We all have hourglass figures;   

Your sand just settles in different places.   

 Octavia Spencer      

 Silicon (Si) is the eighth most common element in the world, and the second most common element in soil (oxygen is first).  The majority of naturally occurring Si is present in highly stable minerals as silica and silicates--think sand. These minerals are highly stable, resistant to dissolving into chemical forms that could be absorbed by the gastrointestinal tract, in other words, not bio-available.  Si is beneficial in many ways to the life cycle of plants and is an essential component in their cell walls supporting structural integrity of plant growth.  Turns out it’s an important component in our skeleton and connective tissue as well.   There’s no official recommended daily allowance for silicon, but the figure 25 mg/day has been thrown out recently as a good guess.  Here are suggestions to reach that goal. 

 Si food content is highest in whole grains, vegetables, and....beer.  So what’s good for breakfast?  A standard serving of oatmeal is ½ cup of oats with a silica content of 10 mg.  For lunch?  Nothing more satisfying, or perhaps disappointing, than sitting down to a cup’s worth of steamed green beans, another 10 mg.  If you’re a fan of India Pale Ale, rejoice at happy hour because a can of IPA delivers 18 mg.  These suggestions are based on information from various web-sites found when searching for “foods high in sililca.”  As noted above, however, that which resides in plants and beer (which is made from plants) is not necessarily bio-available.   

 Researchers in the UK, well-apprised of the Si content of various substances, set out to examine just how much is really absorbed through the GI tract in fasting, healthy test subjects.  A number of high Si-containing substances were tested, including 1) OSA or ortho-silicic acid found in small amounts in soil and naturally in water , 2) monomethyl silanetriol or MMST available as a supplement called LivingSilica, 3) bananas, 4) green beans, 5) choline stabilized OSA (CH-OSA) which also comes as a supplement called Biosil,  and 6) alcohol-free beer.  Absorption, based on testing urinary excretion of Si post-ingestion, was highest for MMST and alcohol free beer (64%) followed by green beans (44 %), OSA (43 %), ChOSA (17 %), and bananas (4%).    

 Si not only is incorporated into bone matrix but also contributes to collagen formation which promotes teeth, strong nails, thick hair, and skin that does not so easily give way to gravity as the years go by.  Brittle fingernails and receding gums are two clues to bone loss.  Aging is a risk factor for decreasing bone density as is a personal history of fracture, a history of osteoporosis or fractures in one’s mother, smoking, and low body weight.  Besides eating vegetables, grains, and maybe drinking beer--but not too much please--if you have signs or test results indicating a loss of bone, you might consider taking a Si supplement.  I personally take MMST, available via Amazon, and I splurge on a third of can of IPA at night.  

Blood Vessel Calcification (or Part III of Should I take calcium?)

Here's the heart of the calcium supplement debate. Does taking extra calcium for prevention and treatment of bone loss associated with aging hasten the calcification of blood vessels, a process which is also associated with aging. That which is normal and healthy for your skeleton, namely the incorporation of calcium crystals into its structure, is neither normal nor healthy within your arteries.  Studies of aging humans and their whole body CT scans suggest that virtually all men and women have some demonstrable vascular calcium by age 70.(1)  Furthermore, the calcification was widespread in 80% of men and 60% of women by that age, and extensive calcification is known to correlate with a high degree of atherosclerosis more commonly known as 'hardening of the arteries'.(2)

This sort of dilemma--a basically good physiological process gone rogue--takes us into a lot of science on calcium, injury, hormones, aging, and inflammation.  The CT scanning study cited above not only confirmed that calcification, and therefore atherosclerosis, is definitely correlated with aging and increases as the years progress, it also, once again, found that menopause with its attendant loss of estrogen is also a time of accelerated progression of vascular disease.  Women under 50 years of age were much less likely than men to have calcium, but the prevalence of calcified vessels greatly increased between 50 and 60, and the gals were as likely as the guys to have calcifications by age 70 (just not as extensive).  Whether or not hormone therapy can slow down this vascular deterioration is another complicated story for another post.

Of note in this discussion, however, is the immune system's response to the presence of calcium crystals in developing atherosclerotic lesions in arteries.  Cells called macrophages which are first responders to bodily harm show up early in the course of blood vessel injury and set immediately to work eating foreign invaders Pac-Man style.  As they gobble up various harmful substances such as oxidized LDL cholesterol or basic calcium phosphate (BCP) crystals, they send out proinflammatory cytokines which are chemical messenger molecules that further activate an immune response.  This is a good thing with regards to incoming foreign bodies such as bacteria or dirt from the sidewalk when you've fallen and scraped your knee, but not so good when it's an ongoing assault from various environmental insults such as LDL-cholesterol, trans-fats, cigarette smoke, or...too much calcium (more on this later).  The inflammation from BCP crystals in activated macrophages "may lead to a positive feed-back loop of calcification and inflammation driving disease progression."(3)  In other words, once blood vessels are disturbed by calcification, the immune response invites the deposition of more calcium.

Here's one more puzzle to set your head reeling (mine is already so why not join me?).  There is a known clinical association between vascular calcification and osteoporosis.  In other words, those of us dealing with loss of bone mineral density are the very people that need to worry most about gaining unwanted vascular mineralization in the form of calcium in our arterial walls.  This suggests a link between bone and vascular metabolism.  Either vascular calcification promotes bone mineral loss, bone loss hastens vascular calcification, or there's a common underlying pathology to both processes.  The latter seems the most likely scenario, and the underlying normal and abnormal physiology of calcification in the body finally leads to some answers about whether or not calcium supplements are a good idea.

More on that in the next post.


____________
1) Matthew A, et al. Patterns and Risk Factors for Systemic Calcified Atherosclerosis. Arteriosclerosis, Thrombosis, and Vascular Biology. 2004; 24:  331-336.                                    
2) Solberg LA, Eggen DA.  Localization and sequence of development of atherosclerotic lesions in the carotid and vertebral arteries. arteries. Circulation; 1971.
3) Nadra, I, et al. Proinflammatory Activation of Macrophages by Basic Calcium Phosphate Crystals via Protein Kinase C and MAP Kinase Pathways. Circulation Research. 2005; 96: 1248-1256.

Should I take calcium? Part II

In Part I of this series of posts, I discussed the science behind calcium intake.  In short, what goes out via intestinal loss (at least 150 mg/day or more) and kidney excretion (at least 100 mg/day or more)(1) must be replaced in order to maintain a steady level of calcium in the extracellular fluid (ECF) including blood.  If calcium out is greater than calcium in, the parathyroid glands release a hormone which facilitates breakdown of bone mineral matrix freeing calcium to enter the ECF. Thus, bone-based calcium is not only an integral part of your skeletal strength but also a readily available calcium reserve in case you're running short.

Clinical research scientists who regularly conduct studies on every sort of medical dilemma have compiled an enormous amount of data on the benefits of calcium intake. Starting from an evolutionary perspective--my personal favorite--let's first consider our ancestors from 10,000 years ago when life was quite different but the human genome was not. 

Radiologists and anthropologists from Emory University have determined that our ancestors--both human and primate--ate a lot of high-calcium insects and high-calcium plant food.(2)  These experts estimate that our Stone-Age predecessors took in at least twice as much calcium, mostly from plant based sources, along with more fiber, micronutrients, and protein than we consume with our modern diet. They ate virtually no grains which are not only a poor source of calcium but certain varieties including wheat contain phytates, a compound which binds minerals and decreases their absorption. X-rays of our foreparents' fossilized skeletons confirm that the outer layers of their bones were nearly 20% thicker than ours.  Strong Cro-Magnon structure was the result of a whole lot of outdoor hunting and gathering plus lots of calcium.  The authors of this review conclude that the best-for-modern-bone plan would include a return to the "nutritional pattern for which we have been genetically programmed by evolution."

There is an enormous amount written about the effects of calcium supplementation, with or without vitamin D, in a modern population that avoids the sun and doesn't snack on praying mantises.  The evidence is clear that calcium intake can promote a positive calcium balance--more in than out--which in turn reduces the rate of bone loss and may result in an increase in bone density.  What is not clear is whether or not this has a positive effect on fracture risk. Some experts point out that many of these studies were too short in duration to fully evaluate the long-term benefits of better bone. One study out of France(3) featuring 3,000+ old ladies with added calcium, however, demonstrated decreased fracture risk in just 18 months of follow-up! Half the subjects in this investigation received 1200 mg of calcium plus 800 units of D each day and ended up 43% less likely to have broken their hips by study's end compared with their colleagues who took look-alike placebos.

The US Preventive Services Task Force spent a lot of time reviewing this mountain of medical evidence.  They considered "meta-analyses" that pooled data from multiple studies and concluded that there was not enough evidence to support a recommendation for the use of supplements, and declared that smaller doses (less than 1,000 mg/day calcium and 400 units D) made no dent in fracture risk at all.  Because extra calcium intake can increase the incidence of kidney stones in susceptible persons, the USPSTF graded such dosing as Grade D, i.e. don't do it!

Uptodate.com, a 'living' on-line textbook for doctors, also considered the data, last updating the section on calcium supplements on August 28, 2013.  The reviewers agreed that the fracture data was variable, but were particularly impressed with the data from the Women's Health Initiative, the same trial that created headline news about negative health outcomes from the long-term use of HRT.  Over 36,000 women were assigned to take 1,000 mg/day of calcium citrate with 400 units of vitamin D or placebo pills.  Those who were most compliant with the regimen, taking at least 80% of the supplements over 7 years of follow-up, had a nearly 30% decreased risk of hip fracture.  Overall, compliant or not, the calcium/D group had a 12% decrease in fractures.

Uptodate's wrapped up their discussion after considering the latest data as of just two days ago by stating "Based upon the meta-analyses discussed above, we recommend 1200 mg of calcium (total of diet and supplement) and 800 int. units of vitamin D daily for most postmenopausal women with osteoporosis."  And, spoiler alert, they took into account the effect of supplemental calcium on the risk of cardiovascular disease.

More on that in Part III.
_____________
1) Houillier, P et al.  "What serum calcium can tell us and what it can't".  Nephrol. Dial. Transplant. (January 2006) 21 (1): 29-32.
(2)Eaton, SB and Nelson, DA.  "Calcium in Evolutionary Perspective." Check it out for the calcium content of grasshoppers and moths!
(3)Chapuy, MC et al.  Vitamin D3 and calcium to prevent hip fractures in the elderly women.  N Engl J Med. 1992 Dec 3;327(23):1637-42.

Should I take calcium? Part I

I have been reading up on that which is good for blood vessels versus that which hastens their demise.  In particular, owning a set of bones increasingly fragile with age, I was curious about the effects of calcium supplementation on vascular health.  Recent headline news from the latest medical research suggests that excess intake of calcium tablets results in deposition of calcium in the walls of arteries--not something you'd wish on your hardworking vessels. I used to recommend adequate calcium intake as  an integral part of the prevention and treatment of age-related bone loss-- 1,000 mg/day total (diet plus  supplements) if on hormone replacement and 1,500 mg/day if not. Now the US Preventive Services Task Force says no. In fact they give a calcium plus D supplementation strategy a "D" grade (which is very strong language for the USPSTF) based on the increased risk of kidney stones but mentioning not at all this vascular business.  Uptodate.com--a widely used on-line resource for physicians says yes.

What's an old lady to decide?  Do I recommend extra calcium for myself and for others? 

After two hours of reading, I realized this was a decision so complex that it could not be answered in a single day nor a single post.  I decided to approach the problem according to the 8 components that I believe are the basis for making medical decisions.  In brief,  I think physicians bring three areas of expertise to the process--the science, the evidence from a constantly changing body of medical literature, and their personal practice experience.  Patients (and in this case I'm filling both roles) bring their current situation, their personal medical history, their family history, and their beliefs to the table.  Finally, and unfortunately, the insurance company brings its willingness to pay into the picture.  This is  not important here as calcium and D supplements are not an insurance-covered benefit.

A steady level of circulating calcium in the fluids and blood surrounding our cells is essential to the proper function of multiple organ systems, especially normal nerve conduction.  Too little can cause spasms, seizures, and abnormal heart rhythm; too much leads to confusion, coma, and abnormal heart rhythm.  As a result, a wonderfully orchestrated system controls serum calcium by balancing incoming sources from both intestinal absorption and internal release from bones with outgoing losses through the colon and the kidneys.  If your serum calcium level is normal on your lab panel, you can thank your intestines, kidneys, bones, and parathyroid glands, but you cannot assume that your calcium intake is adequate nor that your bones are holding up okay. 

In order to maintain that crucial balance, calcium in to the extracellular fluid (ECF) must equal calcium out.  Your parathyroid hormone levels rise in response to decreased ECF calcium which quickly leads to release of bone calcium.  In the short term, only superficial bone layers are involved in the release of mineralized calcium from the bone structure, and this loss is easily replenished.  On the other hand, a negative calcium balance over time, amplified perhaps by vitamin D deficiency or an age-related drop in estrogen and testosterone, can lead to a loss of bone density progressing to osteopenia and osteoporosis.  

So calcium balance is critical to bone density along with many other functions.  There are many conditions which can cause abnormal calcium levels, but what we are considering here is the situation of an otherwise healthy aging person trying to maintain bone health through calcium intake without increased risk to the cardiovascular system.  The next post will cover the evidence with regards to calcium intake and bone health.
____________

 

Swiss chard and lung cancer

If R is you or more specifically your DNA in charge
of cell proliferation, the CH3 or methyl group is your
potential road to ruin.

In the spring of 2008, one of my patients came back from a vacation to Mexico with "pneumonia". But I didn't really think it was pneumonia--the shadow on her x-ray wasn't quite pneumonia-ish, and her symptoms of fatigue and a non-productive cough weren't exactly right either. Anyway, we optimistically tried a course of antibiotics without any change in that infiltrate, and, alas, it was lung cancer after all. Mother of two boys still at home and an ex-smoker for more than a decade, my patient died at home six short months later.

Sometimes rogue DNA--perhaps damaged by aging, smoke, or an errant sunbeam--just gets the best of you despite all that water and veggies and walking at dawn. Still, a person keeps trying to do what she can to avoid the brick wall of mortality, and a recent study in the journal Cancer Research (1) further supports the value of leafy greens. But before we discuss the goodness of greens, a word or two on gene promoter hypermethylation events which are nothing you want occurring in your DNA.

Genes are minute strips of DNA. During a typical 'business-as-usual' day in the life of a normal cell, they are activated by external and internal events and transcribed via RNA to produce worthy proteins that carry on normal activities that include damage repair and control of cell proliferation. If, however, one instructional molecule of the DNA gets permanently tangled up with a methyl group, the entire gene is silenced and its work remains undone. Worse yet, as that cell with its load of methylated DNA replicates itself because no gene product was there to tell it not to, all its offspring cells are also methylated. As a result, an out of control, methylated mass of cells continues to grow unchecked. Sounds like cancer, doesn't it?

So once hypermethylated, can you become demethylated? Such a demethylation process is the dream of scientists looking for chemopreventive strategies. As opposed to chemotherapy drugs which seek and destroy cancer cells, chemopreventive agents act to repair or prevent malignant change. Researchers from the University of New Mexico sorted through sputum from smokers (both current and ex-) seeing if certain dietary strategies were associated with lower levels of methylated genes in expectorated DNA.

Some 1,100 subjects dutifully hawked up their secretions and completed Harvard Food Frequency Questionnaires. As a result, the New Mexican docs were able to identify leafy greens (and we're not talking lettuce here), folate, and multivitamin use as three strategies that correlate with less methyl-generated mess. They proposed that further study might verify these and other agents as ways to reprogram our genome for life without cancer.

Now I'm all for this sort of research as a doctor and an ex-smoker. My problem is that a pile of steamed chard (or kale or greens) is an unappealing mess all its own. Any suggestions of different ways to prepare an appetizing, chemopreventive side dish of greens?
_____
1) Stidley, CA et al. Multivitamins, folate, and green vegetables protect against gene promoter methylation in the aerodigestive tract of smokers. Cancer Res. 2010 Jan 15;70(2):568-74.

Milk thistle for liver protection

I had a patient in yesterday whose medical records show a long history of elevated liver function tests. These enzymes, namely aspartate aminotransferase (ALT) and alanine transaminase (AST), are part of routine blood test panels often ordered to screen for disease. Normally present in liver cells, elevated levels in the blood can indicate disruption of the cells by inflammation or disease. Even minor elevations are taken seriously if they persist over time as progressive destruction of the liver from hepatitis or other disease can occur without major changes in the transaminase values.

Further testing indicated she might be suffering from auto-immune liver disease wherein a misguided immune response against one's own tissue can cause damage to the organ. She wondered what she could do to promote liver health while pursuing a definitive diagnosis with a specialist. I recommended milk thistle only to read the following today on the Consumer Lab web-site.

Consumer Lab is an independent organization that tests nutritional supplements for quality, assuring that these products are pure, contain what they claim, and are free of contamination. The nominal yearly subscription fee is well worthwhile if you are a fan, as am I, of supplements. One of their recent reviews covered milk thistle.

Only one brand was found on testing to contain the amount of active ingredient indicated on the label. Furthermore, the evidence that milk thistle changed the course of chronic liver disease caused by hepatitis or alcohol was weak. The research suggesting that the herbal preparation protects against liver toxicity from acetaminaphen and anti-seizure meds was stronger. The active ingredient in milk thistle--silibinin--has been the subject of recent cancer research and seems to have some promise as a chemotherapeutic agent.

I don't feel quite so enthusiastic about my recommendation now. If you're considering milk thistle supplements, have a look at the ConsumerLab site to choose the best brand.

Vitamin D and blood vessel health

I'm sure you know by now that vitamin D is the new darling of the vitamin world. If you're not taking extra, where have you been? UK investigators(1) tested blood vessel health in type 2 diabetics by an indirect method called flow mediated vasodilation or FMV and added yet another reason to consider letting a little sunshine onto your pasty white skin. And if your skin is not white, all the more reason to make an extra effort to get extra D by sun or by supplement-- darker skin is known to be more resistant to the effects of UV radiation with respect to the production of viratmin D.

First a review of FMV. This rather simple test measures the ability of the brachial artery located in the elbow to dilate in response to increased flow. A pressure gauge measures the force of blood flowing through this upper extremity vessel. A blood pressure cuff is then placed on the subject's arm and pumped up high enough to stop blood flow to the arm below. When released, the surge of blood returning to the artery causes the vessel to expand, accommodating an increased flow to the (briefly) oxygen-starved tissues of the lower arm.

This dilation is the mark of a healthy vessel. People with diabetes and hypertension have blood vessels that don't respond normally when tested--and also, unfortunately, in real-life situations such as exercise. Researchers, therefore, use this test to evaluate certain interventions like medications, vitamins, or dietary strategies that tend to normalize the wacked-out FMVs of those with such chronic conditions.

So Dr. Sugden and his colleagues took a group of sun-starved, diabetic Scots in winter and gave them a single whopping dose of D--100,000 units--testing their FMVs before and 8 weeks after the bolus. All of these subjects had D levels <50 ng/ml prior to the trial, and the D supplement raised their levels on average by 15. Darned if that D didn't do the duty! FMV levels rose significantly at follow-up.

Have you D-cided to up your D yet?

_____
( 1)Sugden, JA et al. Vitamin D improves endothelial function in patients with Type 2 diabetes mellitus and low vitamin D levels. Diabet Med. 2008 Mar;25(3):320-5. Epub 2008 Feb 13.

Vitamin D, influenza, and old ladies

Many epidemiologists now believe that flu is seasonal because vitamin D levels fluctuate seasonally. Vitamin D is a potent immune modulator; individuals tend to have higher levels during summer months with higher exposure to UV radiation and, therefore, are less likely to contract the flu while sun-kissed.

Researchers followed the seasonal health adventures of 208 post-menopausal women over three years as correlated with their monitored intake of D.(1) The results, shown in the bar graph above, were as follows:

• Those ladies in the placebo group (lightest bars) got cold and flu symptoms all year long, but especially in the winter.
• The test subjects (intermediate shaded bars) who received 800 units/day of supplemental D were as likely to get sick in the summer as winter, but were far less likely to take to their beds than their D-ficient colleagues.
• In the final year of the study, the test subjects were plied with 2000 units of D each day. Only one lady (as represented by the itty-bitty dark bar in summer) got sick while D-eeply dosed with the vitamin.

Presumably D same benefits accrue to old guys too.
_____
1)Aloia JF, Li-Ng M: Epidemic influenza and vitamin D. Epidemiol Infect 2007; 135: 1095–1096.

Tuna casserole deficiency or cardiac arrest?

Manytuna Casserole
2 tuna-fish-can-sized cans of the cheapest tuna
1 package broad noodles
1 can condensed cream of mushroom soup
1 package of frozen green peas

Precook the peas. Precook some (not all) of the noodles. Mush together in the pot
you just cooked the peas in (after draining off some of the water): the peas, the tuna
fish, the cream of mushroom soup (just as it comes out of the can), and the following
seasonings: salt pepper paprika oregano and garlic salt
Beginning with the noodles, alternate in your casserole dish layers of cooked noodles
and mush-mixture, ending with mush-mixture. Sprinkle a little paprika on top for local
color. Bake at 350 degrees for 20 minutes or so (there being no cheese to melt in this recipe).

I was never deficient in tuna casserole after my mom sent me "The Impoverished Students' Book of Cookery, Drinkery, & Housekeepery." And a good thing too as medical research confirms that ample tuna casserole (or omega-3 fatty acids in any other form) is a good way to ward off death. Here's what researchers at the University of Washington found:

They gathered blood samples from 300 unfortunates who had pitched over mid-life from sudden cardiac arrest. They then minced up the red cell membranes from the dearly departed, analyzed them for omega-3 fatty acid content. This measurement of omega-3 fatty acids in red cells--specifically DHA and EPA--is called the omega-3 index and measures the levels of these worthy fats as a percentage of total fats in the cell membrane.

The omega-3 indices of the fallen were compared to those of a control group from persons of similar age who were still alive and well. This upstanding group--who doubtless loved tuna casserole or rare tuna steaks or anchovy pizza--were far more likely to own red cells with at least 5% omega-3 content.

A preventive cardiology group at the University of Munich crunched omega-3/risk of death numbers and came up with these compelling statistics for downing capsules even if they make your breath smell like a dead mackerel:

"A review of the literature, expanded by measurements of the omega-3 index, indicates that the risk of sudden cardiac death correlates inversely with the omega-3 index. For persons with an omega-3 index <4%,>8%.

So omega-3 fatty acids, specifically EPA and DHA (read the label on your fish oil supplement selections and choose the capsule with the highest content of these two components), have anti-atherosclerotic (prevents build-up of cholesterol plaque), and anti-arrhythmic (prevents your heart from beating too fast, too slow, or too irregularly) properties. Furthermore, that fishy oil in the red cell membranes makes them less likely to glump together in a clot and more likely to squish through narrow places.

What's your excuse for sneering at tuna casserole?

Moxxor

From an e-mail I received this week:
I was wondering your thoughts on Moxxor. I pasted below an email I got from a friend who is helping promote it. Please let me know your thoughts.

Oh dear, another product about which I know nothing but upon which I am asked an opinion. The standard dilemma--do I write back and say "This is Dr. Paley's secretary. Thank you for your query but unfortunately the doctor is unable to answer individual e-mails." Or do I look it up and give it my best guess. Well that's what I did.

Moxxor is a supplement made of oil d'green-lipped mussels. The thought of eating bi-valves always brings to my mind "The Walrus and The Carpenter" poem from Alice in Wonderland; the first poem I ever memorized (one of three lifetime poems by rote for me) wherein a walrus and carpenter entice little oysters to scurry from their beds for a walk along the beach and ultimately eat them all(2).

Back to Moxxor, just letting you know I'm a little uncomfortable right up front with its origins. I am, however, very pro-omega-3-fatty acids, and Moxxor's green-lipped mussel variety is, per glowing Internet reports, a particularly fine one. GLM-omega-3's are purported to have potent anti-inflammatory properties. One fellow who actually met the guy who developed Moxxor (a toothy, widely grinning fisherman from New Zealand) took his first dose, worked out like mad at the gym that afternoon, then woke up the next day pain-free from his exercise session.

Now if you can wait long enough for the graphics to load (which I did not), mymoxxor.com tells you how you can become an independent distributor of the stuff. Right there that's enough to make me want to write back to this lady about what a silly scam it all is--just buy the 3 for 1 omega-3's at puritan.com. But I looked in on PubMed.gov and learned a thing or two about the health benefits of GLM's.

UK Scientists did a meta-analysis of studies treating osteoarthritis with GLM(1). They concluded "The data... suggests that GLM may be superior to placebo for the treatment of mild to moderate OA. As a credible biological mechanism exists for this treatment, further rigorous investigations are required to assess efficacy and optimal dosage." The credible mechanism is provided by numerous studies that show that GLM's have unique poly-unsaturated fatty acids with significant anti-inflammatory activity.

Whoa, I'm down for that; I've got a finger, two thumbs, a knee, and a foot in serious need for significant anti-inflammatory activity. Maybe I could become a Moxxor dealer and get out of primary care. I'll let you know if I ever get past the graphics delay and my bi-valve aversion to actually order this stuff.
_____
(1) Brien, S, et al. Systematic review of the nutritional supplement Perna Canaliculus (green-lipped mussel) in the treatment of osteoarthritis. QJM 2008 Mar;101(3):167-79.

(2) Here's the part that's put me off my Oysters Rockefeller:

*'But wait a bit,' the Oysters cried,
'Before we have our chat;
For some of us are out of breath,
And all of us are fat!'
'No hurry!' said the Carpenter.
They thanked him much for that.

'A loaf of bread,' the Walrus said,
'Is what we chiefly need:
Pepper and vinegar besides
Are very good indeed --
Now, if you're ready, Oysters dear,
We can begin to feed.'

'But not on us!' the Oysters cried,
Turning a little blue.
'After such kindness, that would be
A dismal thing to do!'
'The night is fine,' the Walrus said,
'Do you admire the view?'

'It was so kind of you to come!
And you are very nice!'
The Carpenter said nothing but
'Cut us another slice-
I wish you were not quite so deaf-
I've had to ask you twice!'

'It seems a shame,' the Walrus said,
'To play them such a trick.
After we've brought them out so far,
And made them trot so quick!'
The Carpenter said nothing but
'The butter's spread too thick!'

'I weep for you,'the Walrus said:
'I deeply sympathize.'
With sobs and tears he sorted out
Those of the largest size,
Holding his pocket-handkerchief
Before his streaming eyes.

'O Oysters,' said the Carpenter,
'You've had a pleasant run!
Shall we be trotting home again?'
But answer came there none --
And this was scarcely odd, because
They'd eaten every one.

Red yeast rice revisited

I sweat along with one of my fifty-something year old patients at weekly Jazzercise sessions. As a result, I know her elevated cholesterol levels have nothing to do with a lack of exercise. We have tried several statin strategies to lower her numbers. Alas, even using CoQ10 supplements, low alternate day dosing of Crestor, and statins less likely to enter muscle cells, all still result in unacceptable side effects for her. She has chosen to motor on without meds.

She recently told me that she was using red yeast rice supplements as a 'natural' way to lower her cholesterol. I asked her how she was feeling, did she have any muscle pain with the supplement? As a matter of fact, she replied, she did notice that. She was surprised to learn that insofar as taking a supplement made by the fermentation of rice with fungus was natural, a process through which Lovastatin is made, she was going natural. So she was actually taking low-dose Lovastatin in an unregulated sort of way, complete with a risk of toxic contamination by the metabolic byproducts of fungus feasting on rice!

If you are interested in supplements, and I certainly am, I recommend you invest $30 or so in an annual membership to consumerlab.com, where you can read reliable information on the science behind those OTC pills we take and the results of their testing various brands for content and contamination.

Medical advice from Whole Foods vitamin clerks

I wonder what their credentials are. And what's in adrenal extracts anyway? Whose adrenals are dried and powdered within, and could they be just offal?