Vitamin D

I know. You’re supposed to get your vitamins and minerals from your food, rather than pills.

But ….

I live in Alaska. The only time I can get really fresh produce is in summer, from my own garden and the farmers’ market. The rest (most) of the year I have to get “fresh” produce that has traveled a loooong way, or frozen food. Being lazy (and suspecting that the frozen stuff may actually be more nutritious than the “fresh” food by the time it gets here) I all too often stick a frozen dinner in the microwave. I doubt seriously that I am getting all the vitamins and minerals I need in my food, so I take a variety of supplements.

Some are subject to a good deal of controversy; some, like Vitamin A, can actually be toxic in large quantities. But I got a surprise on one recently: Vitamin D.

Vitamin D is one that most people can make for themselves if they get enough sunshine on bare skin. Without sunblock. There are foods that have Vitamin D naturally, notably fish and the marine mammals that eat them. This is why the native population, eating a subsistence diet, can survive in Alaska. Believe me, we don’t get much sun on bare skin. Even at the height of summer the sun doesn’t get very high in the sky — about 45°, where I live.

I figured this out years ago. Problem was, at that time vitamin D as a supplement by itself was extremely hard to find. Most often it was combined with vitamin A, as in cod liver oil. Since I eat a lot of carrots I get plenty of vitamin A, and I didn’t want to risk toxicity by taking more — but you wouldn’t believe how hard it was to find vitamin D by itself in those days. I finally found one store that carried it — and it went out of business. Then GNC opened a branch in Fairbanks, and I was able to get vitamin D from them. But the recommended dose was still just enough to prevent rickets.

Now all at once, or so it seems to me, vitamin D is being touted as a miracle pill, needed by the body for a lot of things never heard of in my day. I just knew I wasn’t getting much sunlight, and the light skin of people who’d lived many generations in northern climates was hard to make sense of unless vitamin D was pretty important. But I was still a little worried that my 2000 units a day (possible now without a handful of pills) might be too much.

Apparently it’s not.

Last week I went to the cancer doctor for a follow-up on my breast cancer. The check-up went fine, but he’s had me on Femara for about 4 years now. Apparently one of the possible side effects is reducing bone density, so I got a bone density scan and a blood test of vitamin D (important in keeping bone strong) as part of the check-up. I’ve been taking 2000 units of vitamin D a day for several years now, so I thought my blood vitamin D would be normal to high.

The bone density was a little low, but no lower than it was two years ago. Vitamin D — would you believe at the lowest end of normal? I was actually advised to increase my dose to 4000 units a day, and keep up the calcium supplements and the yogurt and cottage cheese that are a normal part of my diet. So this seems to be a supplement that is needed. Especially for us older folks.

Three Approaches to Health Care

There are three ways of approaching less than optimal health: prevention, treatment and cure. All have their strong and weak points; all are political hot cakes at the moment.

I think most individuals and societies would agree that the best solution is to stay in good health. It is also a solution that is not always possible. It is, however, the approach that is responsible for the dramatic drop in childhood death in developed countries.

Prevention measures are generally lumped as public health. Clean drinking water, proper sewage disposal, nutritious food, clean air and immunizations all fall into this category. So do measures intended to reduce accidental injury or death (such as seat belts) and those encouraging a healthier life style. Prevention would also include such highly controversial measures as not passing on genes known to have a deleterious effect on health.

In general prevention measures are good for the population, but affect individual choice. They may also affect the bottom line of corporations with a great influence on public policy, such as the food industry.

Some of what I need for treatment of diabetes. I want a cure!

By treatment I refer to ongoing treatment — the pill (or shot) for everything or treatments such as dialysis which must be repeated regularly for the life of the patient. Certainly it is better to have a treatment than not! I am alive today thanks to insulin. But treatment is generally expensive and is often lifelong. Further, treatment of this sort almost always has undesirable side effects. In my case, insulin can produce hypoglycemia which can kill. It should be noted that some “cures,” such as organ transplants, may then produce a condition in which lifelong treatment (anti-rejection drugs) is needed.

A cure implies a return to normal health. In some cases (such as the common cold) a cure is mainly a matter of time, with supporting treatment to prevent secondary infections or ease symptoms. Some cancers are curable with surgery, especially if caught early. Broken bones or other traumatic injuries can often be cured, especially in the young. A number of conditions, however, have no cure. Research on cures is ongoing, but the profit from a true cure is usually not as great as from lifelong treatment. Given that most health research today is profit-driven, research on cures tends to take a back seat to research on treatments.

I’ll probably return to this in the future, looking at one of the three approaches at a time. For right now, how would you order the importance of the three approaches?

Health

One of the things I blog about is health and health care. Here are links to posts on this topic. This post will be linked from the Index page, and I will add new posts as they go live.

General
A Pain in the Back 8/12/11
Pain Gel 10/1/11
The Cost of Health Care 10/8/22
Cranberry Recipes 11/24/11
Three Approaches to Health Care 1/21/12
Vitamin D 10/4/12

Cancer
Breast Cancer part 1 2/12/11
Breast Cancer Part 2 2/19/11
Breast Cancer 3: Mammograms 2/27/11
Radiation Therapy for Breast Cancer 3/12/11

Diabetes
Insulin Pumps 5/20/10
Cataract Surgery Complications 1/29/11
Diabetes and Blood Sugar 2/5/11
Complications of Diabetes 5/27/11
Diabetes: What’s in a Name 7/15/11
Conversation Piece (fiction) 10/20/11
Measuring Blood Sugar 11/12/11
Your Mileage May Vary 11/26/11
Continuous Glucose Monitors 12/3/11
Award and Medicare 3/3/12
Meals With Diabetes 5/19/12
Diet Sleuth: A Useful Meal Planning Tool 5/26/12

Indexing Blog Posts

500+ posts is too many for me to keep track of, and quite a few are “reference” posts, such as the ones on planet building or horse coat color genetics. So I’m putting in a new feature, an index page that links to posts linking to the posts on a given topic. (Sound confusing? Try doing it!)

These indexing posts start today (see below) and will appear occasionally until the reference posts are all indexed. After that I’ll just be updating the index posts, which will be accessible from the Index tab above.

Why an Index?

With 550 posts as of today, I’ve started to have problems remembering what I’ve already put on here. This is particularly a problem with posting existing content such as poems, short pieces from the Summer Arts Festival, or science explanations originally written for the Alaska Science Forum. I can’t remember which books or DVDs I’ve posted reviews on. It also is starting to be a problem when I want to link to a previous post and can’t remember when it was put up or what the title was. And there are posts on this blog that have permanent information, like the series on planet building and the one on horse color genetics, or the book and DVD reviews. I want to make it easier for my readers as well as myself to find things.

I made a start some time ago by adding an index page, which can be accessed from the menu at the top of any page. Right now, the only links are to index pages on my author site. This takes you out of the site and sometimes back in, which is rather clumsy. The index list is also incomplete.

I’m going to start posting an occasional entry which is strictly an index of past posts on a particular topic. These posts will be linked from the index page, and will link forward to the individual blog posts. As it takes a while to find all the posts that belong together, this will be a slow process—probably extending over the next few months. The first in this series, on DVD reviews, is already queued for January 3. Others will follow, most on Thursdays.

I probably won’t be indexing every post. Some, like those early posts which were simply glossary entries for my books, are on the author site and really belong there. Others, like the regular Monday updates on North Pole weather starting in November 2010, can be found easily enough just by using the calendar on the site. But I hope that by the time I have finished this, older posts of interest will be easier to find.

The Cost of Health Care

Why is health care growing steadily more expensive?

Well, there are quite a lot of reasons. But the most obvious to me, the elephant in the room (and I’d don’t mean the GOP elephant) is something never mentioned by politicians. What’s more, we all cheer it on.

I mean the advances in medical science.

Face it. One of the man reasons medicine is costing more and more is simply that doctors can do more and more.

Take my own case. A century ago, I would have died before getting my Ph.D., and the most a doctor could have done was tell me that I had diabetes and it would kill me, painfully, probably within a year if not a few weeks. Oh, my life could have been somewhat extended by a starvation diet, but I wouldn’t have lived long, and I probably would not have stacked up much medical cost.

42 years ago, when I was diagnosed as having diabetes, there was a treatment, insulin. It was cheap—a slaughterhouse byproduct. Hypodermics were glass, and my fingertips were often scalded because those glass syringes had to be taken apart and boiled before each use. Blood sugar tests? Those were carried out in a laboratory, and took several hours. Urine tests were available, but it didn’t take me long to realize that I could have urine sugar so high the tests would scarcely read it while I had every physical symptom of blood sugar so low I almost passed out. The medicine of the time kept me alive, but my diabetes was not exactly well controlled. Probably my eye problems today can be traced in part to this poor control.

Since then I have gladly discarded the glass syringes for disposable plastic, swapped beef-pork insulin for genetically engineered (and much more expensive) human insulin, learned to test my blood sugar with a finger prick, begun using artificial insulins genetically engineered to act faster and slower than human insulin, started using an insulin pump, and added a continuous blood sugar monitor. My diabetes is under far better control, and in fact my blood sugar is usually within the normal range. Thank goodness I have good insurance, because all of this is appallingly expensive.

Diabetes is by no means the only disease to see this kind of improvement in care at an increase in cost. Many cancers that were once fatal or “curable” only by gross mutilation can now be treated with far less invasive surgery, drugs and radiation. More and more conditions that were once a death sentence can be treated, even if few can be really cured.

And as one result, medical costs have skyrocketed. People for whom nothing could be done are now treatable.

Greater possibilities are not the only reason medical costs have climbed, and I’ll touch on some of the others later. But we have to recognize that at least part of the cost increase is simply because doctors can do something other than just tell a patient, “You’re going to die soon.”

Radiation Therapy for Breast Cancer

Once I was finished with chemotherapy, I had 6 weeks of radiation therapy to look forward to. By this time it was early December, and radiation therapy was a 5-day-a-week affair, some fifteen miles from where I live. I cannot drive in the dark; laser therapy for diabetic retinopathy has left me essentially night-blind. Luckily the cancer center was willing to schedule my appointments for near noon—the only daylight available this far north in the winter.

The first step is called simulation. This is when the technicians work out the exact position you need to be in for the radiation beams to have a maximum impact on the area from which the cancer was removed and a minimum impact anywhere else. They also mark key points on the breast with tiny tattoos. Laser beams on those tattoos eventually line up the radiation beams.

Door of the radiation room. The white is the edge of the door--and it has a lead core, so you can guess how heavy it is!

The tattoos were tiny—so tiny they were generally circled or otherwise marked with felt pens so the technicians could find them.

Probably the worst part of the procedure was that the position they wanted me in was lying down with both arms over my head. I had a frozen shoulder at one time—it’s still stiff—and lying for 15 minutes with my arms over my head, my hands clutching a rubber ring, was agonizing. The technicians generally had to help me lower my arms after the session was over. I could not move them.

Aside from that, the sessions were simply boring. Nothing much was visible, and I had to keep perfectly still while the machine rotated around me. Because of the intensity of the X-rays, the whole room was shielded and the technicians had to be out of the room while I was actually being irradiated. In fact, I recall that at one point they were having problems with the electric mechanism that opened and closed the thickly shielded doors. It was all they could do to open and close them manually.

Cancer radiation machine. The patient lies on the gurney on the front left which is then pushed under the white head, and the head then rotates around the table.

The worst problem was not the therapy itself, but the weather. January 2009 started out cold. The first ten days of the month not only had minimum temperatures below –40 F, the maximums were often below -40 as well. At those temperatures, both cars and power plant cooling ponds leave contrails. In built-up areas such as Fairbanks, those contrails flow together to create ice fog. In particular, there is a military power plant just north of the main road into Fairbanks from North Pole, where I live, that has caused several fatal accidents because of the ice fog it produces.

There is another way to drive into town, by making a long detour to the north around the base, and that is what I did for the first week of January, when I had daily appointments. Even then, the fog in town was so dense that I had a hard time seeing streetlights or telling exactly where I was, let alone seeing cars more than a couple of car-lengths ahead of me.

In mid-January the weather turned around and we suddenly had four days with highs well above freezing. A touch of relief? NOT. Our roads almost always have ice and snow over the asphalt or gravel in winter, and a midwinter warming just makes everything appallingly slippery.

The only side effect I had from the radiation therapy itself was the equivalent of a mild sunburn on the treated breast. My oncologist gave me some cream to treat this, but it was more a slight reddening than painful. Again, I kept up daily exercise throughout the therapy. I felt a little increase in energy after the chemo and radiation were over, but was not aware of fatigue during the treatments.

Am I cured? Less than three years after diagnosis, it’s impossible to be sure. I’ve had a mammogram and visits with both doctors in the last couple of weeks, and everything looks fine, thanks in large part to the fact that my primary care physician actually caught the cancer a couple of months before my regular annual mammogram was due. The early detection plus the exercise can probably get the credit for the relatively minor side effects I suffered. The cancer also pushed me into going ahead and publishing Homecoming.

And while my hair only thinned rather than falling out entirely during chemotherapy, it did come back in curly for a while. The photo of me, which was taken to go on the back of the book, was taken the summer after my treatments ended. Alas, my hair is now as straight as ever.

Breast Cancer 3: Mammograms.

I meant to cover radiation therapy this week, but I was tripped up by a blizzard. With 18 inches of fresh snow in the driveway, I couldn’t get out for the mammogram (X-ray of the breasts) scheduled Monday, and the radiation oncologist needed that before he saw me Thursday. I wound up getting the mammogram Friday, and have a new appointment with the radiation oncologist next Thursday. I hope I can get a photo of the radiation machine to use with the blog next week.

Business all over Fairbanks sponsor ice carvings as winter outdoor sculpture. The hospital imaging center has this skier, complete with goggles.

There are two types of mammograms: screening (to see if anything looks suspicious enough to look further) and diagnostic (once something else looks suspicious or worse.) Once you’ve been diagnosed with breast cancer, all the mammograms are diagnostic.

Three years ago, I got a diagnostic mammogram (which confirmed my doctor had indeed felt a lump), a biopsy (which involved shooting a sampler into my breast) to confirm that the lump was cancerous, and then surgery to remove the lump and the “sentinel node”—the lymph node most likely to be cancerous itself. If the sentinel node had been positive, all of the lymph nodes would have been removed. I was lucky; my sentinel node test was negative. But since I had chosen a lumpectomy rather than a full mastectomy, I had to follow chemotherapy up with radiation therapy.

Mammograms are uncomfortable but not really painful. Nipples and scars are marked with band-aid-like beads and tape with a metallized line. You stand next to the machine, your breast is squeezed between two plates, and when you are positioned to the technician’s liking you are told to hold you breath for a couple of seconds while the x-ray is taken. Generally they take one picture with the breast squeezed horizontally and one with it squeezed vertically. I think the most uncomfortable part of the process is getting my arms, chin, shoulders and ears out of the way and holding them there. I always finish a mammogram with a stiff neck.

They don’t have to develop film any more. The mammogram comes right up on a computer screen, and can be read at once. When I had mine done Friday, a couple of whitish areas showed up on the good breast, which led to a repeat of the X-rays with a different and smaller compressed area, and a few moments of worry on my part. Turned out to be calcium deposits that had been there all along. And this time I was told to come back next year, instead of 6 months from now.

I still wish Roi (one of my Homecoming characters) was real.

Breast Cancer (Part 2)

As I mentioned last week, my primary concern was that my treatment for breast cancer had as little impact as possible on my diabetic control while having maximum effect on the cancer. I was well aware that chemotherapy would involve stress, and any kind of stress affects blood sugar. So when the oncologist gave me a choice of two types of chemotherapy drugs, I chose the milder but slower regime, 5-FU plus Methotrexate.

It was a mild regime in the sense of minimal side effects, but I had to get an infusion weekly for close to 5 months. And even with this regime I was warned that there was a good chance of nausea, losing my hair or anemia.

Luckily, I could get the infusions in Fairbanks, within driving distance of my home, and between the cancer center and VanTran I had a good chance of getting a ride if I got too sick to drive.

Remember I said that the diabetes actually helped me deal with the breast cancer diagnosis? It wasn’t all psychological. One of the things I have learned in my years of trying to keep my blood sugar under control is that I have to have regular exercise. I’m not much good at walking any more, but I have an exercise bike, a rowing machine and a treadmill all set up facing my television. About the only time I watch TV or a DVD without exercising at the same time is when my blood sugar is dangerously low.

I kept that up throughout the chemotherapy, with at least an hour a day of aerobic exercise. (I have an adult tricycle, too, but I didn’t ride that much the summer I was getting chemo.)

I honestly think that continuing to exercise throughout chemotherapy and radiation treatment had a lot to do with how few side effects I had. It may be that I was simply lucky, that I would have had few side effects from the chemo regardless. I can’t help but believe that some of my generally good health throughout the chemo was due to the fact that I continued regular exercise.

Having the rather large needles inserted into my hand was painful and annoying, especially as they always used the hand on the unoperated side, but I never had to have a shunt. Even my hair, while thinning, stayed on my head. I had to get blood tests before every session, and my white and red cell counts did get low enough I had to get some shots to build my blood back up, but I never really felt sick. I lost some weight I could well afford to lose, though unfortunately it didn’t stay off.

Most of the summer and early fall of 2008 I was driving to the cancer center every week for chemo. I did stretch the space between appointments once, to attend a family reunion. I’m glad I did, as it was my last chance to see two of my aunts, both then in their 90’s, who passed on a few months later.

I’ll talk next week about the radiation therapy.

Note—the Sunday blog would normally be about the genetics of the white splash gene in horses, but February 19 is Writing in the Dark, a writers’ conference held annually here in Fairbanks. Instead of the normal horse genetics, I’ll be blogging on the conference next Sunday. I’ll also encourage attendees to put samples of their writing at the conference up as comments. Our leader and inspiration will be Peggy Shumaker, our state writer laureate, and I’m really looking forward to it.

Breast Cancer (Part 1)

Fairbanks Cancer Center

A breast cancer diagnosis is a downer—no question about that! I think the doctor who had to give me the news that my biopsy was positive was expecting—well—hysteria? Horror at mutilation? Panic at the C-word?

I’ve lived with diabetes for more than 40 years. Of course I was unhappy at the diagnosis, but the prospect of losing a breast worried me far less than the prospect of losing my vision or legs, and I’d lived with both for years. As for fear of cancer, I was already aware that breast cancer, caught early, is one of the most treatable of cancers. And mine was caught early.

Yes, I was worried—I am still worried—about the possibility of recurrence, of metastasis. (I have a mammogram and a follow-up visit with the oncologist a week from now.) But the lump in my breast was caught early, in a regular visit to my doctor’s office. (As a diabetic on an insulin pump, Medicare requires that I see my doctor every three months.) After my doctor found the lump I had what would have been my annual mammogram a couple of months early. The mammogram led to a biopsy, which was positive. Surgery was indicated. (Not that I didn’t wish Roi’s Healing ability was real.)

Because my cancer had been caught early, I had a choice of mastectomy (removal of the affected breast) or lumpectomy followed by radiation therapy. Being lopsided didn’t bother me, but the possibility of surgery affecting the diabetes did. I chose right through to go for the options that might take longer, but would have minimal impact on the diabetes. For surgery, that meant a lumpectomy followed by radiation therapy.

I expected to be miserable after the surgery, but compared to a knee replacement a couple of years earlier it was a breeze. I don’t think I even used the pain prescriptions after the first day or two. I did have a drain, and that was the major annoyance connected with the surgery. I needed to raise my basal insulin for a few days, but aside from that my insulin pump kept my diabetes under control very nicely.

I think my main problem came from the fact that I had two oncologists, one for the radiation therapy and the other for chemotherapy, and they weren’t communicating very well. There was some question as to whether or not I needed chemotherapy, the genetic makeup of my tumor, and which should go first. They finally got it sorted out that chemotherapy should come first.

One thing I should say at this point. Fairbanks Memorial Hospital added a cancer center not too long before I was diagnosed. Before that, I would have needed to go to Anchorage, 350 miles of mountain roads away, for either chemotherapy or radiation therapy. As it was, my therapy was within driving distance of my home.

I’ll get into the post-operative therapy next week. For now, I’ll just say that the diagnosis really woke me up to my own mortality. It was the final push that determined me to go ahead with assisted self-publication for Homecoming. Maybe if I had really kept at it I could have found an agent or a publisher. Certainly the book has garnered some fine reviews and is currently a finalist in one contest. But the cancer diagnosis was the final push.

A few breast cancer links:
Breast Cancer Organization
National Institute of Health
Susan G. Koman Foundation
National Cancer Institute
National Breast Cancer Foundation
Breast Cancer Detection Center of Alaska
Fairbanks Cancer center