Supplements 2: The Dr. Weil Vitamin Advisor

Does a pregnant, white, 20-year old woman living in Miami have the same nutritional needs as a 35-year-old, Asiatic, male athlete living in Seattle? Does either of them have the same requirements as a black, 70-year-old doctor living in rural Ohio? Probably not, and yet the RDA’s and DV’s on the labels of vitamin bottles suggest that the same vitamin will work just as well for any of us. In fact, the vitamin story is a complicated one and getting more so all the time. Age, gender, health, ethnic background, type of work, and living environment are just a few of the factors that can come into play. According to the web site of the Harvard School of Public Health, people who spend most of their time indoors, use sunscreen, live in a northern latitude, have darker skin tones, are older, or have excess body fat have a greater likelihood of being deficient in vitamin D. Recent research has linked low vitamin D levels with cancer, heart disease, depression, and other illnesses.  The new field of nutritional genomics is likely to introduce additional variables that affect each individual’s response to various foods.

What we really need is an analytical tool, like a decision tree, to help us to sort out all these factors. The Dr. Weil Vitamin Advisor, which I discovered today, is a major step in the right direction. You enter your personal information, complete a survey that includes lifestyle questions, gender concerns, family history, and medical history. The web site then lists “areas of concern based on your answers” and provides a list of supplements corresponding to those concerns. You can then purchase vitamin packets from the web site; most of the ones recommended for me I am already taking so I did not place an order.  I am assuming that the Vitamin Advisor is a work in progress; there was no place for me to indicate that I was hypothyroid. Two of the supplements recommended by the site, acetyl l-carnitine and alpha lipoic acid, are said by some to affect thyroid function so I have avoided them in the past and will continue to do so. But this is a minor point.  The Vitamin Advisor is a valuable resource for people seeking individualized guidance about what vitamins to take.

My Problem with “Issue”

Issues are all around us these days.  Anything from a minor disagreement to a major health concern, such as substance abuse, may be called an “issue.”  The current avoidance of the word “problem” suggests an unwillingness to take responsibility for bad situations in our lives or even to discuss them in clear language.  Plumbers know that leaking faucets and burst pipes don’t heal themselves; someone has to wade in and do the actual work of repairing them.  By mischaracterizing problems that require human intervention as “issues” we turn serious matters into vaporous entities, like unpleasant aromas, which may go away on their own.  If it’s an issue then nobody needs to do anything about it; instead, we can sit around discussing the situation at length (think 3-hour meetings).  If it’s a problem, then a person or several people are required to analyze and deal with it, to be problem-solvers.  

At the far end of the problem-solving spectrum are people like surgeons and architects, who want everything to be perfect.  For family doctors and home remodelers, compromise is the order of the day: how much of this problem can I solve without precipitating an even worse one?  Problem-solving has its limits.  When I was young I used to believe that persistence and hard work could overcome any obstacle.  One of the reasons why I like going to the gym is that effort tends to produce visible results, which doesn’t necessarily happen in the rest of the world.  When I was in my forties, partly under the influence of yoga, I came to accept the fact that some imperfections must simply be accepted – the food allergies, the one leg shorter than the other.  No body’s perfect.

"Humana, I Want My Premarin!" Sequel

Last Thursday, after learning from my doctor’s office that my appeal had been denied, I called Humana to ask why.  After going through the usual menu tree, followed by the usual layer of people who don’t deal with this sort of thing, I finally got through to Humana Clinical Pharmacy Review, where a helpful young woman clarified the situation for me.  She said there were now three different transactions relating to my Premarin, each with its own number.  The first two had been denied but the third was still open.  I told her about the blog post I had written and she recommended faxing that, together with my doctor’s latest request, a cover letter referencing all three numbers, and any previous faxes or documents relating to the situation.  Later that day the doctor’s office sent all of this off.

On Thursday at 6pm I got a call from a young man at Humana.  He said that there had been a number of cases like mine and that most had been resolved in the patient’s favor.  The directive about not giving Premarin to women in their 60’s, he said, had actually originated with Medicare.  He hoped that my case would be settled within the next day or so.
 

Around noon on Friday I got a call from the same young man saying that Humana had accepted my appeal.  I now have a new number which I can use when the same situation comes up next year, which it will if I stay with Humana.  RightSource, the mail order drug branch of Humana, didn’t seem to have gotten the word about the recent decision so it took several long waits on “hold” before I actually got the pills ordered - but it’s done now.  From the time I first ordered the refill, the whole process had taken about a month.

On Saturday the mail included a largish wad of papers from Humana telling me that my appeal (the second one, evidently), had been denied and detailing the further appeal procedures that were open to me.  Why hadn’t they e-mailed all this to me when the decision was first made?

From Humana’s side of things, my doctor’s office could probably have laid a more solid foundation for the appeal, based on my current health and medical history.  It seems reasonable for the insurer to expect the doctor and/or patient to make a case for requesting a drug not in their formulary.  On the other hand, this doctor’s office has only known me for a couple of years and no one there would have time to dig through decades of my medical records.

What happens to patients who are not able to appeal a decision? Is someone with a painful or life-threatening condition nevertheless required to wait 72 hours for an “expedited appeal”? How many of them just give up and do without their medication?

Note to Medicare: Since you do not know me personally, nor have you read my medical history, I wish you would leave decisions relating to my health care to my doctor and me.  Please also read my blog post entitled "Statistics and the Twenty Year Rule."

“Please Give Me My Test Results (Not Just An Interpretation)” (posted 9/6/2011): A Relevant New Study

Last Sunday night’s edition of NPR’s “Sound Medicine” featured an interview with Tom Delbanco, MD, of Harvard Medical School about the OpenNotes Project, a new study by to find out what happens when patients have free access to their medical records, including doctors’ notes.  Although American patients have the legal right to see their medical records, doctors typically do not offer to share their visit notes with patients.

For one year, starting in the summer of 2010, 110 doctors in three diverse locations, suburban Boston, rural Pennsylvania, and inner city Seattle, regularly shared their notes with patients.  The study followed these doctors, as well as others who had refused to participate.  Initially, many doctors were concerned that the process would be too time-consuming, would confuse or frighten patients, or might expose doctors to more liability.  At the end of the study, however, not one of the participating doctors wanted to discontinue sharing notes with patients.

Investigators were surprised to find that patients of all ages, economic groups, and levels of education were enthusiastic about the process.  Some believed that it would foster trust and understanding and allow them to have more involvement in their medical care.  Others indicated that it might cause them to take their medications more regularly.  Fifty percent of patients said they might share their medical information with other people, such as family members or friends.

Dr. Delbanco characterized the process as a form of new medicine that will probably not be suitable for every patient.  He said that doctors will need to learn how to use this new tool wisely. 

Room For Improvement: the Wisdom of Tony Horton

Yesterday’s Wall Street Journal had a great interview/article by Kevin Helliker on fitness guru Tony Horton.  The online version comes with a 4-minute video.  Together they give you a good sense of the man we P90X users know and love.  The P90X workouts (X for “extreme”) are designed for people who are already in decent shape and want to advance to the next level.The series consists of 12 tough, briskly paced workouts based on a variety of different types of exercise such as weight lifting, plyometrics, martial arts, and yoga. 

One of the reasons why the program has been such a success is that Tony Horton is fun to watch; in each workout he wears at least five different hats.  He’s leading a group of three or four very fit young men and women in the studio and commenting on what they are doing.  He’s teaching the exercises to us, the viewers, while encouraging us to “Do your best – forget the rest.”  He’s delivering a steady stream of stand-up-like patter: jokes, impressions (Arnold Schwarzenegger, Forrest Gump), and silly faces.  He’s directing the cameramen (“You got that, Jer?”).  At the same time, he’s doing most of the exercises along with everyone else.  Once in a while he gets too many balls in the air and you can catch a trace of the speech impediment he worked to overcome.

Tony’s performance in these workouts is impressive and the workouts are effective but the essence of P90X is a certain attitude toward exercise.  Here are some of the high points:

• Fitness is not a goal but an ongoing process.  The idea is to find an exercise that’s too hard, work on it until it becomes easy, then find something even harder.
•  Everyone has physical limitations and parts of their body they wish were different.   One of the workouts actually features a guy with a prosthetic limb.  Tony talks frequently about his own weaknesses, like the knee shattered in a skiing accident.  Sometimes these become grist for the comic’s mill, as when he tells the cameraman, “Focus on my little calves!”
• Each individual will find some moves easier than others - the strong, muscular men in the class are not as good at stretching and Tony himself has trouble with balances - but the point is to keep trying so that you improve.

Ultimately, P90X seeks to produce not only a buff physique but an understanding, appreciation, and acceptance by each participant of what his or her own body will do, a wonderful gift from Tony Horton.

Why Work with a Personal Trainer?

I used to think that hiring a personal trainer was for celebrities who wanted to work out at home or for people who needed the motivation and structure of having someone oversee their workout.  Since I enjoy challenging myself and don’t mind going to the Y on my own, it seemed a needless expense.  Then in 2007 I read an article in the New York Times Magazine about how Dara Torres was trying a new approach to exercise using lighter weights and stability balls, focusing on stretching and movement as well as strength.  At that time there were few books or DVDs about this type of exercise so I went over to the recreational center at Indiana University and asked for a trainer. 

I was turned over to Bobby Papariella, who was finishing his undergraduate degree.  Over the next several weeks, he put together a routine that involved stability balls, a Bosu, and weights.  Some of the exercises he taught me are still part of my routine.  More recently I’ve been working with Greg Simmons, a world champion powerlifter, who coaches both student and professional athletes.  Greg and his wife Susan introduced me to the New Leaf program, which helped me get rid of the last few pounds I’d been trying to lose.  Greg is currently helping me with my balance, which has never been that good because of my uneven leg length, and with plyo, which is hard for everyone.  I’ve also worked with trainers I’ve met while traveling.  My husband and I have done a couple of workouts with Anne Tierney and Steve Sierra in Florida and I’ve visited Twist in Vancouver, BC.

Based on these experiences, I’ve concluded that there are a number of good reasons to hire a trainer:

• A trainer can help you set realistic goals and monitor your progress.  For me, seeing results is the best motivator.
• Nobody is completely objective about his or her own body.  A trainer brings a detached perspective and can point out particular areas that need work.
•  Some trainers make use of assessment tools that allow them to measure your current level of fitness and design a program that is appropriate for you.
•  Trainers can help you maintain proper form.  Particularly in strength training, good form is essential.
•  Working with a trainer gives you access to the information they have acquired about diet, exercise, and other fitness issues.  Trainers with degrees in kinesiology, like Greg and Susan, are likely to know about the latest scientific research in these areas.
•  And last, but not least, trainers can provide encouragement when the job of staying fit seems way too hard.

"Humana, I want my Premarin!"

This past Tuesday’s Wall Street Journal had an article about two important new web sites in the area of health care.  According to Health Journal writer Melinda Beck, “A start-up company, AdverseEvents Inc., has streamlined the FDA’s often impenetrable database and made it easy to search the adverse-event reports for more than 4,500 drugs, free and online.”  Another start-up, Clarimed LLC, has done the same for reports filed with the FDA on 130,000 medical devices….”  The new web sites created by these companies will be a welcome change for those of us who sift through the masses of information to try to get at the facts about available medical treatments.

During the past few days I have been in the sifting business myself.  Last June, when I turned 65 and went on Medicare, I selected Humana as my drug insurance provider.  For Humana, I should be a pretty good deal:  there are only two medications I take year-round and I rarely need any others.  The ones I take are Synthroid, because I’m hypothyroid, and Premarin, an estrogen-only form of hormone replacement therapy.  I started on Premarin in 1979 after a complete hysterectomy at age 32.  At first I resisted taking it, but my doctor at the time said that I needed it in order to maintain my bone density.  Over the past 30-plus years the pendulum has swung back and forth on HRT.  In 2002 the Women’s Health initiative study of estrogen-plus-progestin was halted when women taking the medication had 8 per 10,000 more cases of breast cancer than those in the placebo group. 

The publicity resulting from this study caused women to abandon HRT in droves, but not me.  Since I was taking an estrogen-only version, it wasn’t clear that these results applied to my situation.  Further research has led to a more nuanced view of the risks and benefits of HRT.  On the plus side, it lowers the risk of osteoporosis, diabetes, and colon cancer, as well as treating post-menopausal symptoms like hot flashes and mood swings.  In healthy women it may also help reduce atherosclerosis and inflammation, which can lead to heart disease.  This last part is of great interest to me because people in my family get heart disease.  On the negative side, there is a small increased risk of stroke and pulmonary embolism,  12 more cases of stroke per 10,000 and 6 more cases of blood clots in the legs, according to the Mayo Clinic web site.

A few weeks ago I ordered a renewal of my Premarin prescription.  Last week I learned that Humana has taken it off its formulary; they will no longer pay for it unless you get a prior authorization.  Instead, they are offering some version of Estradiol, a different form of estrogen therapy.  Right away I started doing research.  If Estradiol were basically similar to Premarin, as a generic would be, I might be willing to change.  They’re not similar, though, and there’s no generic for Premarin.  I looked at the comments of women who had taken one or both products.  The majority of reviews for both products were favorable but most women who had taken both preferred Premarin.

On Humana’s side, I can understand the rationale for discontinuing their coverage of Premarin.  Like other, older generation HRT treatments, its reputation was tarnished by the WHI study and its fallout.  Moreover, the current recommendation for prescribing estrogen treatment has changed; women are now advised to take it for a few years after menopause to deal with post-menopausal symptoms and then discontinue it.  Women with low bone density are steered toward bisphosphonates such a Fosamax.

For me, it is much too late to discontinue Premarin after a short time; I’ve been on it for almost 33 years.  I’ve been healthy during that time and am in better shape than the average 65-year-old woman.  I have no sign of heart disease and my bone density, though on the low side, is stable.  How much of this is the result of my Premarin use no one can say, nor can anyone predict whether I would do as well on some version of Estradiol.  Premarin, which has been around since 1942, has been studied a lot; it is a known quantity, both in general and for me personally.  Taking a new medication might cause subtle changes whose consequences might not be apparent for years.  I hope that Humana will reconsider its decision.  As a practical matter, medical research needs to deal with broad categories of people but medical treatment must be based on the specific needs of the individual. 

UPDATE 2/9/2012  My doctor's office told me that they faxed Humana's prior authorization form on 2/13/2011.  Today they made a follow-up call and learned that the fax number given on the form was not correct.  The form has now been faxed to the correct number.

UPDATE 2/10/2012  Humana has sent me a wall calendar with helpful reminders about taking my medicine as prescribed, etc. 

UPDATE 2/16/2012  After numerous conversations and several faxes among Humana, my doctor's office, and me, the request for Premarin has been denied twice.  I am now initiating an appeal.  Keeping me on Premarin seems like a win/win situation for Humana and me; without Premarin I might end up needing medication for both heart disease and osteoporosis.  Why is this so difficult?

UPDATE 12/11/2014 "Humana, I Still Want My Premarin - So I Wrote to Medicare" and the two sequels.