Simplicity through Innovation

A friend who is also involved with the International Rescue
Committee
, told me about solar phone chargers that also
work as lights. They are being sold and distributed in the third
world and refugee camps as a solution to lack of electricity. A
portion of sales in the US are used to subsidize affordable prices
for the product in the third world. The product is called Waka
Waka
(which means light in Swahili). I immediately
ordered one from Amazon ($65), and I am enthralled. Not only did
the device come in a simple cardboard sleeve (no plastic!) the
instructions were all diagrams. After leaving it in my window sill
for a few hours, I hooked my 30% battery smart phone up through a
USB cable and watched as it recharge it completely in about 15
minutes! The device is design at its best: simple, durable,
elegant. My experience with the Waka Waka has ignited my thoughts
about how we can bring these elements to health care. Like the Waka
Waka, techniques and practices that have been developed for places
with few resources, are now being eyed by those in the US not only
as a way to contain costs, but also to achieve better outcomes. For
example, recent press about heart
surgery in India
has the attention of doctors, policy
makers and payors in the US and Europe. Simplicity can take on many
different meanings when it comes to health care, from simplifying
medication regimens, to coordinating care and health information
technology. However, the goal should be a happier, healthier and
more satisfied patient population. As we think about the future of
US healthcare, lets think Waka Waka: Let there be LIGHT! -Jennifer
Brokaw, MD 20130708-095032.jpg

Our Narratives Through Change

Photo on 6-12-13 at 5.30 PM

“Everything I’ve ever let go of has claw marks on it.” – David Foster Wallace

 Our youngest daughter just graduated 8th grade, and I am really trying not to leave claw marks on her elementary school.  After a total of eleven years there, I’m finding it difficult. First, I am going to miss the familiar faces, rituals and exceedingly pleasant atmosphere in the place. But more significantly, I am finding it difficult to accept that we don’t have young children anymore, and therefore, I must rewrite my inner biography.

Until recently, my narrative involved being a mother to two daughters who needed lunches made, permission slips signed and endless rides to school, soccer, chorus or social activities. I was the woman of the household, the caregiver, but also the one who might get admiring looks from strangers when I dressed up. Now, I am a supervisor who asks that my charges “check in and let me know when you get on the bus”, and when I get looks from strangers, I quickly realize they are actually looking at one of my beautiful daughters. Truth be told, this is not the first time I’ve changed my narrative, but it’s one of the times that I am not completely happy about the plot-line.

This realization has made me ponder the transitions I witness others make all the time at work. As a physician and patient advocate, I am called in when someone has gone from being someone “in perfect health” to someone with cancer, or from being an independent survivor of the Great Depression and WW2, to a person with Alzheimer’s who needs assistance with the most basic functions.  These are not the narratives we want to write. In fact, I remember riding on a crowded elevator with a client who was going for her first chemotherapy session at a cancer center. Someone broke the silence: “Cancer is for the birds” they said. My client replied: “No kidding!” In that moment, her narrative changed from self-pity to solidarity, and she was able to confront her new chapter with resolve rather than resignation.

When the narrative takes on a dark or less-than-heroic turn, our defenses go up and we fight the inevitable. Sometimes it’s in the form of denial (is that why I forgot to buy tickets to the graduation or get teacher’s end-of-year gifts?) and other times it’s overt hostility. Ask any geriatrician what their least favorite task  is, and two out of three will respond: “Taking the keys away”. However, with a little “creative writing”, these moments don’t always have to be so difficult. In one memorable instance, a family member conjured up a very large “repair bill” for his father’s car hoping his father’s Depression–Era frugality would trump his desire to keep driving. By allowing his Dad to “decide” to forego the repairs and find more economical ways to get around, he maintained his narrative as a practical decision maker even in the face of dementia.

Admittedly, sometimes the narrative is impossible to sugar-coat. There are some diagnoses that don’t allow for much hope or “up-side”.  It is in precisely those moments that we must allow the person to salvage as much of their narrative that they can. Talking to patients early on about what’s to come and what to expect is the only way they can write their own final chapter. Without that knowledge, their story might end in the hospital when they really wanted it to be at home, or as the center of a family feud instead of the peace maker.  What I’ve come to learn is that there is always the opportunity to help the dying write their narrative if we give them the chance—and even if the narrative isn’t exactly what they would otherwise choose,  the ability to influence even small aspects of it is very powerful.

            It is with that perspective that I face this small change in the narrative of my life and ask myself how I can turn what seems to be a bittersweet transition into a joyful one. Observing my young women engaged in the wider world is really enough to make it all right, but reconnecting with my husband who has been on the work/parenting treadmill with me for the past sixteen years is an opportunity I cannot pass by.  I am determined that the three day road trip with him while the girls are off being their independent selves this summer be one funny and juicy chapter in my life story.

-Jennifer Brokaw

June 2013

Crazy for Coconut Oil?

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Coconut oil: Is it too good to be true?

What is it? Coconut oil is an edible oil extracted from coconut meat.Most commercially available coconut oil isrefined or “partially hydrogenated”. It is extracted from dry coconut meat and treated with high heat and chemicals.

Virgin coconut oil, on the other hand is extracted from fresh coconut meat and is not chemically treated.

The cure? The information about coconut oil is confusing at best. As a health food there are claims that it helps thyroid disease, heart disease, obesity, diabetes, Alzheimer’s disease and many other conditions. Recent video testimonials are compelling. What do we know about these claims? Very little. There are few good studies on coconut oil and disease outcomes. The best studies are on the short-term impact of coconut oil on cholesterol levels.1 Unfortunately we do not know about its long-term effects or its effects on heart disease. The findings are interesting but there is still no clear answer to the question of harm or benefit.

 The concern: Coconut oil contains 92% saturated fat.1 This is more than butter (64% saturated fat) or lard (40% saturated fat).4 Processed or “partially hydrogenated” coconut oil additionally contains trans fats (bad fats).3 These fats are associated with heart disease and this type of coconut oil is unhealthy.

 On the other hand, virgin coconut oil is not partially hydrogenated and does not contain trans fats but it still contains 92% saturated fat. This is worrisome for many since saturated fats are considered less healthy and can raise your LDL (bad) cholesterol. Conversely the oil may also increase “good” HDL cholesterol levels.4

 Considerations: Do not use refined or partially hydrogenated coconut oil.Virgin coconut oil is a better choice since it does not contain trans fats (bad fats).

Fats in moderation are an important component of a healthy diet. Limit your saturated fats to less than 10% of your total calories.2 Use coconut oil (92% saturated fat) sparingly as it is also high in calories. One tablespoon of coconut oil contains 117 calories, 14 grams of fat, 12 grams of saturated fat and no vitamins or minerals.1

As a food, virgin coconut oil is very interesting. It has a slightly sweet, nutty, coconut flavor that enhances pastries, cakes, frostings, sautéed vegetables, roasted sweet potatoes, etc. Unlike other vegetable based oils, it is a solid at room temperature and a liquid when heated. Due to the saturated fats it has qualities a lot like butter or lard. It is very stable and can be stored at room temperature for 1 to 2 years without going rancid. Check out a tasty coconut oil recipe for a chocolate ice cream topping created by Thomas Keller a renowned chef and restaurateur. http://www.nytimes.com/2011/03/02/dining/02apperex4.html

 The debate about the benefits and risk of coconut oil continues. The scientific evidence does not support the health claims yet. We will know more in the future but in the meantime, as with many things: moderation is the key!

 

1.      Zelman K; The Truth About Coconut Oil; WebMD Web Site; http://www.webmd.com/diet/features/coconut-oil-and-health; March 10, 2011; Accessed May 22, 2013.

2.      Nutrition and healthy eating; Mayo Clinic Web Site; http://www.mayoclinic.com/health/dietary-guidelines/MY01594; Accessed May 22, 2013.

3.      Maloof R; Coconut Oil; MSN Healthy Living Web Site; http://www.healthyliving.msn.com/diseases/cholesterol/coconut-oil-1; Accessed May 21, 2013.

4.      Willit W; Ask The Doctor: Coconut Oil; Harvard Health Publications Harvard Medical School Web Site; http://www.health.harvard.edu/newsletters/Harvard_Health_Letter/2011/May/coconut-oil; May 2011. Accessed May 21, 2013.

 By Alicia Sakai, PharmD

May 23, 2013

 

15 Questions for a Concierge Physican Practice

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Considering changing to a Direct Pay/Concierge or Boutique Physician? Because there is a shortage of primary care physicians, and primary care has suffered declining reimbursement rates from insurers, Direct Pay Medicine is a growing trend. However, because it’s relatively new, there is a striking lack of standardization in pricing or types of services offered. Here are come suggested questions to ask when interviewing a concierge physician:

Fees:

  1. Do you charge annually or monthly? (Are all office visits covered in that fee?)
  2. Will you help submit claims for all non-covered services to my insurance?
  3. Will you see me if I am in the hospital? (Is there an extra charge for that?)
  4. Do you participate in Medicare?

Services:

  1. Do you make house calls?
  2. Can I get a same-day appointment?
  3. Do you offer email communication?
  4. What is included in an Annual Visit (ie. what tests are performed and what counseling will I receive?)
  5. Do you have an area of specialization? Do you have a sub-specialty Board Certification?
  6. Do you have other physicians in your practice? Nurse Practitioners? Physicians Assistants? What role do they play in your practice?
  7. Are there specialists (Cardiologists, Endocrinologists, Othopedic Surgeons) that participate in your concierge practice? Will they give me preferred access?

Philosophy:

  1. What is your attitude toward Complementary and Alternative Medicine, CAM (acupuncture, homeopathy, naturopathy eg)? Are there practitioners of CAM that your regularly refer to?
  2. What wellness or preventive services do you offer?
  3. Will you guarantee to continue to care for me even if I develop a serious illness? (corollary: are there any conditions under which you would dismiss me from your practice?)
  4. What is your philosophy about hospice? Will you care for me until the end of my life?

Can you think of any other important questions? If so, please feel free to share them in the Comment box below.

Re-Making Advance Directives

Filling in an advance health care directiveOn April 16th,  we honored the sixth National Healthcare Decision Day (NHDD). NHDD was established with the goal of increasing the number of people who have Advance Health Care Directives (only 30% of Americans have one) and increasing communication about health care wishes to loved ones and health care providers.  However, in order to achieve those goals, we must re-think the Advance Healthcare Directive altogether and engage the health care system in a new paradigm.

    As it stands now, an Advance Directive legally designates a health care agent (someone who will make decisions for you if you are mentally incapacitated). Most form Directives also ask whether you would want to receive CPR if your heart stopped, and whether or not you wish to be an organ donor.   Unfortunately, those limited instructions do not cover the majority of health care decisions, and place an undue burden on the person named as agent. For example, the desire not to receive CPR does not inform doctors or family members about a desire for emergency surgery when the outcome is uncertain.

People I survey casually about Advance Health Care Directives say they have completed theirs with an attorney, in the form of a Living Will. Because it is written by an attorney, a Living Will is often not written in language that is helpful to physicians, containing vague terms like “terminal” and “vegetable”.  Although it’s better than nothing,  in my twenty years in medicine, I have seen a patient’s Living Will in a hospital chart only once or twice.  Furthermore, most physicians I know are not likely to follow a lawyer’s pro-forma instructions when delivering critical care. The other time people create Directives are when they are being admitted to the hospital, and is a result of the Patient Self Determination Act, passed in 1991. Needless to say, the hospital admissions desk is not an ideal time to create a Directive. Furthermore, there is evidence that Directives as they are written today, are not very effective in the hospital. A study in 1996 showed that simply having a Directive-even when there was an effort to convey its content to physicians, did not reduce ICU stays, number of people put on life support or pain experienced by patients. (1) Sadly, it doesn’t appear that much has changed since then. (2) There are many reasons for this, but I believe that that is largely a reflection of the typical Directive itself, which should be reconsidered entirely. 

On the other hand, a good Advance Care Plan is done with a medial professional and anticipates some medical decisions based on particular health history. It also reflects your values and priorities, and most importantly, expresses the overall goals you have for your quality of life.  A well-written Advance Care Plan can give loved ones and doctors a blueprint to discuss critical decisions about life sustaining treatment, facilitating a dialog that is much more meaningful than “Should we perform CPR?”. It is not surprising that it has been shown that families that have undergone Advance Care Planning have significantly less prolonged grief and increased satisfaction with the health care system after the death of a loved one in the hospital. (3)

To be sure, this is not an easy task and requires special skills, training and significant time to accomplish. To that end, it will require a commitment of resources. Although it will also require a change in mind-set for physicians and hospital administrators, I believe the medical profession must commit to creating better Directives and make a pledge to improve adherence to Directives when patients are unable to speak for themselves. I am glad we now have a National Health Care Decision Day, but without physician’s and hospital’s participation, nothing much will change for patients at the end of life.

References:

(1) http://www.ncbi.nlm.nih.gov/pubmed/7474243

(2) http://www.ahrq.gov/news/newsletters/research-activities/jul12/0712RA10.html

(4) http://www.bmj.com/content/340/bmj.c1345

Dr. Jennifer Brokaw is the Founder of Good Medicine, a private practice specializing in patient advocacy and Advance Care Planning.

A “Dense Dilemma”

4.0.4

Diagnosing Breast Cancer:  A Dense Dilemma

The passage of the Affordable Care Act (Obamacare) and the reelection of President Obama was cause for real hope among those in pursuit of the Holy Grail in medicine: higher quality at lower cost. However, with the passage of what is called the Breast Density Bill in several states, the quality cost equation seems doomed on both ends.  The Affordable Care Act mandates coverage of screening mammograms, without co-pay or deductible, but the Breast Density Bill is destined to push utilization of “non-beneficial” imaging, ie imaging that does not clearly save lives, even further.

The new law authored by Sen. Joe Simitian, was signed into law a couple of months ago in California.  Beginning April of next year, the bill requires facilities that perform mammograms to include a special notice, within the imaging report sent to patients, regarding the high density of breast tissue and the benefit of additional screening tests.   The notice will state the following; “Because your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, depending on your individual risk factors”.

The supporters of the bill make the ethical argument that women have the right to know about how dense breast tissue can obscure mammogram visualization, and should be offered additional test such as ultrasound and magnetic resonance imaging (MRI) to alleviate the doubt.  To provide further support, the SOMO INSIGHT Breast Cancer Screening Study is a nationwide research effort to evaluate if automated breast ultrasound done together with routine screening mammogram is more accurate in detecting breast cancer in women with dense breast tissue.  The study is funded by U-Systems, Inc.; the Silicon Valley based company responsible for the sophisticated and expensive ultrasound technology used in this study.  Thus, one cannot deny the possibility of patient interest being confounded by financial interest.

The patient advocacy movement around breast cancer has been championed by several well-known non-profits, such as Susan B Komen, Are You Dense Inc. and even endorsement by the National Football League.  Yet, the confusion about screening is reflected in the variability of requirements for insurance coverage between states. For example, while Texas and Mississippi require screening mammograms to be covered for all women 35 and older, Utah has no coverage requirement and several other states do not require coverage until age 40.1 Awareness of breast cancer screening is necessary, and the complexities of picking up certain irregularities certainly deserve attention. However, the patient’s “right to know” should also include the right to know about “over-diagnosis”.  Interestingly enough, the term is defined in the bill as one of the harms of mammography screening and is “the identification of cancers that will not become clinically significant, leading to unnecessary treatment”.  This issue, which is often down-played for various reasons, is troubling, yet we keep recommending more tests.

According to Jessica Leung, MD a mammographer and member of the Society of Breast Imaging “Large-scale randomized controlled trials over several decades have proven that screening mammography reduces breast cancer mortality.  Though mortality data are not available with respect to adjunctive screening with ultrasound or MRI, recent studies have shown that an increased number of favorable-prognosis breast cancers may be diagnosed with these imaging methods. ” In other words, ultrasound or MRI will certainly pick up more early, “favorable prognosis” cancers, even in dense breasts. But will they save lives?

Not necessarily, according to Dr. H Gilbert Welch from the Geisel School of Medicine at Dartmouth College.2 Based on Surveillance Epidemiology and End Results (SEER) data, if we follow 2500 women, of 50 years of age, undergoing annual mammography for 10 years, 1 – 2 of them will avoid cancer death.  About a thousand of those women will have at least one false positive result during that time, and about half of them will end up getting at least one biopsy.   But what most people don’t know, is that 5 – 15 women out the 2500 being followed, will end up being “over-diagnosed”, and receive unnecessary treatment for a cancer that would not have led to harmful clinical symptoms otherwise.  An estimated 70,000 women were over-diagnosed in 2008 itself, accounting for 31% of all breast cancer diagnoses that year.Welch and his colleagues believe that mammography, the gold standard test in breast screening over-diagnoses many cancers that would not have caused harm to the patient if left undetected. To extrapolate this reasoning to ultrasound and MRI, which are more likely to pick up “something” even in dense breast tissue, the problem balloons.

The mandate proposed by the bill is based on a justified intention to inform the patient about the risk of high density breast tissue.  But there needs to be caution, because high breast density is not a proven independent risk factor for breast cancer, and only women with specific risk factors (such as family history, genes) may truly benefit.  False positive and over-diagnosis rates are expected to be much higher for breast ultrasound and MRI, and defensive medicine will prompt physicians to recommend more testing in fear of liability.  This is the template for how our health care costs spiral out of control and patients will not necessarily benefit from it.  Paying for the extra tests may be difficult for patients on certain health plans, like Medicaid, and a possible state-mandated coverage requirement for additional testing can lead to higher insurance premiums.

A mandate is not the solution; but if it prompts an unbiased discussion between the patient and physician, then it may accomplish the ethical goal of informed patient choice.  Engaging patients in the decision making process, informing them of the best evidence, and tailoring the plan of care according to their individual characteristics, risks and expectations is the right approach to the dilemma of dense breast screening.

-Anubhav Kaul, MD and Jennifer Brokaw, MD

Dr. Anubhav Kaul is a recent medical graduate from Ross University School of Medicine, and he is currently pursuing a Masters in Public Health at The Dartmouth Institute of Health Policy and Clinical Practice.

Dr. Jennifer Brokaw is the Founder of Good Medicine Consult and Advocacy and the editor of the Good Medicine blog. She is married to a mammographer.

References

1      “Paying for Breast Cancer Screening.” Breast Cancer: Early Detection. The American Cancer Society, n.d. Web. 27 Dec. 2012. http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-paying-for-br-ca-screening.

2      Welch HG. Screening mammography–a long run for a short slide? N Engl J Med. Sep 2010; 363(13).

3      Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med. Nov 2012; 367(21).

Read Before Taking: Calcium!

 

Calcium supplements are natural, readily available, and safe…… or are they? A new study suggests a link between calcium supplements and heart attacks: in 24,000 people studied in Switzerland, those that reported taking calcium supplements were more likely to have heart attacks. (Heart Journal; June 2012) Notably, there was no ability to show cause and effect. Furthermore, there has been no evidence that heart attacks are linked to dietary intake of calcium.  Calcium supplements have also been linked to kidney stones.  Take some time to learn the basics about calcium supplementation before you buy a bottle at your local drugstore!

If calcium supplements are recommended, use these tips to help you make your selection:

Calcium carbonate and calcium citrate are the two most common forms of calcium supplementation.

  1. Calcium carbonate should be taken with food
  2. Calcium citrate can be taken with or without food
  3. Use calcium citrate if you are on stomach medications like Prilosec, or are elderly.
  4. Do NOT buy natural calcium supplements from coral or dolomite sources
  5. Do NOT take more than 500 mg of elemental calcium at one time

What should you know about calcium supplements:

 Over-the-counter calcium supplements have been widely used and viewed as a natural and safe way of preventing bone fractures. This view is beginning to change. Recent studies have shown a potential link between calcium supplements and a higher risk of kidney stones and heart attacks. In June 2012, the US Preventative Task Force (an independent panel of experts that evaluates the latest scientific evidence to access the merits of preventative measures) announced a proposed recommendation that healthy postmenopausal women should not take low dose vitamin D and calcium supplements to prevent bone fractures due to the lack of evidence for effectiveness and a possible increased risk for kidney stones.6  Keep in mind that this is still a preliminary recommendation and the issue is still being debated. These recommendations also do not apply to those who have calcium deficiencies, bone disorders, or those at risk for osteoporosis. The decision to take calcium supplements is an important one and should be discussed with your physician.

How much calcium should I be taking?

That depends on your age, your health, the medications you are taking, your dietary calcium intake and your disease states. Calcium containing antacids, multiple vitamins and other products should be included in your total daily calcium intake. For instance, Tums, a commonly used antacid has up to 1000mg of calcium carbonate in its strongest formulation! Discuss this with your physician especially in light of the new calcium supplement link to heart attacks and kidney stones.1 Carefully read the Supplement Facts Panel on the label to find the amount of calcium per serving. Note: a serving may not be the amount per tablet.

 Calcium carbonate or calcium citrate?

There are many different types of calcium supplements available today. The majority are in the form of calcium carbonate (such as Caltrate®, Tums®, Viactiv®, OsCal®) or calcium citrate.  (such as CitraCal®).

Calcium carbonate

Advantages: Calcium carbonate is the cheapest calcium supplement. It also contains the most amount of elemental calcium (40%) by weight of all the supplements and fewer tablets are needed. 1

Disadvantage: Calcium carbonate must be taken with food to maximize absorption. In some patients calcium carbonate can cause more stomach side effects like gas, bloating, and constipation.1 It is also a larger tablet and some find it hard to swallow. Do NOT purchase natural products made from dolomite, or coral because they may contain contaminants like lead.

Calcium citrate

Advantages: Calcium citrate has very good absorption and should be taken by those on proton pump inhibitors, the elderly or individuals who want the flexibility to take calcium with or without meals.1,3 (Proton pumps inhibitors include Prilosec, Nexium, Dexilant, Zegerid, Prevacid, Protonix, AcipHex, Vimovo, etc).

Disadvantages: Calcium citrate contains 20% elemental calcium and more tablets are needed to equal the same amount of elemental calcium found in calcium carbonate. Taking more tablets per day is also more expensive.

Can I take calcium once a day?

 The maximum amount of calcium absorbed is 500 mg at one time.1 Taking 1000 mg once a day will only provide you with 500 mg of calcium. The rest is not absorbed. To get the most out of your calcium supplements limit your dose to 500 mg or less and take it several times daily depending on your total daily dose.

Can calcium interact with other medications? 2,3,4,5

 Many antibiotics (like tetracycline, ciprofloxacin, and levofloxacin), thyroid medications and Betapace® (sotolol): Calcium can interfere with the absorption of these medications and should not be taken within 2-4 hours of your calcium supplement.

Bisphosphonates (like Actonel, Fosamax, or other drugs used for osteoporosis) should be taken at least 30 minutes before your calcium supplements to avoid decreased absorption.

Blood pressure medications, digoxin, or if you have kidney disease: Speak with your physician before taking calcium supplements. If you have any questions about drug interactions ask your pharmacist or physician for advice.

What else helps to keep bones healthy?

Exercise stimulates bone strength, muscle strength and coordination. Lets not forget that a well balanced diet with calcium and vitamin D rich foods provides important nutrients for healthy bones and has not been linked to an increased risk of heart attacks or kidney stones. Additionally and surprisingly there is mounting evidence that smoking is associated with increased risk of bone fractures and osteoporosis.7 The best thing a smoker can do to protect their bones is to quit smoking.

When additional calcium is needed your physician can advise you on how much you should take or if it is needed at all.

  1. Dietary supplement Fact Sheet: Calcium; Office of Dietary Supplements, National Institutes of Health; http://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/: Reviewed August 1, 2012; Accessed August 18, 2012.
  2. What you need to know about calcium: Harvard Health Publications; http://www.health.harvard.edu/newsweek/What_you_need_to_know_about_calcium.htm: April 2003; Accessed August 18, 2012.
  3. Comparison of Oral Calcium Salts. Pharmacist’s Letter/Prescriber’s Letter 2008; 24(10):241008
  4. Calcium: Natural Medicines.13th ed. Stockton, CA: Therapeutic Research Faculty; 2012:305-316.
  5. Betapace [package insert]. Bayer HealthCare Pharmaceuticals Inc., Wayne, NJ; Rev February 2011. http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/019865s020lbl.pdf. Accessed August 19, 2012
  6. Vitamin D and Calcium Supplementation to Prevent Cancer and Osteoporotic Fractures in Adults: US Preventive Services Task Force Recommendation Statement Draft; US Preventive Services Task Force; http://www.uspreventiveservicestaskforce.org/uspstf12/vitamind/draftrecvitd.htm. July 2012; Accessed August 22. 2012.
  7. Smoking and Bone Health; NIH Osteoporosis and Related Bone Diseases National Resource Center; www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/bone_smoking.asp. January 2012; Accessed September 4, 2012.

Alicia Sakai, PharmD October 2012