Obesity - St. Louis Pain Management Center | Best Pain Management Doctor

Diabetes and Neuropathy

Diabetic Peripheral Neuropathy (DPN) is the most common complication of diabetes, and often presents as a distal, symmetric, sensorimotor neuropathy. In the United States, 26.8 million people are affected by diabetes; by the year 2030, that number is predicted to increase to approximately 35.9 million people.

In the U.S. alone, the annual total direct medical and treatment costs of diabetes were an estimated $44 billion in 1997, representing 5.8 percent of total personal healthcare expenditures during that year. When it comes to diabetic peripheral neuropathy and its complications, management is resource intensive and long-term, accounting for a large proportion of this total expenditure. In 2001, the total annual cost of diabetic peripheral neuropathy and its complications in the U.S. was estimated to be between $4.6 and $13.7 billion. Up to 27 percent of the direct medical cost of diabetes may be attributed to diabetic peripheral neuropathy.

More than half of patients who have type 1 or 2 diabetes develop DPN. Diabetes is associated with both macrovascular and microvascular complications, in which the major microvascular complication is diabetic neuropathy (DN) with a prevalence of 50–60%. The neuropathy progresses with decreasing nerve functionality and nerve blood perfusion which may result in malnourished nerve and leads to permanent nerve damage. The clinical manifestations of diabetic neuropathy include numbness, burning and tingling sensation, and intractable pain.


Many patients with neuropathy simply don’t now they have it

You may have nerve damage well before you experience its symptoms. The first time you may notice diabetic nerve pain symptoms is when the nerve damage has already progressed. Neuropathy is known to develop well before the patient has any symptoms, and the literature states unequivocally that the sooner treatment can be initiated, the greater the chances of reversal of the symptoms. Microvascular circulatory deficiencies, caused by errors in glucose metabolism, for example, have direct effects on the circulation to the nerves, and there are direct effects on the nerves themselves. Pain signals, in turn, trigger secondary peripheral and central hyperalgesia which enhance the body’s response to the microvascular insult. On a local level, microinflammation and edema around the nerves also contribute to the neuropathy. While this nerve damage can cause pain, it can also result in a loss of feeling in the feet and hands. Numbness can cause cuts and foot ulcers to go unnoticed. These cuts can lead to an infection. In severe cases, an untreated infection can even result in amputation.


DPN affects the nerves in the hands and feet, causing numbness, tingling, and pain. Clinical symptoms associated with DPN involve poor gait and balance associated with large sensory fibers and abnormal cold and/or heat sensation associated with small sensory fibers. Chronic pain associated with diabetes is represented by hyperalgesia, allodynia, paresthesias, and spontaneous pain. Symptoms are described as tingling, “pins and needles,” burning, itching, and an abnormal sensation to pain and temperature. Over time, these symptoms may advance from the toes to the foot and up the leg, and these symptoms may occur in the fingers and hands.

Tingling and Numbness

Scientists aren’t sure exactly how diabetes damages nerves. Some theorize that the excess blood sugar affects the protective coating on nerves. Others believe decreased blood flow to the nerves can cause damage.

Either way, as the disease progresses, patients may feel a tingling or numbness in the fingers, toes, hands, and feet. Patients may also report a “pins and needles” feeling, or even a burning sensation.


Shooting Pain

A nerve that’s pinched or suffering from damage may send out signals that cause shooting pains. People also described this sensation as an electric shock, or a sharp, stabbing pain. The sensations usually come and go, but they may also remain more constant at times.

These types of pains are most common at night, and can disturb sleep. They may also be the result of damaged nerves that are sending out mistaken signals to the brain (misfiring).


Inability to Feel Hot and Cold

Our nerves help us to sense the world around us. They are how we notice when we’re feeling hot or cold. They also tell us when we’ve stubbed a toe or suffered a paper cut.

When nerves are severely damaged, they can actually die off. Suddenly, you may no longer be able to tell when you’ve stepped on a tack or suffered a blister. That means small injuries can go unnoticed and untreated. This can cause more problems down the road.


Foot Problems

Once a person loses function in some of the nerves in the feet, they may not notice a blister, infection, or wound until it becomes infected, swollen, and inflamed. Nerve damage can also lead to changes in the shape of the toes. This can require shoe-fitting adjustments. Doctors always recommend that people with diabetes check their feet and hands daily for injuries, especially those who’ve suffered nerve damage and lack feeling in the fingers or toes.


Difficulty Walking and Performing Other Daily Tasks

It’s because of our nerves we can button up a shirt, create a hairstyle for ourselves, or even open a doorknob. Nerve damage in the hands and feet can make these everyday tasks more difficult or even impossible. But there are tools available that can help. Specialized orthotic inserts, diabetic shoes, and gripping tools are just a few examples.


Autonomic Symptoms

Did you know that nerves control the digestive system? They are also involved in perspiration, sexual function, heart rate, urinary function, and more. If diabetes affects any of these nerves, patients may experience the following symptoms:

  • stomach upset (constipation, diarrhea, nausea, vomiting)
  • urinary problems (incontinence or urinary tract infections)
  • erectile dysfunction or vaginal dryness
  • inability to stay warm or cool
  • difficulty focusing your eyes
  • dry, cracked skin


Nerve Pain and Sleep

Some nerve pain is worse at night and as a result, the individual can have difficulty sleeping. This loss of sleep can cause additional problems so people with this type of nerve pain need to discuss the problem with their doctor to receive early treatment.


Coping with Nerve Damage

To avoid or limit any of these symptoms, concentrate on controlling your blood sugar levels. The more you can keep your levels in the normal range, the slower any nerve damage will progress. Exercise regularly, manage your weight, and take steps to reduce stress.

Talk to your doctor about lifestyle changes and tools that can help you cope once nerve damage has occurred. Medications and specific treatment methods are also available to help reduce symptoms. Your doctor is your partner in controlling nerve pain. By answering all questions asked (pain type, duration, and how it has changed your lifestyle), you help your doctor to determine the cause of the pain and how to treat it.


Treating diabetic nerve pain requires a specific treatment:

Diabetic nerve pain, or painful diabetic peripheral neuropathy, is a separate condition from diabetes that is caused by high blood sugar related to diabetes. This nerve damage may cause foot pain and hand pain. If you suffer from diabetic nerve pain, you can’t undo the damage that has already occurred but it’s very important that you don’t ignore your pain either. The pain, which may get worse over time, can be treated.

Control of your blood sugar

If you have diabetes, it is important to control your blood sugar. Your doctor has probably tested your A1C level before. This measures your average blood sugar level over the past 3 months. The American Diabetes Association recommends a goal of 7% or lower.

Do something about your diabetic nerve pain

Controlling your blood sugar can prevent further nerve damage. However, that won’t reverse the damage or relieve your diabetic nerve pain. And since nerve pain isn’t like other kinds of pain, you may need to receive a specific diabetic nerve pain treatment.


What treatment options are available for diabetic nerve pain?

The most common approach is oral medications that only mask the symptoms.

  • 50 percent of patients with diabetic peripheral neuropathy receive treatment with opioids
  • 40 percent take anti-inflammatory drugs
  • 20 percent use serotonin selective reuptake inhibitors (SSRI)
  • 11 percent take tricyclic inhibitors
  • 11 percent take anticonvulsants (Neurontin and Lyrica).


Although there is a range of pharmacological agents available for treating the pain associated with diabetic neuropathy, only duloxetine and pregabalin are approved by US Food and Drug Administration (US FDA) for the treatment of diabetic neuropathic pain. The “gold standard” in treating peripheral neuropathy, pregabalin (Lyrica, Pfizer), helps 39 percent of patients achieve a 50 percent reduction in their discomfort and pain, but causes at least 38 percent to have complications. These medications have drawbacks and major adverse effects.


Over-the-counter pain relief pills are not approved by the FDA to treat this specific pain. Diabetic nerve pain is a form of nerve pain, a unique type of pain that is different than other types of pain, like pain from a headache, muscle ache, arthritis or sprained ankle. Over-the-counter pain relief pills are not approved by the FDA for the treatment of diabetic nerve pain.


What is Combined Therapy?

Combined therapy incorporates two well established procedures that have been combined into a protocol that is showing great promise as an effective treatment solution for diabetic and idiopathic neuropathies. Combined therapy consists of two procedures, an ankle block performed with local anesthetic, and Electronic Signal Treatment (EST), as delivered by a unique sophisticated electroanesthetic wave generator.


Ankle Block

The ankle block targets five nerves responsible for sensory supply distal to the ankle. The nerves consist of four branches of the sciatic nerve (the superficial peroneal, the deep peroneal, the sural, and the posterior tibial nerve) and one cutaneous branch of the femoral nerve (the saphenous nerve). The sciatic nerve gives off two terminal branches, the common peroneal and the tibial nerve.


Electronic signal treatment

EST is an electrical signal wave treatment that regenerates nerves and increases blood flow by using electrical waves to simulate nerve function in the damaged areas. Electronic signal treatment utilizes computer-controlled, exogenously delivered specific parameter electronic cell signals using both varied amplitudes (AM) and frequencies (FM) of electronic signals. This

digitally produced electronic sinusoidal alternating current with associated harmonics produces scientifically documented and/or theoretical physiological effects when one applies them to the human body. The electronic signal treatment medical device uses sophisticated communications technology to produce and deliver higher frequency signal energy in a continually varying sequential and random pattern via specialty electrodes. This alternation of sequential and random electronic signal delivery eliminates neuron accommodation.

With the help of 0.25% Marcaine, which is a vasodilator (opens the blood vessels for a short time to increase blood flow) and a local anesthetic. The more blood flow that your nerves get while stimulated the faster your regeneration takes place.


Combined therapy is believed to:

  • Increases cellular growth
  • Increases Metabolic Activity
  • Reduces swelling around the nerve
  • Stimulates nerve function
  • Increases oxygen and blood directly to the nerve
  • Promotes wound healing
  • Anti-inflammatory action
  • Reduces scar tissue development

The patient has the ability to attain increased movement once again with an effective and favorable pain management treatment plan.

What to eat?

It’s about a way of life, not some temporary adjustment.

Often times, patients ask, “what should I eat,” or “what is the best diet?”  They focus in on the concept of dieting, which implies a short-term change in food intake, with return to normal eating once they have reached a target weight.  Conceptually this is why less than 12% of people maintain weight balance long term, they resume the same habits that made them obese in the first place.  Keep in mind that the human body and all of its individual cells are highly adaptive, once the body senses a period of starvation or significant nutrient depletion, the fat cells DNA activate a storage mechanism, which causes immediate weight restoration upon nutrient return, often with an overshoot of the fat cell size, in anticipation of a future starvation event.  This overshoot during return of normal food intake results in the paradoxical yo-yo effect where every period of dieting leaves the patient a few pounds heavier than they started.

Don’t think of this as a diet, diets make you feel restricted and are unsustainable.  This is a way of life, the livehealth.com lifestyle, not some fad you will pickup for six weeks and then drop for the next fad.


Food as a nutrient medication?

Food should be considered a medication; it can have specific benefits and adverse side effects.  Approaching your food intake with an eye towards its specific actions and interactions will allow you to program your body; in how you feel, how effectively it works, and how you look.  You should become aware of every item you place in your mouth, and even the cosmetics and creams you apply to your skin.


What’s wrong with eating carbohydrates?

Conventional nutrition seems to focus heavily on carbohydrate ingestion, seemingly focused on what the best grain to eat is.  Conventional farming, with grain harvest and storage, has existed for approximately 10-15,000 years, not enough time for evolutionary adaptation to a continuous nutrient dense carbohydrate intake.

Human evolution takes hundreds of thousands of years, and we have barely begun adapting to the agricultural revolution, let alone the industrial revolution or the new digital age.  Our created environment has changed dramatically, yet our ability to extract nutrients from ingested food remains oriented to periods of feast and famine, unrefined carbohydrates, and high fiber consumption.  Carbohydrate ingestion historically was limited to end of season harvests, ripe berries and fruits, in anticipation of fat storage for long periods of winter starvation.  The continuous consumption of carbohydrates has produced disequilibrium with ongoing storage of fat even when anticipated starvation is improbable, hence the epidemic of obesity.


So what should I be eating to be healthy?

Avoid refined carbohydrates.

Refined carbohydrates are anything that is a processed sugar, whether it comes from a grain or a fruit.  Refined carbohydrates are unnatural and have had the fiber removed, producing over-nutrition.  In addition, the bacterial and parasitic load is refined out of the carbohydrate by industrial processes, which permits much higher gut absorption of carbohydrate. Ingested carbohydrate is converted preferentially to fat reserves; akin to how grain fed beef is finished and produces excess fat and weight, and an unnatural fat deposition pattern between the muscle fibers.


Avoid all liquid carbohydrates

Many patient’s fail to recognize the impact of the liquids they consume, they fail to recognize that soda may contain 300 Calories of straight carbohydrate, without any protein, fat, insoluble fiber or other nutritional benefit.  Some patients consume two to six soda’s per day, and then wonder why they can’t seem to loose weight.  The same goes for fruit juices with the removal of fibrous materials.

Diet soda is not any healthier, as the artificial sweeteners cause tremendous insulin dumping and secondary hypoglycemia resulting in subsequent insulin resistance.


Avoid Milk

Milk from cows contains growth factors to rapidly increase the size of the newborn calf.  Unfortunately these growth factors also rapidly increase the size of adult humans, causing an accumulation of fat tissue since vertical growth is limited by a closed growth plate.  The milk industry has done an amazing job of branding and marketing milk as a healthy substance, geared towards calcium and bone health.  Unfortunatley this is simply not true, milk contains very little Vitamin D and the available calcium is less than what is found in cruciferous vegetables (Swiss chard, broccoli, cabbage, Brussels sprouts, cauliflower, watercress, radish, horseradish, turnip, rutabaga, wasabi, rapini, arugula, spinach, turnip, kale, and bok choy.).  Milk fortified with Vitamin D contains approximately 100 IU per eight ounce glass, whereas being in the sun for 15 minutes produces 20,000 IU of available Vitamin D.  What milk will do is cause rapid fat accumulation.  Whole milk and cheese is not as bad as low fat milk.  Ghee, which is clarified butter with the growth factors and proteins removed is probably far healthier than regular butter.


Eat unrefined carbohydrates (fiber)

Unrefined carbohydrates, such as vegetable, are rich in slowly digestible fiber, which reduces the overall nutrient load density, and facilitates the removal of toxic metabolites.  Additionally, fiber material reduces hunger by maintaining a sense of fullness, and lower peak glucose levels, which prevents the feeling of hypoglycemia.  Dietary intake should include at minimum 10 grams of fiber per meal.


Live harmoniously and eat dirt (micronutrients, bacteria, and parasites)

The human gut has co-evolved with bacteria and parasites, with dietary sterilization leading to in the unintended consequence of obesity and autoimmune disorders.

Although it would seem contrary to good hygiene, the beneficial effects of coexisting parasitic infections include a reduction in inflammatory mediators, a function of the parasite changing its local environment in order to grow inside its parasitic host.  This anti-inflammatory action prevents expulsion of the parasite, and at the same time reduces the inflammatory activation against key antigens.  Reintroducing parasites has been shown beneficial in Crohn’s disease, Multiple Sclerosis and severe peanut allergies.  It should not be unsurprising that the epidemic rise in rates for multiple sclerosis and food allergies is associated with the advent of flush toilets, which reduced human parasite transmission.  There is also a significant relationship between obesity and chronic gut inflammation.

Gut bacterial biodiversity is necessary for optimal health, and the balance between the different bacteria determines the likelihood of obesity.  These bacteria create a fermentation effect in the gut, historically permitting metabolism of fiber rich compounds, providing nearly 25% of the bodies total energy as a fermented alcohols.  Unfortunately antibiotics and toxic highly concentrated carbohydrates disrupt this bacterial ecosystem.  Bacterial balance is so important that transplanting bacteria from an obese mouse to a skinny mouse causes the skinny mouse to become obese.  The mechanism is related to the overall absorption of nutrients, which is enhanced by bacteria found in obese individuals and can quickly proliferate in thin individuals fed a carbohydrate nutrient rich diet.  An example of this is often seen in individuals who undergo a carbohydrate free diet, but then develop abdominal cramping and bloating once exposed to nutrient dense carbohydrates, due to a change in fermentation capacity and absorption.  Additionally, during the carbohydrate cleanse phase, a tremendous amount of gut inflammation is reduced with mobilization of excessive edema, with many patient’s experiencing ten to fifteen pound weight loss from reduced gut edema alone.

The cleanliness of our food supply, by use of pesticides, herbicides, and meticulous cleaning and removal of soil materials has reduced available micronutrients and vitamins necessary for optimized metabolic function; leaving many people feeling sluggish.  For example, we are experiencing a resurgence of Vitamin D deficiency, at the same time we are experiencing obesity and over nutrition.  The genetic engineering of foods has also dramatically reduced the diversity of insects, some of which contain beneficial cofactors for human consumption.


Eat healthy fats

Avocados, fish oils, olive oil, and ghee are all acceptable fats.  Egg yolks have gotten a bad reputation in the nutrition literature, but the cholesterol in egg yolks is a fundamental precursos for good hormonal health and there is a poor relationship between consumed cholesterol and blood levels of bad  LDL.  The use of animal fat does pose concerns, if burned it is a carcinogen.


Eat plenty of healthy protein

Whether the protein comes from animal or plant is irrelevant, as long as it is not combined with unnatural compounds.  Protein load should be1 gram per pound of body weight per day.  Avoid engineered proteins such as soy, which contains estrogens, avoid proteins from grains, and avoid unnecessary fats hiding in proteins


Eat slowly digesting foods

Proteins combined with slowly absorbing fats in a matrix of insoluble fiber forces the gut to expend energy in metabolizing, as is demonstrated by the significant exothermic heat production necessary to digest a steak compared to the minimal energy used to digest cotton candy.  Similarly a glass of apple juice is quickly absorbed as compared to digesting an apple.  In general, the harder it is to chew, the more energy it will take to absorb, and the better it is for you.


Exercise your metabolism, as you would exercise your muscles

In all things there is an ebb and flow, a pulse of plenty followed by a period of depletion.  This period of fasting runs counter to much of the nutrition literature, which suggests nearly continuous feedings, which is not how the human body was designed.  In fact. the creation of breakfast and lunch is less than three hundred years old, and certainly near constant snacking is related to marketing efforts by the snack food industry hoping to capture revenue dollar.  Timing of feeding is also critical, in that a period of activity should occur after the last meal of the day rather than a period of rest and sleep.  Training the fat cells to release nutrition and accumulated fat cell toxins reduces the inflammatory load.

Nine reasons why weight loss is so important for chronic pain patients.

Nine reasons why weight loss is so important for chronic pain patients.

1. Pain reduces activity

Pain often leads to reduced activity and exercise, which can cause patient’s to gain weight, due to loss of metabolically active muscle.

2. Pain prevents restful sleep

Pain disrupts sleep, reducing growth hormone production, which causes patients to gain weight.  Pain also causes elevated cortisol levels and epinephrine levels, which reduce sleep and independantly cause obesity.

3. Pain effects hormones

Excessive fat accumulation leads to a buildup of visceral fat which produces xenoestrogens, which inhibit the production of testosterone, which causes further fat weight gain and loss of muscle mass.

4. Obesity predisposes patient’s to diabetes

Excessive fat accumulation decreases insulin sensitivity and produces insulin resistance, a form of pre-diabetes.

5. Pain effects your pocketbook

Pain often leads to significant functional disability, reducing the patient’s standard of living, which encourages the consumption of subsidized foods, often rich in carbohydrates (food stamps buy significantly more calories of carbohydrates than protein).

6. Obesity effects joint load bearing

Excessive weight dramatically increases the amount of load joints must support. For every extra one-pound of fat you have, you increase the force on your lower back by nearly 20-24 pounds. If you are 10 pounds overweight, your back is carrying an extra 240 pounds of force, and if you lose 10 pounds of weight you will reduce load bearing by 240 pounds.

7. High blood sugar reduces the effects of pain medications

Patient’s with elevated blood glucose experience significantly more pain and find that their pain medications are less effective as the glucose level rises and more effective as the glucose levels fall. There is a direct effect on the opiate receptor by excessive glucose, which prevents activation of the receptor.

8. High blood sugar makes proteins sticky (Glycation)

Glucose or sugar is a sticky carbohydrate. Imagine if you poured sticky goo into the engine of your car, it would bind up the machinery. Extra glucose binds onto nearly all of the proteins in your body, making them work less efficiently, and predisposing patient’s to heart attacks and early aging.

9. Carbohydrates are themselves addictive

Although eating sugar may give you an immediate lift or rush, it quickly disappears when insulin drives the blood sugar into the cells, which then leaves you craving for more sugar because your blood sugar level drops precipitously. Elevated blood sugar temporarily seems to partially activate the endogenous opiate receptors and some people do actually become “addicted” to carbohydrates, requiring ever increasing dosages, which leads to fat accumulation.


Nutritional Supplements


Successful weight loss is best complimented by a customized nutrition plan based on your individual needs. Ensuring a daily dose of heart-healthy vitamins, getting your metabolism in balance and ensuring you have all the nutrients necessary will help build the energy you need to transform your body and mind during your weight loss journey.

Policosanol (or polycosanol) is a natural extract of plant waxes (a mixture of alcohols isolated from Cuban sugarcane wax) It is used as a supplement to lower LDL cholesterol (“bad” cholesterol) and increase HDL cholesterol (“good” or “healthy” cholesterol), and to help reduce atherosclerosis.  It also decreases the stickiness of particles in the blood known as platelets, which might help reduce blood clots, and may have a significant blood thinning effect when combined with garlic extract.


Alpha-lipoic Acid (ALA)

Alpha-lipoic acid regenerates other antioxidants.  Antioxidants neutralize “free radicals,” which are waste products that can damage cells in the body.  Most antioxidants work only in water (such as vitamin C) or fatty tissues (such as vitamin E), but alpha-lipoic acid is both fat- and water-soluble, working throughout the body, by regenerating other antioxidants and make them active again.

Alpha-lipoic acid has been used for years to treat diabetic peripheral neuropathy, and diabetes-related condition called autonomic neuropathy such as cardiac autonomic neuropathy.  There is also evidence to support improved insulin sensitivity.


Vitamin B12 (cobalamin)

Vitamin B12, also called cobalamin, is one of 8 B vitamins, which help the body convert food (carbohydrates) into fuel (glucose), and also help the body use fats and protein.  Fatigue is one of the symptoms of a vitamin B12 deficiency.

Vitamin B12 is an especially important vitamin for maintaining healthy nerve cells, and it helps in the production of DNA and RNA, the body’s genetic material. Vitamin B12 also works closely with vitamin B9, also called folate or folic acid, to help make red blood cells and to help iron work better in the body. Folate and B12 work together to produce S-adenosylmethionine (SAMe), a compound involved in immune function and mood.

Vitamins B12, B6, and B9 work together to control blood levels of the amino acid homocysteine. High levels of homocysteine are associated with heart disease.


Green Tea

Green tea extract is an herbal derivative from green tea leaves, which contain potent antioxidants called catechins, which are 20 times stronger than the antioxidants contained in Vitamin C and Vitamin E.  In addition there are caffeine like substances, which increase metabolic rate, amounts of carotenoids, vitamin C, and trace elements (including chromium, manganese, selenium and zinc).   Additionally, Epigallocatechin-3-gallate (or EGCG), which is an important compound found in green tea reduces lipid absorption.  It should be noted that caffeine, independent of its effect on metabolism, is also a cathartic agent and serves to reduce transit time and nutrient absorption in the colon.


Garlic Extract

Garlic is rich in antioxidants, which help destroy free radicals — particles that can damage cell membranes and DNA, and may contribute to the aging process.  Garlic may reduce heart disease, by slowing atherosclerosis (hardening of the arteries) and lowering blood pressure, between 7% and 8%. Garlic also seems to be an anticoagulant, meaning it acts as a blood-thinner, which may also help prevent heart attacks and strokes, and works in conjunction with polycosanol.



Weight loss program using Qsymia.

What is Qsymia?

Qsymia is a prescription medicine that contains phentermine and topiramate extended-release that may help some obese adults or some overweight adults who also have weight-related medical problems lose weight and keep the weight off.

Qsymia should be used with a reduced calorie diet and increased physical activity. It is not known if Qsymia changes your risk of heart problems or stroke or of death due to heart problems or stroke.

It is not known if Qsymia is safe and effective when taken with other prescription, over-the-counter, or herbal weight loss products.

It is not known if Qsymia is safe and effective in children under 18 years old.


[box type=”warning”] Qsymia is a federally controlled substance (IV) because it contains phentermine and can be abused or lead to drug dependence. Keep Qsymia in a safe place, to protect it from theft. Never give your Qsymia to anyone else, because it may cause death or harm them. Selling or giving away controlled medicine is strictly against the law.[/box]

Who can take Qsymia?

Qsymia is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of:

  • 30 kg/m2 or greater (obese), or
  • 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity such as hypertension, type 2 diabetes mellitus, or dyslipidemia




WARNING:  Qsymia is a Pregnancy Category X Medication, it contains Topiramate

Topiramate, a component of Qsymia, in pregnancy is associated with a 2- to 5-fold increase in risk of oral clefts.

Females of reproductive potential are women who have NOT had a hysterectomy, bilateral oophorectomy, or medically documented spontaneous ovarian failure, and have not gone through menopause. Menopause should be clinically confirmed by an individual’s healthcare provider.

ALL women, except those who have gone through menopause or undergone surgical sterilization, should be advised to consistently use effective contraception, even women who have had difficulty getting pregnant in the past.

If there is a female of reproductive potential in the house, the patient knows to keep Qsymia in a secure location and not share it with anyone else.




What are the dangers of Qsymia?

Qsymia can cause serious side effects, including:

Birth defects (cleft lip/cleft palate).

If you take Qsymia during pregnancy, your baby has a higher risk for birth defects called cleft lip and cleft palate. These defects can begin early in pregnancy, even before you know you are pregnant.

Women who are pregnant must not take Qsymia.

Women who can become pregnant should:

1. Have a negative pregnancy test before taking Qsymia and every month while taking Qsymia.

2. Use effective birth control (contraception) consistently while taking Qsymia. Talk to your healthcare provider about how to prevent pregnancy.


If you become pregnant while taking Qsymia, stop taking Qsymia immediately, and tell your healthcare provider right away. Healthcare providers and patients should report all cases of pregnancy to:

•FDA MedWatch at 1-800-FDA-1088, and

•The Qsymia Pregnancy Surveillance Program at 1-888-998-4887


Increases in heart rate.

Qsymia can increase your heart rate at rest. Your healthcare provider should check your heart rate while you take Qsymia. Tell your healthcare provider if you experience, while at rest, a racing or pounding feeling in your chest lasting several minutes when taking Qsymia.


Suicidal thoughts or actions.

Topiramate, an ingredient in Qsymia, may cause you to have suicidal thoughts or actions.


Call your healthcare provider right away if you have any of these symptoms, especially if they are new, worse, or worry you:

o          thoughts about suicide or dying

o          attempts to commit suicide

o          new or worse depression

o          new or worse anxiety

o          feeling agitated or restless

o          panic attacks

o          trouble sleeping (insomnia)

o          new or worse irritability

o          acting aggressive, being angry, or violent

o          acting on dangerous impulse

o          an extreme increase in activity and talking (mania)

o          other unusual changes in behavior or mood


Serious eye problems which include:

o          any sudden decrease in vision, with or without eye pain and redness,

o          a blockage of fluid in the eye causing increased pressure in the eye

(secondary angle closure glaucoma).

These problems can lead to permanent vision loss if not treated. Tell your healthcare provider right away if you have any new eye symptoms.



[box type=”warning”] Do NOT take Qsymia if you:

  • are pregnant, planning to become pregnant, or become pregnant during Qsymia treatment.
  • have glaucoma
  • have thyroid problems (hyperthyroidism)
  • are taking certain medicines called monoamine oxidase inhibitors (MAOIs) or have taken MAOIs in the past 14 days.
  • are allergic to topiramate, sympathomimetic amines such as phentermine, or any of the ingredients in Qsymia.


Initial Qsymia dosing guidelines: (Once daily, in the morning, with or without food)

  • 14 days on Qsymia 3.75 mg/23 mg
  • 30 days on recommended dose of Qsymia 7.5 mg/46 mg


After 12 weeks at recommended dose of 7.5 mg/46 mg:

  • 14 days on Qsymia 11.25 mg/69 mg
  • 30 days on Qsymia 15 mg/92 mg


How do I get my Qsymia?

Qsymia is available only through certified mail order pharmacies that provide a Medication Guide and Risk of Birth Defects patient brochure with every prescription and refill.

Patients may receive their Qsymia every 30 days

Patients may receive up to 5 refills


F: 1-401-652-1807      F: 1-800-332-9581



About Vitamin D

What is Vitamin D?

Vitamin D is not truly a vitamin.

Compounds are called vitamins only if they cannot be synthesized , and must be obtained from the diet.  Vitamin D, however, is produced in sufficient quantity in the presence of sunlight and cholesterol and should not be considered a vitamin.

In addition, cholesterol is the precursor for most hormones, and Vitamin D should really be viewed as a light dependent fat-soluble hormone.

Historically we have thought that Vitamin D was involved in the absorption of Calcium and Phosphorous from the intestine, and were concerned primarily about its involvement as an osteoporosis risk factor.  However, the reality is that Vitamin D is involved in a variety of metabolism functions, not just bone health.


  • Abnormal low levels of Vitamin D are associated with increased risk of death and disability from cardiovascular disease and cancer.


  • Vitamin D is also involved in general metabolism and reducing obesity through effects on testosterone, thyroid hormones, and insulin.


  • Vitamin D is also involved in neurologic autoimmune dysfunctions such as Multiple Sclerosis and Alzheimer’s.


Why is my Vitamin D level low?

There are a variety of  reasons why Vitamin D levels are found to be low in an otherwise healthy person:

Inadequate Vitamin D intake, which could be a function of poor diet or a diet contaminated with other fat-soluble agents, such as organochlorine pesticides, which prevent adequate absorption.

Inadequate sunlight exposure, due in part to industrialization and conversion to an indoor lifestyle and also to medical recommendation to reduce sunlight exposure and in fact even use sunlight blocking agents.  Sunscreen blocks sunlight and an SPF (sun protection factor) of 8 blocks 95% of the sun, so there needs to be a careful balance between over- and under- sun exposure.

Drinking milk is not a good source of Vitamin D, as an 8 oz glass of fortified milk contains merely 100 IU in comparison to 15 minutes of sun exposure which generates 20,000 IU of Vitamin D.


How do I replace my Vitamin D?

We typically replace Vitamin D only if the measured levels are found to be low; and this is usually associated with other endocrine abnormalities which can be addressed simultaneously.  Vitamin D replacement therapy is done by oral supplement, typically using a once a week preparation.  Retesting of the level should be done after three to six months of consistent replacement.  Replacing Vitamin D should only be done after a blood test confirms that the levels are low, because too much Vitamin D can also cause serious complications.


Where to buy Vitamin D?

Vitamin D3 is typically prescribed, but is also available over the counter.  I typically recommend purchasing it inexpensively through Amazon, since a two year supply of Vitamin D3 (50,000 units) taken once a week is cheaper than copay for a one month supply from the traditional pharmacy.