the use of chemotherapy in adult malignancies. Survival data were drawn from the Australian cancer registries and the US National Cancer Institute’s Surveillance Epidemiology and End Results (SEER) registry spanning the period January 1990 until January 2004. The authors deliberately over-estimated the benefit of chemotherapy if the data was uncertain. Even with that fudge factor, they concluded that chemotherapy contributes just over 2 percent to improved survival in cancer patients.
Currently, doctors are paid by a simple formula: the average sales price of the drug, plus 6 percent. Pretty generous for a drug that might coast ten grand , right? But what if the drug is sold to the doctor for $5,000, and is paid by Medicare at the full $10,000. In that case, which is apparently a likely example, the doctor not only gets the 6% ($600), the doctor also pockets the extra five thosand dollars paid by Medicare, i.e. YOU and I! Changes in this scenario are being offered by the Obama administration but are being vehemently opposed by BIG Pharma, physicians groups, and “fake” patient organizations which are funded by BIG Pharma.
And you wonder why chemo is so readily offered. Check this out on

I’ve discussed the opioid problem before and some of the weird ways that we pay for these drugs. This PDF from the American Society of Addiction Medicine has most of the latest numbers. Drug overdose is the leading cause of accidental death in the United States. Here is a great article from the American Journal of Public Health that describes, in depth, the depths of Purdue’s marketing of Oxycontin, including the free giveaways like the music CD, “Get in the Swing With OxyContin” and cute little stuffed animals oxy teddy bear and nifty fishing hats: oxy-hat If you don’t think highly educated doctors can be influenced by these trinkets, the free dinners, and the island “educational” get-a-ways, you should come and spend some time in my pharmacy.

Maybe the $3 billion offered by Mark Zuckerberg and Priscilla Chan will help to change things also. Interestingly they said, “The first disease to be wiped off the face of the earth must be ignorance. The health care industry has impeded progress because it has failed miserably in the effective use of available data. It has been the poster boy of ignorance.” Yes, the health industry has failed miserably, in large part intentionally.

Cholesterol: the Good, the Bad, and the Sexy

Billions are spent in this country to lower cholesterol blood levels. The two newest agents would cost $14,000 per year, FOR THE REST OF YOUR LIFE! Or at least until something better comes along. It’s a safe bet that the something new will NOT be cheap!

I have been thinking more about things that we have labeled as bad for us in such extreme ways that we may have overreacted and caused ourselves more harm than if we had just tried a little moderation and try to “act naturally,” meaning use our bodies as they are designed. As I discussed, some sunlight is essential for our bodies, particularly for synthesizing Vitamin D. It occurred to me that many of our issues regarding high cholesterol are a result of our modern lifestyle and nutrition. In order to see how we arrived at the point where over 70 million of us in the United States have high cholesterol (actually high LDL, AKA “bad cholesterol”), we must first have some idea what roles cholesterol has in the healthy body.

Cholesterol is an interesting molecule, on one end a -OH (hydroxyl), making it an alcohol and slightly water soluble, then four hydrocarbon rings, the hallmark of a steroid, and finally a hydrocarbon “tail” which is the oil soluble portion of the molecule. These characteristics give cholesterol its unique qualities. Cholesterol is transported around the body via the blood by lipoproteins. That is where the infamous LDLs and the happy HDLs come into the story. The cholesterol carried by these proteins is the same, only the proteins are different.

Cholesterol is a part of virtually every cell in your body, maintaining cell wall structure, integrity, and function. It is the key starting material for the sex hormones for both genders, for the corticosteroids, and bile salts, which are essential for digestion. Cholesterol is sexy beyond its conversion to testosterone, estrogen and progestins. Cholesterol and related sterols are part of sperm production, transport, and even seem to play a role in capacitation of the sperm after ejaculation. When sperm come in contact with various sterol-binding biochemicals produced by the uterus the sperm is “turned on” and now able to fertilize the egg. Changes in cholesterol levels have been linked to changes in vaginal lubrication, pH, and possibly other factors affecting female fertility. Every sexual act requires cholesterol, with climax and ejaculation consuming some cholesterol each time. To some degree, sex (yes, even by yourself) directly lowers cholesterol, not to mention the other healthful benefits for mind and body.

Cholesterol is converted to vitamin D as discussed previously in this blog. It is also critical for serotonin receptors and other neurotransmitter receptors. It protects our nerve fibers and plays many roles in the brain, many yet to be clearly defined.

Obviously, dietary sources of saturated fats plays a role in the soaring incidence of high cholesterol. However, when seeing all the important functions of cholesterol in the body, I cannot help but wonder if our modern way of life, beyond nutrition, also plays a role in our dysfunctional lipid profiles. I already discussed how we have been taught to shun the sun. Could this avoidance of a normal biological process that uses cholesterol be a factor in higher cholesterol? I recently read that millennials are having less sex than previous generations (mine included!). Could this reduction in sexual frequency also contribute to higher cholesterol? There are some studies looking for a link between SSRIs and other psych drugs and high LDL cholesterol. Are we monkeying with normal biological pathways that require cholesterol for proper function and thus raising cholesterol levels? Are we denying our bodies the fun and frolic that keep us healthy?

Human physiology is amazing and its complexity continues to hold many secrets. Our biochemistry is a wonderful dance of chemical reactions, all trying to reach equilibrium and all part of a great feedback system that strives to keep us going. All those chemical reactions will only reach final equilibrium when we are dead. We have learned that when you tinker with one part of a biological process with drugs or other exogenous material that we can get unexpected results or “side effects” such as the dry cough from the buildup of bradykinins due to ACE inhibitor drugs.

It is clear that we function best when we eat mostly unprocessed foods low in saturated fats, and live an active lifestyle with regular exercise and sexual activity. Get outside, move around, make love, laugh, eat healthy, and you may find high cholesterol does not come knocking on your door. When I pay attention to what I eat, get outside and walk or ride my bicycle, and have some time to frolic, I not only feel better, my lab work shows numbers like this:
Cholesterol: 136
HDL: 48
LDL: 68
Those are my last lab results.
They took 3 blood pressure readings:
Blood Pressure Reading 1: 120/70
Blood Pressure Reading 2: 130/80
Blood Pressure Reading 3: 122/80

I report all this to show that even a man in his sixties can make lifestyle choices that lead to good health without pharmaceutical assistance. Somewhere around 25 million people take a statin drug to lower cholesterol. What if we didn’t just look for an easy answer like taking a pill and embraced cholesterol as a vital part of us that can be harnessed and utilized for good physical and mental health?

I believe that it is possible. Live and love!

D3D2: Into the Light

Vitamin D2, 50,000 units, is a fast mover in our pharmacy. This baffles me, because we have known for quite some time that vitamin D3 is a far superior form of vitamin D. The cool thing about D3 is that our bodies can manufacture D3 from cholesterol and exposure to sunlight, specifically, UVB light. I’m not going to go through the hard science here, but I do think it is fascinating and worth your time if you are so inclined. Vitamin D is important for your bones, your muscles, and your mental health!

I’ve been doing a lot of walking lately, getting ready for the Susan G. Komen 3-Day walk. I was about 3 miles into a morning walk when a fellow motioned to me that he wanted to talk to me. I turned off my headset and he proceeded to tell me that this was not the best time of day to get my vitamin D and started talking about “solar noon” which he described as from after 10AM till 2PM. I had taken my shirt off to get some sun and he must have assumed that I was on a mission to get some vitamin D. I do indeed like getting my vitamin D naturally and I also like not looking like a beached white whale when I visit Hawaii or the Caribbean. Hawaii But, please take note! I try very hard to limit my sun exposure, paying close attention to the length of time and the time of day that I walk around without a shirt on. I’m pretty white. To tan, I must expose myself very gradually to the sun, which works out great for vitamin D production. The usual recommendation is about half the time it takes for the skin to turn pink. For my skin, that’s about 20 to 30 minutes depending on time of day.

Living in Arizona, this whole “solar noon” thing intrigued me. Walking at high noon in Arizona, in August, is just plain crazy. It’s friggin’ hot! I told the guy that the amount of UV radiation reaching us during the day is somewhat of a bell curve so I was still getting my vitamin D even though it wasn’t even 9AM yet. That’s what my logical, scientific mind thought, anyway, and later I decided to see if I could verify that theory. I discovered the WillyWeather website that has the UV index for the Phoenix area, day by day, hour by hour. Lo and behold, it’s a bell curve!

My science served me well in this case, at least as far as the bell curve theory. But am I getting any vitamin D synthesized? Most sources that I checked suggested a balance between exposure and protection. It appears that a UV index around 3 is what will yield good vitamin D synthesis while minimizing the risk of skin damage and the formation of those dangerous radicals that could lead to skin cancer. I am pretty happy to discover all that. During these training walks we often start at 5AM. I will often take my shirt off around 7 to 7:30, if in an appropriate environment, and get covered back up by 9AM. This seemed intuitive to me and I feel more comfortable doing this now that I have done the research. The UV index in the Phoenix area hits 3 between 8AM and 9AM. Again, I trust in that bell curve and feel that even when the index is 2, I am synthesizing some vitamin D. Plus it feels good to have the morning breeze on my skin! We all live under the same sun and as long as we respect its power, we can all benefit from it.

Getting back to those bottles of 50,000 IU vitamin D2 on my shelf.. How long will it take for prescribers to catch up with the science and start ordering D3 for their patients? Both forms are very low cost and well tolerated. For some great guidance and solid information, visit the Vitamin D Council website. I encourage my pharmacist friends to spread the word so that we can get D3 onto that shelf where we have the D2 stacked now. To my physician and other prescriber friends, what are you waiting for?

Boob News

I’m in the middle of training for the Susan G. Komen 3-Day Walk for breast cancer. I’ll be joining my wife and her team to walk 60 miles in 3 days in the Twin Cities (August 19-21). I’ve helped out the team in the past 8 years by running errands, fetching jackets, taking jackets away, bringing ice cold Diet Cokes or G2 and ferrying the team from day’s end to the hotel and back again in the morning. In that role I’ve been called “team bitch,” “walker stalker,” and last year a lady gave me my personal favorite, “underwire.”
You have to realize that there are hundreds of teams and thousands of walkers for these events and their team names often eschew normal political correctness with team names proudly flaunted, using every variation of slang for breasts from ta-ta’s to tits (including itty bitty titties), boobs and boobies, of course, hooters, second base, cupcakes, and many more. So pardon any lack of decorum on my part.

It’s no wonder then, that I am attuned to breasts and stories about breasts when I see them. Who am I kidding? I’ve been tuned into breasts since my first ex utero meal. Here are couple developments that I recently noticed:

I caught this headline in USA Today: “Why Millennials are Going Braless” and I just had to see what was going on (or coming off!). It seems that this generation of young women are opting for lighter, wireless “bralettes” of simply doing without. As a teenager in the 60’s, I recall stories of women burning their bras as a statement of liberation for women. For young men like myself, our solidarity in that cause may have been somewhat tainted by the desire to see nearly naked boobies parading around our neighborhoods. Right on, sister!
This new phenomenon of minimal breast support is even having an impact of sales at places like Victoria’s Secret, where bra sales are are sagging and its stock price is down 30% this year. With about 1/3 of their revenue traditionally coming from bra sales, that is no surprise. The Wonder Bra is on the way out in favor of the more natural style preferred by Millennials. Victoria’s Secret now offers bralettes that are very light, offering little support or padding but are stylish and meant to be exposed. Maybe sales will bounce back. Celebrities are leading the way as they do in most areas of fashion. It looks like my underwire nickname may be in jeopardy. Also, according to Plastic Surgery News there were 279,000 breast augmentations in 2015 and that is down 2% from the previous. For the record, I like ’em natural.

About half of US states have breast density notification laws. Now before you guys start running around hefting the boobs in your lives, this is actually medically important because high breast density is a risk factor for developing breast cancer. The problem is that there is huge variation in how mammogram density results are interpreted and/or obtained. The human reading the results is the primary cause of variation as different providers must be subjective in their finding. There are no clearly measurable results that can be shared in a uniform manner. Even different brands of mammography equipment will show differing degrees of tissue density. Of course, BMI, race and ethnicity are also factors. Finally, the amount of compression used on the breast during the procedure can result in a different appearance. Talk about having your tit caught in a wringer! Roughly 2 out of 5 women have dense breasts and would be considered for additional tests such as MRI or ultrasound. There is hope that computer models will bring some objectivity to the measurement of breast density. Until that happens keep doing your self exams and always discuss your options with your trusted doctor.

Support a 3-Day walker!

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