Statins may be overprescribed for the primary prevention of cardiovascular disease. Stock photo
Do primary prevention benefits outweigh the risks?
By David Dunaief, M.D.
Dr. David Dunaief
Statins were first approved in the U.S. over 30 years ago. Today, they are one of the most commonly prescribed medications in the United States. Yet, many in the medical community still disagree about who should be taking a statin and for what purpose; some believe that more patients should be on this class of drugs, while others think it is overprescribed. This is one of the most polarizing issues in medicine — probably rightly so.
The biggest debate is over primary prevention with statins. Primary prevention is treating people with high cholesterol and/or inflammation who may be at risk for a cardiovascular event, such as a stroke or heart attack. Currently, recommendations of the American College of Cardiology and the American Heart Association do not align with those of the U.S. Preventive Services Task Force, which is currently reviewing its own recommendations because of data updates.
Most physicians agree that statins have their place in secondary prevention — treating patients who have had a stroke or heart attack already or who have coronary artery disease.
We will examine benefits and risks for the patient population that could take statins for primary prevention. On one side are those who point to statins’ benefits: reduced cancer risk, improved quality of life and lowered glaucoma risk. On the other, we have those who note statins’ side effects: increased diabetes risk, fatigue and cataracts, to name a few. Let’s look at some of the evidence.
Effect on cancer
A study published in The New England Journal of Medicine involved 300,000 Danish participants and investigated 13 cancers. It showed that statin users may have a 15 percent decreased risk of death from cancer (1). As you can imagine, this news was greeted with excitement.
However, there were major limitations with the study. First, researchers did not control for smoking, which we know is a large contributor to cancer. Second, it was unknown which of the statin-using population might have received conventional cancer treatments, such as radiation and chemotherapy. Third, the dose of statins did not correlate to risk reduction. In fact, those who took 1 to 75 percent of prescribed statin levels showed more benefit in terms of cancer mortality risk than those who took more. We need a better-designed trial to determine whether there really is an effect.
Another study, a meta-analysis of 13 observational studies, showed that statins may play a role in reducing the risk of esophageal cancer. This is important, since esophageal cancer, especially adenocarcinoma that develops from Barrett’s esophagus, is on the rise. The results showed a 28 percent risk reduction in this type of cancer. The authors of the study surmise that statins may have a protective effect (2).
Although there is an association, these results need to be confirmed with randomized controlled trials. Aspirin has about the same 30 percent reduction in colorectal cancer, yet is not recommended solely for this use because of side effects.
Eye diseases: mixed results
In two common eye diseases, glaucoma and cataracts, statins have vastly different results. In one study, statins were shown to decrease the risk of glaucoma by five percent over one year and nine percent over two years (3). It is encouraging that the longer the duration of statin use, the greater the positive effect on preventing glaucoma.
Statins also help to slow glaucoma progression in patients suspected of having early-stage disease at about the same rate. This was a retrospective study analyzing statin use with patients at risk for open-angle glaucoma. We need prospective (forward-looking) studies. With cataracts, it is a completely different story. Statins increase the risk of cataracts by over 50 percent, as shown in the Waterloo Eye Study (4). Statins exacerbate the risk of cataracts in an already high-risk group, diabetes patients.
Quality of life and longevity:a mixed bag
In a meta-analysis involving 11 randomized controlled trials, statins did not reduce the risk of all-cause mortality in moderate to high-risk primary prevention participants (5). This study analysis involved over 65,000 participants with high cholesterol and at significant risk for heart disease.
However, in this same study, participants at high risk of coronary heart disease saw a substantial improvement in their quality of life with statins. In other words, the risk of a nonfatal heart attack was reduced by more than half and nonfatal strokes by almost half, avoiding the potentially disabling effects of these events.
Fatigue effect
Some of my patients who are on statins ask if statins can cause fatigue. A randomized controlled trial published in the Archives of Internal Medicine reinforces the idea that statins increase the possibility of fatigue (6).
Women, especially, complained of lower energy levels, both overall and on exertion, when they were blindly assigned to a statin-taking group. The trial had three groups: two that took statins, simvastatin 20 mg and pravastatin 40 mg; and a placebo group. The participants were at least 20 years old and had LDL (bad) cholesterol of 115 to 190 mg/dl, with less than 100 mg/dl considered ideal.
In conclusion, some individuals who are at high risk for cardiovascular disease may need a statin, but with the evidence presented, it is more likely that statins are overprescribed in primary prevention. Evidence of the best results points to lifestyle modification, with or without statins, and all patients with elevated LDL (bad) cholesterol should make changes that include a nutrient-dense diet and a reduction in fat intake, as well as exercise.
References:
(1) N Engl J Med 2012;367:1792-1802. (2) Clin Gastroenterol Hepatol. 2013 Jun; 11(6):620–629. (3) Ophthalmology 2012;119(10):2074-2081. (4) Optom Vis Sci 2012;89:1165-1171. (5) Arch Intern Med 2010;170(12):1024-1031. (6) Arch Intern Med 2012;172(15):1180-1182.
Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.
Radio Central Amateur Radio Club vice-president Richie Fisher and St. Charles Hospital Director of Public and Community Relations Marilyn Fabbricante look on as radio club president Neil Heft presents a $1,000 donation to Lisa Mulvey, Executive Director of the St. Charles Hospital Foundation. (photo credit: Frank Mazovec)
In a show of appreciation for its service to the community during the COVID19 pandemic, the Radio Central Amateur Radio Club (RCARC) recently presented a $1,000 donation to St. Charles Hospital in Port Jefferson.
“We are grateful for the tireless hours put in by not only St. Charles doctors and nurses, but also by all of the medical support staff, facility personnel, security officers and the multitude of people needed to keep the hospital running smoothly,” said Radio Central’s president, Neil Heft. He explained that the group “wanted to do something more than just putting up a thank you sign, so we took up a collection from our forty members who live in the community.”
In a brief ceremony on October 16th, Heft accompanied by RCARC vice-president Richie Fisher and board member Frank Mazovec presented the donation to Lisa Mulvey, Executive Director of the St. Charles Hospital Foundation, and Marilyn Fabbricante, St. Charles Hospital’s Director of Public and Community Relations.
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The Radio Central Amateur Radio Club (RCARC) was formed in 1977 by a group of Amateur Radio operators to commemorate the enormous contributions to communications made by RCA’s Radio Central transmitting facility established in Rocky Point, NY. In 1921 as the world’s largest, most powerful transmitting facility, sending messages to land stations and ships at sea around the globe. More information on RCARC can be found at: www.rcarc.org. Information about Amateur Radio can be found at: www.arrl.org
In response to the growing number of COVID-19 cases on Long Island, Stony Brook University Hospital has reopened its “forward triage” site at the Ambulatory Care Pavilion.
Patients who arrive at the emergency room between 1 p.m. and 9 p.m. are asked to stay in their cars, where a member of the staff will determine the correct emergency care setting. Hospital staff will then direct patients to go to the main Emergency Department or to the coronavirus triage location. The site aims to limit patients with suspected COVID-19 from co-mingling with people coming to the hospital for other medical services.
After seeing nearly 2,600 patients, Stony Brook Medicine closed its “forward triage” site back in May after a decline in patient visits. The site staffed with board-certified emergency medicine physicians and emergency medicine nurses was open from March 9 to May 4.
The state drive-through testing site located in Stony Brook University’s South P Lot off Stony Brook Road remains open. Residents looking to get tested must make appointments in advance by phone at 888-364-3065 or online at www.coronavirus.health.ny.gov/covid-19-testing. Walk-ins are not accepted and will not be seen. The site is open seven days a week. Monday through Friday 8 a.m. to 6 p.m. Saturday and Sunday 8 a.m. to 3 p.m.
I know this is a busy time of year for you. I’m sure it’s all you can do to field all the requests you’re receiving through email, Twitter, WhatsApp, and old-fashioned, handwritten letters. Still, I’d like to suggest that you can provide far more value by becoming a model for good health than you can with any wrapped package tucked under a tree.
Think about the example you’re setting for all those people whose faces light up when they imagine you shimmying down their chimneys. With your abnormally high BMI (body mass index), I know you can do better.
We already have an epidemic of overweight kids, leading to an ever-increasing number of type 2 diabetics at younger and younger ages. According to the Centers for Disease Control and Prevention, as of 2018, more than 100 million U.S. adults are living with diabetes or prediabetes. It complicates the issue that approximately two-thirds of the U.S. population is overweight and/or obese. You can help change this.
Obesity has a much higher risk of shortening a person’s life span, not to mention affecting their quality of life. The most dangerous type of obesity is an increase in visceral adipose tissue, which means central belly fat. An easy way to tell if someone is too rotund is if a waistline, measured from the navel, is greater than or equal to 40 inches for a man, and is greater than or equal to 35 inches for a woman. The chances of diseases such as pancreatic cancer, breast cancer, liver cancer and heart disease increase dramatically with this increased fat.
Santa, here is a chance for you to lead by example (and, maybe by summer, to fit into those skinny jeans you hide in the back of your closet). Think of the advantages to you of being slimmer and trimmer. Your joints wouldn’t ache with the winter cold, and you would have more energy. Plus, studies show that with a plant-based diet, focusing on fruits and vegetables, you can reverse atherosclerosis, clogging of the arteries.
The importance of a good diet not only helps you lose weight, but avoid strokes, heart attacks and peripheral vascular diseases, among other ailments. You don’t have to be vegetarian; you just have to increase your fruits, vegetables and whole-grain foods significantly. With a simple change, like eating a handful of raw nuts a day, you can reduce your risk of heart disease significantly. Santa, future generations need you. Losing weight will also change your center of gravity, so your belly doesn’t pull you forward. This will make it easier for you to keep your balance on those steep, icy rooftops.
Exercise will help, as well. Maybe for the first continent or so, you might want to consider walking or jogging alongside the sleigh. As you exercise, you’ll start to tighten your abs and slowly see fat disappear from your midsection. Your fans everywhere leave you cookies and milk when you deliver presents. It’s a tough cycle to break, but break it you must. You — and your fans — need to see a healthier Santa.
You might let slip that the modern Santa enjoys fruits, especially berries, and veggies, with an emphasis on cruciferous veggies like broccoli florets dipped in hummus, which have substantial antioxidant qualities and can help reverse disease. And, of course, skip putting candy in the stockings. No one needs more sugar, and I’m sure that, over the long night, it’s hard to resist sneaking a piece, yourself.
As for your loyal fans, you could place fitness videos under the tree. You and your elves could make workout videos for those of us who need them, and we could follow along as you showed us “12 Days of Workouts with Santa and Friends.” Who knows, you might become the next Shaun T!
You could gift athletic equipment, such as baseball gloves, footballs and basketballs, instead of video games. Or wearable devices that track step counts and bike routes. Or stuff gift certificates for dance lessons into people’s stockings. These might influence the recipients to be more active. By doing all this, you might also have the kind of energy that will make it easier for you to steal a base or two during the North Pole Athletic League’s softball season. The elves don’t even bother holding you on base anymore, do they?
As you become more active, you’ll find that you have more energy all year round, not just on Christmas Eve. If you start soon, Santa, maybe by next year, you’ll find yourself parking the sleigh farther away and skipping from chimney to chimney.
The benefits of a healthier Santa will ripple across the world. Your reindeer won’t have to work so hard. You might fit extra presents in your sleigh. And Santa, you will be sending kids and adults the world over the right message about taking control of their health through nutrition and exercise. That’s the best gift you could give!
Wishing you good health in the coming year,
David.
P.S. If you have a little extra room in your sleigh, I’d love a new baseball glove.
Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.
Kisa King, resident in the Department of Emergency Medicine at the hospital, received the first dose of the Pfizer vaccine, administered by pharmacist Ian Pak. Photo by Julianne Mosher
Dr. Susan Donelan, medical director of healthcare epidemiology at SBU Hospital was there for the first vaccines administered. Photo by Julianne Mosher
Paramedic Travis Kaller was one of the first people to receive a Pfizer-BioNTech COVID-19 vaccine. Photo by Julianne Mosher
Local elected officials are unhappy with the way vaccines, like this one from Stony Brook University Hospital, have been rolled out by the state. File photo By Julianne Mosher
Hospital staff line up to be some of the first in the hospital to receive the Pfizer COVID-19 vaccine. Photo by Julianne Mosher
Stony Brook University Hospital received its first batch of the coronavirus vaccine, helping dozens of frontline workers at the highest risk of exposure.
Kisa King, resident in the Department of Emergency Medicine at the hospital, received the first dose of the Pfizer vaccine, administered by pharmacist Ian Pak.
King said that she was “honored” to be the first one injected.
“I am so excited and thankful to be a part of the solution,” she added. “Not only does this mean that I can continue delivering care to my patients, but it also means I am providing protection to my family, friends and community.”
On Dec. 15, more than 250 personnel at the hospital working in emergency rooms, critical care units and other high-risk hospital units received the vaccine.
“We’ve been through so much altogether as a community, as a nation, as a world and this is really the first steps towards normalcy,” Pak said. “I think it’s really important for everyone to have hope and be able to look towards the future so that everything we’ve done paid off — not to mention the countless lives that will hopefully be saved by this.”
This major milestone comes after the U.S. Food and Drug Administration issued the first emergency use authorization for a vaccine for the prevention of COVID-19 in individuals 16 years of age and older. The emergency use authorization allows the Pfizer-BioNTech COVID-19 vaccine to be distributed in the U.S. The vaccine has been found to be more than 90% effective in preventing COVID-19 after two doses.
Pak said he wasn’t expecting that he’d be the first Stony Brook Hospital pharmacist to help out. “It’s just one tiny part of a humongous machine that everyone has contributed to throughout these months,” he said.
Healthcare workers Feliciano Lucuix, Gene Rogers and Carolyn Germaine share their stories of testing positive for COVID-19 earlier this year, saying that their stories should serve as a warning during this second viral wave. Photos from St. Catherine and Mather
Health care professionals often sympathize with their patients, offering support as they deal with painful and difficult symptoms. With COVID-19, some health care professionals in the local area also became patients themselves. Feliciano Lucuix, Gene Rogers, two patient care assistants at St. Catherine of Siena Medical Center, and Carolyn Germaine, Director of Nursing for the Transitional Care Unit at Mather Hospital, shared their experiences with TBR News Media.
Feliciano Lucuix
Feliciano Lucuix, whose last name is pronounced like “lou quicks,” battled through COVID-19 in the first few weeks after the pandemic hit Long Island. A patient care assistant at St. Catherine of Siena Medical Center, she was in a restroom in March with a COVID-19 patient who vomited on her. Days later, she said she had a high fever and struggled to breathe.
Feliciano Lucuix, a patient care assistant at St. Catherine hospital, was a COVID patient herself earlier this year. Photo from St. Catherine
When her symptoms started, she had a 99.7-degree fever and pain throughout her body. She lost her sense of smell and her fever climbed to 102.8. She took a COVID test, which would take three days to provide results.
Before her diagnosis, she reached a point where she couldn’t tolerate losing her appetite and having her throat “feel like sandpaper,” she said.
Lucuix, who never smoked and practices yoga twice a week and swims, drove herself to the hospital, where she remained for six days, from March 24 through March 30. During that time, her daughter and son couldn’t visit.
Her son called every day and spoke to the nurses. Lucuix said he didn’t believe her when she said she was okay. The son also spoke with the doctor, who said his mother’s condition was improving.
While she endured challenging symptoms and discomfort, she appreciated the help and attention she received.
“Everybody take care of me wonderful,” said Lucuix, who was born in Argentina to an Italian mother and a French father and speaks Spanish, Italian, English and some French.
Even after she left St. Catherine, she couldn’t return to work for 37 days, as she traversed the slow road to recovery.
During Lucuix’s rehabilitation, her son, whose wife had his first child and Lucuix’s fourth grandchild, urged her to consider retiring.
Lucuix couldn’t wait to return to the COVID floor at St. Catherine. She has used her experience to offer patients on her floor empathy and support.
“I tell my patients, I take their hands, I say, ‘Listen, I was in there, too. I know what you’re feeling,’” she said. “I know you’re scared. I know you’re feeling you can die. If I can do it” then the patient can, too.
COVID-19 continued to affect her in other ways, even after her fever broke and she started to recover. Lucuix had headaches and started to lose her hair. She also had trouble sleeping, as viral nightmares interrupted her rest. Her doctor recommended that she speak with a therapist.
“I feel more comfortable every day,” she said.
Lucuix does what she can to protect herself, including taking vitamins, using personal protective equipment and washing her hands regularly.
Lucuix shares her experiences with her coworkers and her patients. She has also donated her antibody-filled plasma twice.
“I donated blood so other people can survive,” Lucuix said. “I’m proud to do that.”
Lucuix’s daughter, who works as a Patient Care Assistant, is following in her footsteps. Her daughter has applied to nursing programs to study to become a registered nurse. Lucuix with her granddaughter about considering the same field.
They would “like her to follow” in their footsteps, Lucuix said.
Lucuix said she is prepared to help patients during the second wave, which started to hit the Long Island community amid the colder weather and as families and friends gather in smaller groups.
“I’m ready to fight again,” Lucuix said. “I want to be strong for my patients, strong for my family.”
Gene Rogers
A patient care assistant at St. Catherine of Siena Medical Center, Gene Rogers started to feel ill March 23. He had a 101-degree temperature and was told to take a few days off, drink plenty of fluids, and take Motrin. He locked himself in his room, in case he had COVID, preventing his wife Bethan Walker-Rogers, their 16-year old son Phoenix and 10-year old son Charlie and even his dogs from having any contact with him.
St. Catherine Patient Care Assistant Gene Rogers suffered in th ER during his own bout with COVID. Photo from St. Catherine
Two days later, he was so uncomfortable that he decided he needed to go to the hospital. Walker-Rogers asked if she wanted her to drive him, but he said she should stay home and take care of their younger children. The Rogers also have an older child, Maya, who is 21.
As he drove, Rogers said he felt the car swerving when he passed a police officer.
“I was shocked he didn’t pull me over,” Rogers said.
When he arrived at St. Catherine, his temperature had spiked to 103.8.
Mary Jane Finnegan, Chief Nursing Officer at St. Catherine, offered Rogers reassurance.
“I don’t remember the whole thing about the ER that night,” Rogers said. “I remember [Finnegan] coming over to me and saying, ‘We’re going to take good care of you.’”
Like Lucuix, Rogers had no appetite. He was also having trouble breathing. The nurses kept telling him to lay on his stomach.
He had an odd sensation in his feet and was achy. He was in the hospital for eight days.
Rogers felt that the entire staff lived up to Finnegan’s promise. When he had a fever of 104.1, the nurses put ice packs under his arms.
“I’m putting them at risk while they are taking care of me,” he thought to himself on the bed. “Everyone I see, I try to say, ‘Thank you.’”
Walker-Rogers works in the dietary department at St. Catherine. Even while he was in the hospital, she couldn’t visit. She did walk by and look in the window, but she wasn’t allowed in.
Rogers entered the hospital on March 26 and was discharged April 3.
Although he was eager to return to work, a low-grade fever and, eventually, double pneumonia, kept him out for seven weeks.
Yet again, he isolated from the family and his dogs, who were scratching at the door regularly to see him.
During the worst of his condition, Rogers lost 35 pounds, which, he said, he has since regained.
Rogers added he never considered leaving his profession or St. Catherine.
“The people here are like my second family,” said Rogers, who has been at St. Catherine for 35 years. “I see them more than I see my own family.”
Rogers’s mother, Janice Foote, who lives in Raleigh, North Carolina, suggested that it might be time to retire or to do something else.
He said he had to return.
“I love my job,” Rogers said. “I enjoy what I do. I couldn’t wait to come back.”
When he started to work, Rogers said he was short of breath from running around.
Recalling the uncertainty and difficulty he and his family faced when he was sick, Rogers said his wife asked him what she’d do if anything happened to him. During the worst of his experience, Rogers said his oldest daughter Maya got so upset that she had to leave and take a walk.
As for how the experience affected him professionally, Rogers said, “you definitely look at it from a different perspective, being in someone else’s shoes.”
Rogers described himself as the type of person who is always asking if a patient needs something else.
“It look at it even more now, after being to that point” with his own illness, Rogers said.
Rogers’s daughter Maya, a junior at St. John’s University in Queens, is following in her parents’ footsteps. A biology major, she aspires to be a physician and is leaning towards emergency medicine.
Carolyn Germaine
Of all the tangible and intangible gifts Carolyn and her husband Malcolm Germaine have exchanged during the over four decades they’ve known each other, this had to be the worst.
Carolyn Germaine, the Director of Nursing for the Transitional Care Unit for Mather, had to make it through high fevers and extreme nausea during her fight with COVID-19. Photo by Stu Vincent/Mather
Director of Nursing for the Transitional Care Unit, Carolyn Germaine contracted COVID-19 in March and, soon thereafter, passed it along to Malcolm.
Her husband was choking at night and, despite being a nurse, Carolyn Germaine felt helpless, particularly in the earlier phases of the disease when health care workers weren’t using steroids that have become a part of more effective treatment.
“I feel terrible he got sick,” Germaine said. “It’s not something you ever want to bring home with you.”
Germaine’s battle with COVID-19 started March 23, when she developed a fever and aches all over her body that felt like every one of her joints had arthritis. By the 26th, she had a positive diagnosis. When she started to feel better, she thought she might return to work.
The next morning, she woke up with a 103-degree fever and, like so many other COVID patients, struggled to catch her breath.
“Nurses are bad patients,” Germaine said. “We think we can manage everything ourselves.”
Nonetheless, by Tuesday, the 31st, she recognized that the oxygen in her blood, which she tested on her own at home, was dropping to the low 90s. She went to the ER, where she convinced her colleagues to let her return home.
Another hospital official called and said, as Germaine recalled, “What are you doing? You need to come back.”
She was admitted on Tuesday evening, where she struggled through the most extreme discomfort she’s ever had. Her nausea, fatigue, and brain fogginess made her so uncomfortable that she asked her doctor to knock her out.
“It’s terrifying because you are isolated, and you want to stay isolated,” Germaine said. She didn’t want any of her friends or staff members to come into the room, where she could expose them to the virus that was challenging her system.
Germaine described the care she received as “exceptional.” The staff at Mather regularly checked in on her, even if it was just from the door. Struggling with thirst, she received numerous drinks at the door.
She knew the staff managed through extreme stress. Even in her brain fog, she could hear all the code blues and rapid response alerts all day.
“I’ve been in the hospital for 33 years and that doesn’t happen,” she said. “If there’s a code blue or rapid response, those are rare occurrences.”
While she was trying to recover in the hospital, Germaine said she was incredibly short of breath, even when she made the short walk from the bed to the chair. She forced herself to go back and forth, which she knew was better than remaining in bed all day.
Germaine vomited so frequently that she lost 15 pounds in the five days she was hospitalized.
“I didn’t think I was ever going to feel better,” said Germaine, who also lost a sense of smell that has only partially returned nine months later.
When she finally left the hospital, it took her five weeks to return to work. Germaine credits her daughter Laura, who lives with Carolyn and Malcom and is a social worker at Northwell, with taking care of her parents. Somehow, despite being around them through the worst of it, Laura, who is hoping for a “normal” wedding next summer, didn’t get sick.
During that period, the Germaine’s first grandchild, Greyson, was born April 12. She and her husband couldn’t visit him in person right away.
An avid walker who runs up and down the stairs at the hospital, Germaine needed a few more months to feel more normal.
She said she has also felt some sense of survivor’s guilt, because she wasn’t able to help out at the hospital when the need was the greatest.
Germaine said the staff has already been dealing with the effects of the second wave.
Within a 90-minute period recently, the hospital had four rapid responses, which means a dramatic change for patients, either because of oxygen levels dropping, a change in mental status, a drop in blood pressure or anything that might require immediate attention.
The rapid response call brings a whole medical team to the bedside.
The hospital would normally have a few of these in a week but having four in 90 minutes is extraordinarily stressful.
“People who don’t work in the field do not understand the amount of stress that the staff is feeling,” Germaine said. “It’s the entire staff. It’s every department that works here. It’s a very unpredictable time.”
Unlike the first wave, when other states sent medical teams to help in Suffolk County, those states are in the midst of their own crises, which means that no help will be coming, she said.
Germaine urged people to wear masks, remain socially distanced and limit any gatherings, even during the holidays.
Despite the anxiety, tension and memory of her own hospitalization, Germaine said she never considered leaving the hospital or her profession.
“Nothing is more satisfying than taking care of patients and helping families,” Germaine said. “You’re made to do it. I can’t imagine not doing it.”
Having the virus affects Germaine’s approach to her job.
“Every personal experience makes you a better nurse,” Germaine said. “You can go to patients and their families from a place of knowledge.”
With vitamin D supplementation, more is not necessarily better.
By David Dunaief, M.D.
Dr. David Dunaief
Here in the Northeast, we are quickly approaching the point in the year when we have the least daylight hours. This is the point at which many reach for vitamin D, one of the most important supplements, to compensate for a lack of vitamin D from the sun. Let’s explore what we know about vitamin D supplementation.
There is no question that, if you have low levels of vitamin D, replacing it is important. Previous studies have shown that it may be effective in a wide swath of chronic diseases, both in prevention and as part of the treatment paradigm. However, many questions remain. As more data come in, their meaning for vitamin D becomes murkier. For instance, is the sun the best source of vitamin D?
At the 70th annual American Academy of Dermatology meeting in 2012, Dr. Richard Gallo, who was involved with the Institute of Medicine recommendations, spoke about how, in most geographic locations, sun exposure will not correct vitamin D deficiencies. Interestingly, he emphasized getting more vitamin D from nutrition. Dietary sources include cold-water fatty fish, such as salmon, sardines and tuna.
We know its importance for bone health, but as of yet, we only have encouraging — but not yet definitive — data for other diseases. These include cardiovascular and autoimmune diseases and cancer.
There is no consensus on the ideal blood level for vitamin D. For adults, the Institute of Medicine recommends between 20 ng/ml and 50 ng/ml, and The Endocrine Society recommends at least 30 ng/ml.
Cardiovascular mixed results
Several observational studies have shown benefits of vitamin D supplements with cardiovascular disease. For example, the Framingham Offspring Study showed that those patients with deficient levels were at increased risk of cardiovascular disease (1).
However, a small randomized controlled trial (RCT), the gold standard of studies, called the cardioprotective effects of vitamin D into question (2). This study of postmenopausal women, using biomarkers such as endothelial function, inflammation or vascular stiffness, showed no difference between vitamin D treatment and placebo. The authors concluded there is no reason to give vitamin D for prevention of cardiovascular disease.
The vitamin D dose given to the treatment group was 2,500 IUs. Thus, one couldn’t argue that this dose was too low. Some of the weaknesses of the study were a very short duration of four months, its size — 114 participants — and the fact that cardiovascular events or deaths were not used as study end points.
Most trials relating to vitamin D are observational, which provides associations, but not links. However, the VITAL study was a large, five-year RCT looking at the effects of vitamin D and omega-3s on cardiovascular disease and cancer (3). Study results were disappointing, finding that daily vitamin D3 supplementation at 2000 IUs did not reduce the incidence of cancers (prostate, breast or colorectal) or of major cardiovascular events.
Mortality decreased
In a meta-analysis of a group of eight studies, vitamin D with calcium reduced the mortality rate in the elderly, whereas vitamin D alone did not (5). The difference between the groups was statistically important, but clinically small: nine percent reduction with vitamin D plus calcium and seven percent with vitamin D alone.
One of the weaknesses of this analysis was that vitamin D in two of the studies was given in large amounts of 300,000 to 500,000 IUs once a year, rather than taken daily. This has different effects.
Weight benefit
There is good news, but not great news, on the weight front. It appears that vitamin D plays a role in reducing the amount of weight gain in women 65 years and older whose blood levels are more than 30 ng/ml, compared to those below this level, in the Study of Osteoporotic Fractures (4).
This association held true at baseline and after 4.5 years of observation. If the women dropped below 30 ng/ml in this time period, they were more likely to gain more weight, and they gained less if they kept levels above the target. There were 4,659 participants in the study. Unfortunately, vitamin D did not show statistical significance with weight loss.
USPSTF recommendations
The U.S. Preventive Services Task Force recommends against giving “healthy” postmenopausal women vitamin D, calcium or the combination of vitamin D 400 IUs plus calcium 1,000 mg to prevent fractures, and it found inadequate evidence of fracture prevention at higher levels (6). The supplement combination does not seem to reduce fractures, but does increase the risk of kidney stones. There is also not enough data to recommend for or against vitamin D with or without calcium for cancer prevention. But as I mentioned previously, the VITAL study did not show any benefit for cancer prevention.
When to supplement?
It is important to supplement to optimal levels, especially since most of us living in the Northeast have insufficient to deficient levels. While vitamin D may not be a cure-all, it may play an integral role with many disorders. But it is also important not to raise the levels too high. The range that I tell my patients is between 32 and 50 ng/ml, depending on their health circumstances.
References:
(1) Circulation. 2008 Jan 29;117(4):503-511. (2) PLoS One. 2012;7(5):e36617. (3) NEJM. 2018 published online Nov. 10, 2018. (4) J Women’s Health (Larchmt). 2012 Jun 25. (5) J Clin Endocrinol Metabol. online May 17, 2012. (6) JAMA. 2018;319(15):1592-1599.
Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.
Patients line up outside the CityMD Urgent Care in Commack. Facilities have seen more patients than usual in recent weeks due to COVID testing. Photo by Lina Weingarten
Over the last few weeks, a popular conversation among residents is the length of the lines outside CityMD Urgent Care walk-in clinics.
Patients wait in line at the CityMD in Lake Grove. Photo by Rita J. Egan
With many seeking COVID-19 tests to spend time with family members over the holidays, for upcoming surgeries or to meet college testing requirements, residents over the last few weeks have seen nearly two dozen or more people standing outside of the urgent care offices, in most cases, socially distanced and wearing masks. Several have commented that they have visited CityMD and have waited for hours in line where patients who are not being tested for COVID, but for other illnesses are also waiting. The urgent care doesn’t bifurcate the line into COVID-related and non-COVID concerns.
One Smithtown woman, who asked not to be named for privacy reasons, said her husband went to one urgent care location for stitches when his hand was bleeding, and he didn’t want to go to a hospital emergency room, not wishing to take away precious time from health care personnel. Once he found out he would have to wait three hours at the urgent care, he wound up going to St. Catherine of Siena Medical Center.
On Sunday, Nesconset resident Mary Jo Orr said she waited in line with her daughter who needed a rapid test because she was starting in a new school. She noticed the line wasn’t that long when they got there at a little before 11 a.m.
“Apparently, early in the morning one of the workers decided to make a list of the first 100 people,” she said. “They were all given a number and were told to wait in their cars and they would be texted when it was their turn.”
However, management squashed the idea and others who didn’t make the list had to stand outside in line.
“We were there for 3 1/2 hours,” Orr said.
She added that she was prepared to wait, even though she wished the visit went quicker. To deal with the cold weather, she and her daughter took turns waiting in their car.
A spokesperson for CityMD said the locations are all walk-ins and do not take appointments, but the company’s goal is to treat as many people as possible. The urgent care centers offer three forms of COVID-19 testing: the rapid test; polymerase chain reaction, most commonly known as PCR test and needs to be sent to a laboratory; and serum antibody IgG blood test.
“Demand for COVID-related visits, including testing, remains consistently high,” the spokesperson said. “This is creating long lines at almost all our 130-plus walk-in CityMD Urgent Care centers, so we ask patients to please plan accordingly.”
Many have asked why CityMD doesn’t split the line into two or allow patients to wait in cars until they are called into the building.
“Wherever possible, our team members walk the lines and triage patients who need to be seen urgently,” the CityMD spokesperson said. “But, there are potential HIPAA issues with asking patients in line to disclose their condition in front of others.”
She added that CityMD is “piloting a queue system with hopes of a broad rollout.”
“Our goal is to see as many patients as we can in the safest way possible — whether it is for typical urgent care needs or for medical evaluation and a COVID-19 test.”
Many community members have said they have gone to Northwell Health-GoHealth Urgent Care centers instead. The locations require an appointment for COVID-testing. Northwell offers both COVID-19 testing and antibody testing.
Dr. Betsy Koickel, associate medical director of Northwell Health-GoHealth Urgent Care, said the appointments for COVID-related visits were necessary so the staff could better prepare for such visits.
“While we always welcome walk-ins for illness and injury care, we require a spot to be saved for COVID-19 testing in our centers so that we can safely prepare for each patient’s visit,” she said. “During the surge in the need for testing, our teams are working diligently to see all ill and injured patients while also increasing availability for COVID testing.”
The doctor said some walk-in patients may have to wait during peak times as staff members are safely preparing rooms. Even though there are no significant lines outside, patients are asked to wear masks while socially distancing or wait in their cars.
Others in the community have also recommended CVS Pharmacy locations and Stony Brook University Hospital’s testing. Both require an appointment and require the patient to fill out an assessment.
Northwell Health President and CEO Michael J. Dowling, who marshalled tens of thousands of his workforce this spring to battle the deadly coronavirus disease 2019 (COVID-19) surge in the New York metropolitan area, has been named to Modern Healthcare magazine’s “100 Most Influential People in Healthcare,” ranking second overall.
This year’s top spot has been reserved for the frontline worker – doctors, nurses, respiratory therapists, environmental service workers and administrators – who put their lives at risk daily to care for COVID-19 patients.
While Northwell Health is combatting the second surge of COVID-19, Mr. Dowling’s innovation, leadership and strong stance on social issues such as gun violence as a public health crisis as well as immigration and the opioid epidemic, have also contributed to him earning a place on Modern Healthcare’s prestigious list for the 14th consecutive year. The list includes the nation’s most prominent health care CEOs, elected officials and government administrators.
“This year has shown us how vulnerable we are to the various pandemics facing health care,” Mr. Dowling said. “COVID-19 devastated us. Gun violence continues to cripple us. And there are numerous other issues that are keeping our communities from thriving. It is our responsibility to partner with them to finally move the needle in the right direction.”
To date, across Northwell’s network, the health system has treated 101,000 COVID-19 patients, including 16,000 who were hospitalized, more than any other hospital system in the country.
Mr. Dowling wrote about the lessons Northwell learned, as well as a prescription to avoid the spread of future viral illnesses in his latest book, “Leading Through a Pandemic: The Inside Story of Humanity, Innovation, and Lessons Learned During the COVID-19 Crisis.” His vision and crisis management expertise helped manage the surge, establish one of the nation’s most state-of-the-art testing centers at Northwell Health Labs, innovate new ways to alleviate supply shortages and utilize the entire integrated health system to improve patient care..
During his tenure as CEO, Mr. Dowling has developed Northwell Health into New York State’s largest health system with 23 hospitals, approximately 800 ambulatory and physician practices, and $13.5 billion in annual revenue. His ability to grow the health system into a vast clinical, academic and research enterprise builds on a legacy of innovation dating back to his 12 years of public service overseeing health, education and human services for former New York Gov. Mario Cuomo.
Health care leaders ranked among the top 10 in Modern Healthcare’s 2020 list were Marc Harrison, MD, president and CEO of Intermountain Healthcare (third) and Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (ninth).
People aren’t just testing positive for COVID-19 during the second wave; they are also entering the hospital and, in some cases, dying.
Suffolk County has reported over 1,000 positive tests in recent days, as area hospitals have seen an increase in patients needing treatment for their COVID symptoms.
Hospitalizations are now at 394 people, with 67 residents in the intensive care unit. Gregson Pigott, Commissioner in the County Department of Health, said about 2/3 of the people admitted to the hospital were over 64.
The number of deaths has also been climbing over the last six weeks. During the entire month of November, 35 people died. In just the first week of December, COVID has contributed to the deaths of 34 people.
Those numbers are up from six in October, 15 in September and five in August.
“We are not even halfway through this month [and the number of deaths] are more than August, September and October combined,” County Executive Steve Bellone (D) said on a conference call with reporters. These figures are a “stark reminder of the danger this virus poses.”
Bellone urged residents to continue to wear masks and remain socially distanced.
Even as the first night of Hannukah, during which some families gather together to celebrate the Festival of Lights, Bellone urged caution amid small gatherings.
The Suffolk County Health Department is monitoring 13 clusters from Thanksgiving or family gatherings, some of which were below the 10-person limit.
A small gathering in East Islip involved five people, who have all tested positive for COVID-19. Another get-together in Manorville resulted in six out of nine people contracting the virus, while another in Southampton triggered seven out of 10 with the virus.
“None of these gatherings violated the state’s limit,” Bellone said. “That doesn’t mean the virus won’t spread.”
Testing
Bellone said the county is continuing to expand its testing, which “remains one of our most valuable tools.”
After testing over 2,000 students in Hampton Bays, Riverhead and East Hampton, the county started testing in East Islip on Thursday.
The county is also launching a new testing initiative for first responders. Members of fire, rescue and emergency services and emergency medical service providers will have access to rapid testing at six sites throughout the county. That testing will occur on weekends and will start this Saturday.
The county will also make testing available to county law enforcement and partner agencies.
SCPD Limits
The Suffolk County Police Department has reinstated policies to limit contact for officers. While precincts remain open, the SCPD is encouraging residents to limit visits. The SCPD is also providing limited public access to the lobby at police headquarters in Yaphank.
Residents can file police reports online at www.suffolkpd.org or by phone at (631) 852-COPS.
Crimes residents can report online include harassing communications, lost property, crmiinal mischief, non-criminal property damage, minor motor vehicle crashes, identity theft and some larcenies.
The Pistol Licensing Section will be open for purchase orders and pistol license renewals only.
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