Antacid Abuse = Bad Breath, Gas, and Then What?

Dr. Harriott's Comment: Acid is not the ultimate enemy. Alkaline is not nervana. Balance is the objective. The body knows what to do, given the chance. If you get a symptom, and automatically think, "what medicine can I take to fix this?", please come talk to me.

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ACG: Chronic Acid Suppression Linked to Bacterial Overgrowth

By Charles Bankhead, Staff Writer, MedPage Today
Published: November 06, 2009

Action Points
Explain to patients that chronic use of acid-suppressing drugs might lead to abnormal bacterial growth in the small intestines.


The findings are based on a small number of patients from a retorspective review of data at a single institution.
SAN DIEGO -- Chronic acid suppression therapy may predispose otherwise healthy individuals to clinically significant small intestinal bacterial overgrowth (SIBO), according to data reported here.
Half of patients on chronic acid suppression had positive lactulose breath tests, compared with about 30% of a control group. Chronic acid suppression was associated with a significantly higher proportion of bacteria that produced mixed hydrogen-methane gas.

"If a patient has small-bowel bacterial overgrowth and has no other risk factors for it, physicians might consider stopping the patient's treatment with a proton pump inhibitor, if the patient can tolerate it, to prevent recurrence of the bacterial overgrowth," Walter Chan, MD, of Brigham and Women's Hospital in Boston, said during a presentation at the American College of Gastroenterology meeting.

"Particularly in patients who respond to treatment and then have recurrent symptoms, or who fail to respond to treatment-stopping PPI treatment might be considered as an adjunct to treatment of the small-bowel bacterial overgrowth."

Previous studies had suggested increased bacterial-colony formation in duodenal aspirates of asymptomatic patients on chronic acid suppression. However, no study had examined the effects of acid suppression on clinically significant SIBO, and the role of chronic acid suppression in symptomatic SIBO remained unclear.

To examine the association, Chan and colleagues retrospectively analyzed data on 108 adults who underwent lactulose breath test. The study population consisted of 43 patients who reported daily acid suppression therapy for at least two months and 65 patients who reported no acid suppression.

A positive breath test was defined as >20 ppm rise in breath hydrogen or methane within 60 minutes.

Baseline characteristics between the acid-suppression and control groups were similar, although women made up a higher proportion of the control group (86.1% versus 74.4%, P=0.06).

Among patients on chronic acid suppression, 49% had positive breath tests compared with 26% to 27% of the control group. The difference translated into more than a twofold greater likelihood of a positive test in the patients on chronic acid suppression (OR 2.311, P=0.019).

Gas-producing characteristics of the breath test showed that about 30% of the acid suppression group and about 20% of the control group generated hydrogen, and fewer than 10% of each group exhibited methane production.

About 10% of the acid-suppression group had mixed gas production, which was significantly different from the control group rate of about 1% (P=0.03). The finding indicated that chronic acid production might promote growth of a wider variety of bacterial species.

In light of findings, physicians might consider discontinuation of acid-suppressing drugs in patients with positive breath tests, particularly those who have recurrent symptoms of SIBO, the investigators concluded.

Need Help with Depression?

Dr. Harriott's Comment: Chiropractic, St. John's Wort, Exercise, and now the Mediterranean Diet. If you are considering a medical consultation for depression, try this approach before you reach for a pill. Positive mental activity is just one side benefits of a healthy lifestyle.
============================

Mediterranean Diet May Protect Against Depression

The Mediterranean diet, with its emphasis on consumption of olive oil, legumes, vegetables, and fruits, may help protect against major depression, a prospective Spanish study suggested. When study participants were scored on their dietary practices...

full story http://www.medpagetoday.com/Psychiatry/Depression/tb/16283

Primary source: Archives of General Psychiatry
Source reference: Sanchez-Villegas A, et al "Association of the Mediterranean dietary pattern with the incidence of depression" Arch Gen Psych 2009; 66: 1090-98.

Low-Dose Aspirin NOT recommended

Dr. Harriott's Commentary:

I hear this all the time, "I take aspirin every day, just in case." It has very real adverse effects on the digestive tract, it has questionable cardiovascular benefits. Dietary changes incorporating reduced sugars, empty carbs, and saturated animal fats with increased vegetables, omega-3 fats and other anti-imflammatory lifestyle changes including regular exercise, of course) are what created SIGNIFICANT improvements in cardiovascular health.

There is no pill that delivers health. THERE IS NO SUCH PILL!!!


=======================
Use of Low-Dose Aspirin in Primary Prevention of Cardiovascular Events Not Recommended

August 30, 2009 (Barcelona, Spain) — The use of low-dose aspirin in the primary prevention of cardiovascular events in healthy individuals with asymptomatic atherosclerosis is currently not warranted, according to the lead researcher of a large "real-world" study presented today at the European Society of Cardiology (ESC) 2009 Congress.

In the randomized trial of 3350 subjects deemed at high risk for cardiovascular and cerebrovascular events because of a low ankle-brachial index (ABI) (<0.95), aspirin had absolutely no effect on reducing events compared with placebo, Dr Gerry Fowkes (University of Edinburgh, Scotland) reported on behalf of the Aspirin for Asymptomatic Atherosclerosis (AAA) trialists.

full story: http://www.medscape.com/viewarticle/708139?sssdmh=dm1.522428&src=nldne

Organic - It's the Pesticides, not the Nutrition

Dr. Harriott's Comment:

It has been said that organic produce has higher nutrient value because it is grown in better soil. That is the result of a logical train of thought that is not regulated or even proven. This study suggests that the only differences in the organic v. non-organic foods is related to the fertilizers used (nitrogen, phosphorus, etc) and does not affect the quality of the nutrition. OK, I can accept that. But that isn't the reason why I choose local organics over mass-farmed foods. It's the pesticides and herbicides that cause untold damage to our bodies through estrogen mimicry and liver toxicity and ground water contamination that I am concerned with. So... move along... nothing to see here.

==================================================

Organic No More Nutritional than Conventional Foods

By Kristina Fiore, Staff Writer, MedPage Today
Published: July 30, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
Earn CME/CE credit
for reading medical news


LITTLE FALLS, N.J., July 30 -- When it comes to nutrition, there's no difference whether patients consume organic or conventionally produced foods, researchers say.

A review of more than 50 studies found no difference in nutrient content -- including vitamin C, calcium, potassium, and zinc -- between the types of food, Alan Dangour, PhD, of the London School of Hygiene & Topical Medicine, and colleagues reported.

The study appears in the September 2009 issue of the American Journal of Clinical Nutrition.

Marion Nestle, PhD, MPH, an expert on nutrition and food studies at New York University, disputed the scope of the findings. Action Points
Explain that a large review found no overall difference in nutritional content between organic and conventionally produced foods.


Note that there were differences in nitrogen and phosphorous content, but that was likely due to the type of fertilizer used.
"Plenty of studies have shown organics to have higher levels of nutrients," she said. "Nutrient levels ought to be higher in plants grown on better soils."

The "organic" label is reserved for farms that limit pesticide and herbicide use in crops and drug use in livestock.

Organic foods are typically more expensive, but sales have been booming because of the perception that they're healthier than conventionally produced foods.

So, to determine whether there is a difference in nutritional benefits, the researchers conducted a review of 55 studies published between Jan. 1, 1958 and Feb. 29, 2008.

They evaluated foods' nutrient content, including vitamin C, phenolic compounds, magnesium, potassium, calcium, zinc, copper, and total soluble solids.

They found no evidence of a difference between organic and conventional crops in terms of eight of those nutrient categories.

Conventional crops contained more nitrogen, while organics had more phosphorus and greater acidity.

The researchers said the differences were likely due to differences in fertilizer use and ripeness of fruits and vegetables at harvest.

But they said it's "unlikely that consumption of these nutrients at the levels reported in organic foods in this study provide any health benefit."

Nor did the researchers find nutritional differences with regard to animal-source foods -- although they noted that there were far fewer studies on these foods compared with produce. That made analysis was more limited, they said.

Also, the researchers did not include an analysis of contaminants or chemical residues used in the food products.

Chemical fertilizer, herbicides, and pesticides may also affect the chemical content of foods, they said, and the organic foods may have an advantage because of their controlled use of chemicals and medicines. That warrants further study, the researchers said.

Niyati Parekh, PhD, professor of nutrition at New York University who was not involved in the study, said the findings regarding nutritional content are not surprising. The larger concern with organic versus nonorganic foods is chemical content.

"The person who spends the extra $5 to buy organic is not doing it for the nutrients," Dr. Parekh said. "They're concerned with the chemicals."

She said there is not a large body of literature on the chemical content of organic versus nonorganic food because organic labeling is still a "gray area."

"No one has defined what organic is," Dr. Parekh said. "Until we do that, it's hard to study."

Maria Romano, MS, RD, clinical nutritionist for adult oncology at Montefiore Medical Center in New York, said that even though they're difficult to design and execute, studies comparing organic and nonorganic products are important.

"We know pesticides pose a risk to human health even in small doses, or those considered safe by industry," she said. "They can have toxic effects and in the long term can contribute to cancer."

Meanwhile, Dr. Nestle emphasized that "organics aren't about nutrients. They are about cleaner and more sustainable production methods," including "lower levels of pesticides and herbicides, which seems like a good idea."

The authors noted the possibility of reporting bias, which is a potential limitation of systematic reviews.

Flax Reduces Blood Cholesterol

Dr. Harriott's Comment:
In reviewing this article referenced below the interesting take away points are: 1) Flax oil did not render the benefit that whole flax seed did. 2) It appears that the benefit is only towards lowering cholesterol and LDL, not towards increasing HDL, and 3) the effects on women appear to be on the order of 3 times higher than the the effects on men. Interesting stuff...

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Flaxseed Reduces Blood Lipids
http://www.medscape.com/viewarticle/706641?sssdmh=dm1.506978&src=nldne

July 29, 2009 — Whole flaxseed and flaxseed lignans significantly reduce circulating total cholesterol and low-density lipoprotein (LDL) cholesterol levels, showing their greatest effect in postmenopausal women and individuals with high initial cholesterol concentrations, according to the results of a meta-analysis published in the August 2009 issue of the American Journal of Clinical Nutrition.

...

There were no significant changes in HDL cholesterol or triglyceride levels.

Interpret Findings With Caution

The authors point out that the limitations of their study include the heterogeneity of the studies in the meta-analysis, and a lack of information on the quality, quantity, and bioavailability of the flaxseed that was used. Therefore, they write, their findings must be interpreted with caution.

The results of this meta-analysis indicate that flaxseed consumption may be a useful dietary approach for the prevention of hypercholesterolemia, especially in some patient subgroups, the authors conclude. They add that further studies should be done to investigate the effectiveness of flaxseed supplementation on cardiometabolic risk factors other than blood lipids and, ultimately, on cardiovascular disease–related morbidity and mortality.

Lower Your Risk of the Leading Cause of Death 50%

Dr. Harriott's commentary:

Cardiac disease is the leading cause of death in the United States. In the general population that risk at the age of 40 years old is about 20%. The study below reports that the risk drops to about 10.1% for men who adopt 4 out of 6 of the following lifestyle modifications:

1. Recommended body weight,
2. Non-smoking,
3. Regular exercise,
4. Moderate alcohol intake,
5. consumption of breakfast cereals, and
6. consumption of fruits and vegetables.

So, question for you to ponder if you are not doing this already... What other benefits do you suppose you would enjoy if you were to be in a low cardiac risk category? We always seem to focus on the end, but I want you to think about what happens between now and then. A healthy lifestyle means, more activity, better sleep, better sex, fewer medications, more vacations. Get on the wagon everyone :) !!!!


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Relation Between Modifiable Lifestyle Factors and Lifetime Risk of Heart Failure
http://jama.ama-assn.org/cgi/content/abstract/302/4/394?etoc

Luc Djoussé, MD, ScD, MPH; Jane A. Driver, MD, MPH; J. Michael Gaziano, MD, MPH

JAMA. 2009;302(4):394-400.

Context The lifetime risk of heart failure at age 40 years is approximately 1 in 5 in the general population; however, little is known about the association between modifiable lifestyle factors and the remaining lifetime risk of heart failure.

Objective To examine the association between modifiable lifestyle factors and the lifetime risk of heart failure in a large cohort of men.

Design, Setting, and Participants Prospective cohort study using data from 20 900 men (mean age at baseline, 53.6 years) from the Physicians' Health Study I (1982-2008) who were apparently healthy at baseline. Six modifiable lifestyle factors were assessed: body weight, smoking, exercise, alcohol intake, consumption of breakfast cereals, and consumption of fruits and vegetables.

Main Outcome Measure Lifetime risk of heart failure.

Results During a mean follow-up of 22.4 years, 1200 men developed heart failure. Overall, the lifetime risk of heart failure was 13.8% (95% confidence interval [CI], 12.9%-14.7%) at age 40 years. Lifetime risk remained constant in men who survived free of heart failure through age 70 years and reached 10.6% (95% CI, 9.4%-11.7%) at age 80 years. Lifetime risk of heart failure was higher in men with hypertension than in those without hypertension. Healthy lifestyle habits (normal body weight, not smoking, regular exercise, moderate alcohol intake, consumption of breakfast cereals, and consumption of fruits and vegetables) were individually and jointly associated with a lower lifetime risk of heart failure, with the highest risk in men adhering to none of the 6 lifestyle factors (21.2%; 95% CI, 16.8%-25.6%) and the lowest risk in men adhering to 4 or more desirable factors (10.1%; 95% CI, 7.9%-12.3%).

Conclusion In this cohort of apparently healthy men, adherence to healthy lifestyle factors is associated with a lower lifetime risk of heart failure.

You'll Never Guess What Else Causes Heartburn and Acid Reflux!!

Dr. Harriott's Commentary: this is why you are stonger and healthier when you heal and recover naturally, without dependence on medical procedures or lotions and potions. The body does what it does for a reason. You can often jumper past or bypass a system to force a response, but there will be ramifications that the MD cannot often predict. It's often like a toss of the dice...

Rebound Acid Reflux with PPIs May Induce Dependence

SAN FRANCISCO, July 2 -- Proton-pump inhibitors (Nexium) may cause or aggravate the very acid-reflux symptoms they're used to treat, according to a randomized trial.

Nexium Causes Gerd?

Apparently, a double-blind, placebo controlled trial showed that 44% of people with no heartburn to begin with, developed heartburn after taking Nexium for two months. Wow, who'd have thunk it?

The Miracle of Baking Soda and Your Overall Health

The write-up below was provided to me by the office of Dr. Thomas MacKinnon, DDS MAGD

My only objection to this is the use of fluoride toothpaste. I am not a dentist and I would not want to go head-to-head in a dental debate with Dr. MacKinnon, but I have not seen any information to suggest that fluoride does anything for adult teeth. On the other hand, I have heard of health problems associated with fluoride ingestion, including interference with normal iodine metabolism/absorption/excretion which is critical to our health. That being said...

Here is the write-up from Dr. MacKinnon:

"I now brush my teeth with baking soda and peroxide. New research on how to clean your mouth and teeth has shown that baking soda does a great job of breaking up the hard to remove oral biofilm. This same research points out the importance of regular visits to the dentist to get your teeth cleaned professionally. The heart of keeping your teeth for life is the mechanical removal of these stubborn deposits that will collect even in the face of the best flossing and brushing...

... The use of baking soda will whiten up your teeth since it can remove stains and it leaves your mouth feeling really clean. There are a lot of way s you can use baking soda. It is well researched as Dr. Keyes has studied it for 40 years. Visit his website for additional ideas about how to use this inexpensive and effective dental cleaning material.

Additional material on this subject can be obtained at the links below:
I use his "powerful antibacterial combination"
http://www.drpaulhkeyes.com/writings/dentifrice-01.html

If you know a young lady that may become pregnant, this is a good site for oral hygiene information. I still see gum disease in some of my pregnant patients and it can lead to real problems like early tooth loss or pregnancy problems:
http://www.baby-place.com/oralhealth.html

This site shows how to use baking soda and is written in a humorous style:
http://www.frugallawstudent.com/2007/06/11/frugall-esperiment
After the author used the baking soda a few times he had bad breath (I didn't experience this) my guess is that he should have used it for a week. He would then have removed the bulk of oral biofilm that caused the bad breath. Using regular toothpaste will also help this during the transition. I still use a fluoride toothpaste once a day."

Supplements and Dietary Change Make a Difference in Age-Related Macular Degeneration

Dr. Harriott's Comments:
This study acknowledges that modest levels of omega 3 fatty acid intake and a low glycemic diet are beneficial for AMD. It then shows, however that,concurrent supplementation with anti-oxidants like C, E, etc may necessitate higher levels of consumption of omega 3 fatty acids to maintain the benefit in earlier stages of the disease.

Take home message would be that omega 3 fatty acid supplements (these fatty acids are found in flax oil, walnut oil, fish oil, among other sources) are a good thing. Also, a low glycemic load diet is once again shown to be a clear path to healthy living. And lastly, if you have early stage AMD, additional anti-oxidant supplementation may interfere with the benefits of omega 3 fatty acids for that disease. Further study will be necessary to come up with specific dietary recommendations for AMD.

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Other Factors May Affect Link Between Omega 3s and AMD
http://www.medpagetoday.com/Ophthalmology/GeneralOphthalmology/14789?
userid=69947&impressionId=1245645053617&utm_source=mSpoke&utm_medium=
email&utm_campaign=DailyHeadlines&utm_content=Group1

LITTLE FALLS, N.J., June 19 -- The association between omega-3 fatty acids and lower risk of age-related macular degeneration (AMD) appears to be modified by other dietary supplements and disease stage, researchers found.

As expected, high intake of the omega-3s docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) was associated with a lower risk of progression to advanced AMD in a secondary analysis of a randomized trial, Chung-Jung Chiu, DDS, PhD, of Tufts University in Boston, and colleagues reported online in the British Journal of Ophthalmology.

For early AMD progression, however, the apparent protective effect of DHA was eliminated in patients taking supplements containing high doses of antioxidants, zinc, or both as part of the Age-Related Eye Disease Study.

"The present study adds additional support to the idea that diet and, if necessary, supplementation can be optimized for the prevention of AMD," the researchers said.

The original research showed that high doses of antioxidants protected against the progression of advanced age-related macular degeneration. (See High Antioxidant Diet May Delay Age-Related Macular Degeneration)

A number of other studies have also identified a link between high consumption of omega-3 fatty acids and a reduced risk of AMD, and some evidence points to a protective effect of a low glycemic index diet.

However, it had remained unclear how all of these dietary factors interacted, the researchers said.

So they performed an analysis of data from 2,924 patients participating in the Age-Related Eye Disease Study, an eight-year supplementation trial. Dietary intake was assessed using food-frequency questionnaires.

There were four arms in the trial: placebo, antioxidant supplementation with vitamins C and E and beta-carotene, supplementation with zinc, or combined supplementation.

The highest intakes of DHA (HR 0.73, 95% CI 0.57 to 0.94) and EPA (HR 0.74, 95% CI 0.59 to 0.94) and the diets lowest in glycemic index (HR 0.76, 95% CI 0.60 to 0.96) were linked to lower risk for progression to advanced AMD, independent of the type of supplementation.

There were significant interactions between dietary glycemic index and both DHA (P=0.0003) and EPA (P=0.0001) intake, such that patients who had low glycemic index diets and high consumption of the omega-3 fatty acids had lower risks of progression to advanced AMD than patients with high intakes alone.

Patients in the early stages of AMD, however, only derived a benefit from consuming large amounts of DHA if they were not taking additional supplementation as part of the study (HR 0.58, 95% CI 0.37 to 0.92).

"It appears that the high-dose supplements of the antioxidants and/or the minerals somehow interfered with the benefits of DHA against early AMD progression," said study co-author Allen Taylor, PhD, also of Tufts.

The levels of DHA and EPA consumed in the study were much lower than the recommended intake, according to the researchers.

To hit the target, individuals could consume two to three servings of cold-water fatty fish, such as salmon, tuna, mackerel, sardines, and herring, as well as shellfish.

However, it would be premature to make specific dietary recommendations for patients with AMD, the researchers said.

"Taken together, these data indicate that consuming a diet with higher levels of omega-3 fatty acids, antioxidants, and low-glycemic index foods may delay compromised vision due to AMD," Dr. Taylor said.

"The present study adds the possibility that the timing of a dietary intervention as well as the combination of nutrients recommended may be important," he said.

The study was funded by the U.S. Department of Agriculture, the NIH, the Johnson & Johnson Focused Giving Program, the American Health Assistance Foundation, and the Ross Aging Initiative.

The authors reported that they had no conflicts of interest.

Primary source: British Journal of Ophthalmology
Source reference: Chiu C-J, et al "Does eating particular diets alter risk of age-related macular degeneration in users of the age-related eye disease study supplements?" Br J Ophthalmol 2009; DOI: 10.1136/bjo.2008.143412.

Alternative Sweeteners - Wow! Too Good To Be True?

So I finally made it to Henry's to buy myself some Stevia and some Xylitol to try out as an alternative to some other sweeteners I have been using.

I have been using fresh apple juice in my oatmeal with raisins, molasses, cinnamon and mashed banana. While I was OK with it, my daughter and son really missed the brown sugar we used to put in it. So I bought some Agave nectar, but while I was assured it is a lower glycemic product, I remain unconvinced.

So, back to the Xylitol and Stevia. What can I say, but "outstanding"? Stevia has a little aftertaste when I tasted it by itself, but once added to an actual food, I couldn't tell any more. ANd zero calories. And it is a safe natural herbal extract.

Xylitol still has 2/3 of the calories of sugar with the same sweetness, but it is still a low glycemic index product, so.... cool. Literally cool... Beccause it leaves a cool sensation on your tongue when you taste it alone, but not really a problem when in recipe. Oh yeah, and oral bacteria that cause cavities are actually reduced by the consumption of Xylitol.

I bought them both and will likely use Stevia most of the time, although the dental benefits of Xylitol will mean that I keep it in my cupboard to use as well.

I feel I'm in a too good to be true situation. Let me know if you know of any downsided to either of these products.

How About Iodine?

This doc makes a compelling case. Certainly worth looking into further. The video is long, but it is worth watching.

Links to Meal Recipes

I just added a couple great recipes to lunch and dinner. In case you have any difficulty finding the meal posts, I have re-listed them below... Remember, the recipes are listed as comments. Please add your own, as well.

===============

Breakfast:

http://drharriott.blogspot.com/2009/05/breakfast-meal-plans.html

Lunch:

http://drharriott.blogspot.com/2009/05/lunch-meal-plans.html

Dinner:

http://drharriott.blogspot.com/2009/05/dinner-meal-plans.html

Dessert / Snack:

http://drharriott.blogspot.com/2009/05/dessert-or-snack-meal-plans.html

TT&G Day 4

Loving that oatmeal with the raisins, banana, a little molasses and a dash of almond milk.  This week has been a whirlwind with school concerts, open houses, awards banquets and preparing for the backpacking trip this weekend.  That will present it's own challenge since we will be stuck with the dehydrated food that we find at the camping store.  I am not that creative so I'm not going to try to reinvent backpacking food.  We'll just get back on the wagon on Monday :)  For now, though, I have some shopping to do....   By the way, Maddy said to me yesterday, "Gee, I haven't found anything we've been eating bad.  I don't know why we didn't eat this way already..." Was that question pointed at me?  LOL

TT&G Day 2

Well Maddy and I did out scans yesterday.  She wasn't able to start the dietary changes because of her schedule, but when she gave me the "Oh, I need lunch" today, and then told me she didn't have time to plan / prepare it, I did it for her and told her, "this is the last time" :)

So, this morning, she and I got up just before 5 a.m. did a fast walk to the gym, stationary bikes for 20 minutes and fast walk back home.  She had two bananas and an apple for breakfast because she didn't have time to do anything else.

I put together her lunch:

Apple

Ziploc Baggie of assorted nuts

Romaine Lettuce Salad w/ chopped tomatoe, oninon and red bell pepper

Basic Salad Vinagrette (from Day 1 menu already posted)

Tunafish to put on top of her salad.

I gotta' get to the store today with my shopping list. ...

BTW, I am about to head over to the office to do BIA scans.  If you are interested, I'll be there today from 10 to noon and again from 5 to 6pm.  If you can't make those times, or get this post too late, call me to schedule another time (949)360-1112.

Dr. Harriott

Dessert or Snack Meal Plans

Recipe or plan contributions can be seen by clicking on "comments" at the bottom of this posting. If you have any desserts or snacks you'd like to contribute, please add as another comment here so that others may try them:

Breakfast Meal Plans

Recipe or plan contributions can be seen by clicking on "comments" at the bottom of this posting. If you have any breakfast meal plans or recipes you'd like to contribute, please add as another comment here so that others may try them:

Lunch Meal Plans

Recipe or plan contributions can be seen by clicking on "comments" at the bottom of this posting. If you have any lunch meal plans or recipes you'd like to contribute, please add as another comment here so that others may try them

Dinner Meal Plans

Recipe or plan contributions can be seen by clicking on "comments" at the bottom of this posting. If you have any dinner meal plans or recipes you'd like to contribute, please add as another comment here so that others may try them:

Basic Dietary Guidelines - Foods to Avoid

Fruits: Oranges, orange juice

Vegetables: Corn; any creamed vegetables. Optional - Nightshade vegetables - potatoes, tomatoes, eggplant, peppers.

Starch: Wheat, corn, barley, spelt, kamut, rye; all gluten-containing products.

Breads & Cereals: Products made from wheat, spelt, kamut, rye or barley.

Legumes: Tofu, tempeh, soybeans, soy milk; other soy products.

Nuts & Seeds: Peanuts, peanut butter

Meat & Fish: beef, pork, cold cuts, franfurters, sausage, canned meats (other than water-packed fish), shellfish.

Dairy Products: Milk, cheese, cottage cheese, cream, yogurt, butter, ice cream, frozen yogurt, non-dairy creamers, soy milk, eggs.

Fats: Margarine, butter, shortening, processed and hydrogenated oils, mayonnaise, spreads, palm oil, poultry skin, deep fried foods (chips, donuts).

Beverages: Sodas, diet sodas, sports beverages, and other soft drinks and mixes; alcoholic beverages; coffee, tea, other caffeinated beverages.

Spices & Condiments: Chocolate, ketchup, chutney, soy sauce, BBQ sauce, bottled mustard, other condiments. Food sensitivity alert: Ketchup and other condiments may contain corn syrup.

Sweeteners: White or brown refined sugar, honey, maple syrup, corn syrup, high fructose corn syrup, or evaporated cane juice.

Other: Processed foods containing and baking soda or corn starch. Processed starch foods containing any ofthe the ingredients or sweeteners to avoid.

Basic Dietary Guidelines - Recommmended Foods

Fruits: Fresh, unsweetened, dried, frozen, canned, water-packed fruits; fruit juices (except orange)

Vegetables: All fresh raw, steamed, sauteed, juiced or roasted vegetables

Starch: Rice, oats, millet, quinoa, amaranth, teff, tapioca, buckwheat, potatoes

Breads & Cereals: Products made from rice, oat, buckwheat, millet, potato flour, tapioca, arrowroot, amaranth, or quinoa

Legumes: All legumes including peas and lentils (except soybeans)

Nuts and Seeds: Almonds, cashews, pecans, walnuts, sesame (tahini), sunflower, pumpkin, nut butters (except peanut).

Meat & Fish: All fresh or frozen fish, chicken, turkey, wild game, lamb; canned water-packed fish.

Dairy Products & Milk Substitutes: Milk substitutes such as rice milk, almond milk, oat milk, coconut milk, or other nut milks; egg replacer.

Fats: Oils, cold-pressed olive oil, flaxseed, canola, safflower, sunflower, sesame, walnut, pumpkin, almond, grapeseed.

Beverages: Filtered or distilled water, decaffeinated herbal tea, seltzer or mineral water

Spices & Condiments: Vinegar (except malt); all spices including salt, pepper, cinnamon, cumin, dill, garlic, ginger, carob, oregano, parsley, dry mustard, rosemary, tarragon, thyme, or turmeric.

Sweeteners: Brown rice syrup, fruit sweeteners, blackstrap molasses, stevia, agave nectar.

Exercise?

Don't kill yourself.  

For the Taut Tan and Gooch contest, just think in terms of stepping up the exercise you are already doing. 

If you aren't exercising now, then start. But start SLOWWWW. Start by walking and then think about doing some hills, and then upping your pace.  

If you are already exercising, try increasing the effort both in repetitions and stress (weight, incline, speed). Also, don't forget that we humans are basically lazy. You have to change up your routine regularly or else your body will "expertly" minimize your effort to accomplish the task.

And keep the peripheral efforts minimized. Huh? What I mean to say is, if you have to "find" a solid 1 + 1/2 hour break every day to work out, then this is going to be difficult to do for 30 days and impossible to sustain thereafter - at least is would be for me. I've just got too much going on. Try to figure out how to incorporate exercise into your day. 

Example: I could pack my workout bag with all my toiletries, bring my work clothes with me, drive to the gym, put my stuff in a locker, go do an elliptical machine for 45 minutes, then turn around and do some weight training for another half hour, and then go shower, get dressed and go to work. Then, when I get home, I have to unpack my stinky bag, and get my clothes together for the next day. 

How long do you think you''re going to stay motivated to do this routine? Good grief Charlie Brown, getting ready seems like more work than the exercise itself. If you have a gym about a mile away from your house as I do, forget the eliptical, just walk to the gym and back and stick to the weight training at the gym. If you aren't so lucky, then break it up. Do the weight training in the morning or evening and do the walking at lunch time. The point is, you need to make it easy to get a workout in. Plan for the worst day. If you really aren't looking forward to working out today, then how excited will you be to have to struggle just for the opporunity?

Happy puffing!

Meal Plans?

"Meal plans? How do I know what will decrease fat and increase muscle?"  

Good question. What I recommend you try to do is:  

A general strategy... Eat frequently, but in smaller portions. You don't need to necessarily include portion sizes in your posted meal plans, but understand that caloric intake sets metabolism. And, the amounts of glucose in the blood affect the way the body deals with the calories. So a steady intake of reasonable calories will keep the glucose/insulin spikes at bay, thereby reducing fat storage. And, it will also help to quell the gnawing appetite.  

Sustainable

I would like you to try eating in a way that will be sustainable after the contest is over. But the best diet is no longer a mystery. You can google and find loads of information on diets, meal plans, recipes. And when you find something great, by all means, please share it by posting a comment!

Eat Your Veggies

In general, try to eat a lot of vegetables, fruits, and reasonable lean protein portions (think the size of the palm of your hand). To the extent that you can stay away from fatty foods, do so.  

Drop the Processed Foods and Sugar

Try not to eat a lot of processed or packaged foods as there is typically way too much salt and sugar added, not to mention a bunch of preservatives, color and other nasty stuff we don't need. Try to drop sugar, candies, cookies, etc. altogether when you can.

Fats

There are good fats and bad fats from a dietary standpoint. In general, if it is solid at room temp, that is a fat you should try to minimize. Go towards olive oil for cooking when you can. Don't forget your Omega-3 fats (walnuts, flax seeds, fish, supplements).

Who needs milk?

Remember, milk is NOT an essential dietary element. If you are concerned about vitamin D and calcium, these supplements are extremely inexpensive. Milk is a high density infant food and humans are the only species on the planet that eats dairy after infancy. Take this opportunity to try some milk alternatives, like almond or rice milks for your whole grain cereals. Drink more water.  

Here is a link to the list of recommended foods:http://drharriott.blogspot.com/2009/05/basic-dietary-guidelines-recommmended.html#links

And here is a link to the list of recommended foods TO AVOID: http://drharriott.blogspot.com/2009/05/basic-dietary-guidelines-foods-to-avoid.html#links

Let me know if you want my opinion about any of this and...  Good luck  

Ed

10 Day Detox

As part of the Taut Tan & Gooch contest, Maddy and I will do a 10 day detox program. [Update: We've decided to wait until after the TT&G contest is over to do the detox].

This detox program is based on a Metagenics detox system which follows the 10 day guidelines below but uses Metagenics Medical Foods and supplements.

What you take depends on your health condition and, obviously, I am NOT requiring everyone who wishes to participate to come in for a physical exam. But just know that if you have any serious medical conditions, you should consult with me personally or with another licensed doctor before doing a radical diet change. I'm sorry, but you will have to apply some judgment here :).

You can do a quick 10 day detox program with rice protein powder available at any Henry's or Mother's Market. But you should understand that Metagenics has great detox products in their UltraClear line and they are about the best tasting on the market (I didn't say they taste good:). The program which Metagenics researched and developed also includes a liver support supplement and a heavy metal detox supplement. In case you would like to follow the program as designed by Metagenics, you will need to order the following products (approximately $150) from me or any other Metagenics outlet:

Advaclear, 1 btl. 

Metalloclear, 1 btl 

UltraClear Plus pH, 1 container

The advaclear provides metabolic support to the liver to make the detox less stressful on your body and to keep you from feeling really crappy as your body's stored toxins are mobilized. This is a good idea. 

The Metalloclear increases the body's elimination of heavy metals.  The bottle listed above is a one month supply since this is not something you would only want to do for 10 days but rather you should finish the bottle over the following 20 days.

The UltraClear Plus pH is basically rice protein powder with some other proprietary ingredients that help to lower your body's pH, taste good, and some other "magic" (you know what I mean).  It has been demonstrated that lower pH allows for better mobilization and breakdown of fat.  Also, very few of us wouldn't benefit from lower pH. So the couple of dollars extra for the pH version of this product is a necessity in my opinion.

If you would like to order these products, just call my office and I will have them drop shipped to your home.

Now, please don't feel obligated to purchase the Metagenics products just to participate in the Taut, Tan & Gooch contest.  In fact, you don't even have to do a detox - it's just that Maddy and I originally planned to and I wanted everyone to have the opportunity.

10 Day Express Detox Program

Day 1

Eliminate all:

• Refined sugars - anything with added sucrose, high fructose corn syrup, or alcohol (cakes, cookies, candies, pastries, beer, wine, liquor)
• Caffeinated drinks (sodas, coffee, tea)
• Artificial colorings, flavorings, and sweeteners (packaged and processed foods)
• Flex foods (beef, pork, lamb, poultry, fish, wild game)

Day 2

In addition to eliminating foods listed for Day 1, 

Eliminate all:

• Dairy products and eggs

Start Medical Food (protein powder) - 1 scoop twice today

Day 3

In addition to eliminating foods listed for Days 1-2,

Eliminate all:

• Gluten grains - wheat, rye, barley, spelt, kamut, corn and oats

Note:  you may eat quinoa, rice, millet, and buckwheat today

Continue Medical food - 1 scoop twice today

Day 4

In addition to eliminating foods listed for Days 1-3,

Eliminate all:

• Remaining grains (quinoa, rice, millet, buckwheat)
• Nuts and seeds

Note:  you should now be eating vegetables, fruits, and legumes only (along with the medical food)

Increase Medical food - 2 scoops twice today

Days 5-7

In addition to eliminating foods listed for Days 1-4,

Eliminate all:

• legumes (beans, peas, lentils)

Note:  at this point of the detox you would only eat those fruits and vegetables listed below:

• Cruciferous vegetables (broccoli, cauliflower, kale, cabbage, Brussels sprouts)
• Raw greens (red and green lettuce, romaine, spinach, endive)
• Fresh apples and pears (whole or freshly juiced)
• Canned apple or pear juice (no sugar added)

Increase Medical food - 2 scoops 4 times per day

Day 8

Now gently add back fruits, vegetables, and white rice (only) to diet.

Decrease Medical food - 2 scoops three times today

Day 9

Add back:

• Quinoa, millet, and buckwheat
  
• Legumes and nuts

Finish Medical food - 2 scoops twice today

Day 10:

You are done! You have successfully completed the 10-day Express Detox Program. For maximum benefit from this program, it is important to slowly reintroduce the foods which you have not added back to you diet yet. If you suspect that you have food allergies, try only one new food at a time and wait 24-48 hours to see if you not a reaction. If unsure about a reaction, wait until symptoms recede and eat only foods that do not cause a reaction. Then ingest the suspicious food again and take note.

Taut Tan & Gooch Contest

So Maddy, my daughter, and I, have decided we're going to do a friendly competition to see who can improve their muscle to fat ratio the most in 30 days.  And we have found some neighbors and some docs and staff at my office, some patients and even some friends on Facebook who want to play along.  The key is that you some way to determine your fat mass and your muscle mass.  This is a friendly competition and everyone is on his/her honor in terms of accuracy.  But I have offered up a pre and post meaurement using my Biomarkers 2000 impedance tester which is very accurate and gives a print-out showing muscle, fat, bone and water mass readings. A very good explanation is available here: http://tinyurl.com/What-Is-BIA

But if you have access to any device that will allow you to objectively measure your percent body fat and percent muscle mass, you are welcome to use that instead.

Now for the plan:

Maddy and I will be doing our readings today.  Then I will be doing the "before" BIA analyses  from my office on Tuesday from 10 to noon and from 5 to 6 pm. for $5. Anyone interested should call me at (949)360-1112 to schedule in those time slots.  Also, I will be doing "after" readings on Thursday, July 2nd,  at the same times.

Maddy and I were going to do a 10 day detox (http://drharriott.blogspot.com/2009/05/10-day-detox.html#links ) as the first part of this, but we have a backpacking trip scheduled for next weekend and so we will start the detox next week.  

In the meantime, we are going to develop meal plans and workout plansfor ourselves on a weekly basis.  Here is were collaboration becomes really key...  If everyone participating posts meal plans for one or two days, we can cross populate and no one person has to be so creative. Today, Maddy and I will develop our strategy and meal plans we come up with and I will post that later today.

Anyone else who wants to post their meal plans, or any other comments or suggestions, PLEASE CONTRIBUTE A POST!

Thanks, and good luck. Scoring:  Every one percent of fat mass that is reduced with a corresponding increase in muscle mass of one percent will equal one point. Now I know that I said we would not be using the scale to measure progress.  But weight is required as part of the body scan and a tie will be decided based on total pounds lost.

Good luck everyone!

Ed

Back Pain, Tylenol and the AARP

Well, the AARP almost got it right in their recent article about low back pain. 

http://www.aarpmagazine.org/health/the_back_story.html

They just missed it by thaaaaat much. Yes, we have a lot of back pain here in the U.S.  And yes, it can become symptomatic with some unforeseen simple maneuver that on any other day would be no problem but for some reason, on that day, at that moment, "Aaaagh!"

In the end, the author concludes that he doesn't feel like he has learned the trick to avoid back pain, but that he knows how to treat it when it does occur.  

It doesn't surprise me when I look at the expert they consulted: a Physical Therapist.  Of course the PT suggests Non-Steroidal Anti-Inflammatories (NSAIDS) and Exercise.  What else does she have? "I have a hammer, so you are a nail."   

I am not intending to slam PT's,  but come on now!  The story gives only passing mention to the significant role of obesity and stress and then fails to address how these can effectively be minimized.  Meanwhile, the whole article remains entirely mechanistic but describes our spine as a stack of pancakes. This analogy while useless in understanding the spine, does say a lot about why we find ourselves in this predicament, doesn't it?

And the PT would have you heating your back to soothe muscles after 3 days. Along with some more anti-inflammatories, I would imagine.  Interesting approach, but wrong. It is well understood that the acute inflammatory response lasts from 3 to 5 days.  But 3 days after an acute injury is just too early to consider applying heat to a new low back injury. If you want to soothe muscles, try a hot epsom bath and then ice after so that the tissues cool again before you go to bed. This will keep the temp well below that which could exacerbate the local swelling while still having the muscle relaxation effect you are looking for.  Then the ice will prevent any increase in inflammation that does result from continuing through the night.  This would be a wiser approach to deal with the acute SYMPTOMS.

But I have a better idea... Let's try a Chiropractic approach which deals with what your body does right while helping you to heal yourself, and do so more completely and more quickly and more permanently... We'll rely on your natural healing mechanisms to recover while we restore and maintain normal joint function and mobility with a low force adjustive technique.  And while we are working to restore function, we will manage pain and inflammation with natural pain relievers that don't increase your risk of stroke or gastric bleeds or liver damage or any of the other problems that NSAIDS are known to cause.

By the way, while we are speaking of NSAIDS, did anyone else see the coverage regarding Tylenol (Acetominophen) in the news yesterday? Apparently, people aren't aware that taking an extra Tylenol here and there can lead to severe liver damage. http://tinyurl.com/KillerTylenol  Ha!  This is old news that I've been telling my patients for years. And yet so many people rely on daily NSAIDS to manage arthritis pain.  You want a natural alternative that is effective but won't kill you?  Check this out: http://www.youtube.com/watch?v=TE5ff6f3LWQ.

Anyway, I got off track with the anti-inflammatories because I was pointing out that the real answer to avoiding back pain is to avoid avoiding pain altogether.  Pain is not your enemy.  We need to stop fleeing disease and start pursuing health instead. Health is all there is.  There is no disease, just a loss of health.  And Americans continue to throw it away, day by day, Motrin by Motrin until there is no health left.

At some point, you know, deep in your heart that the Tylenol and the Motrin won't work any more. Is that when you are going to start pursuing health?  Just so you know, this is what I do.  Chiropractors don't "crack backs". Chiropractors teach you how to modify your lifestyle so that it is congruent with a long, productive and healthy lifetime. And with every specific chiropractic adjustment, your chiropractor allows your body to refresh and renew its own  strategy for dealing with the daily physical, chemical and emotional attack that comprises our existence.

If you don't have a chiropractor, you should go find one right now and try Chiropractic and reclaim your health.  Health is real and it is something you can do something with. But you can't escape disease. Your fear is real, but the Boogie Man isn't really there.  

Occasionally I'll hear someone say that he is afraid to see a chiropractor because then he will have to see the chiropractor for the rest of his life...  and I have to chuckle. I say, "No, you got it all wrong. You'll be running from doctor to medicine to surgical procedure to avoid dreaded disfunction, disease and death for the rest of your life. Or, you will enjoy the benefits of chiropractic care in your aggressive pursuit of the best of  your life." You will always have that choice.

100 Year Life PLUS!

We just heard recently from Obama's HHS cabinet secretary that Medicare will be kaput by 2017 at the current rate of depletion.  And Obama is interested in getting healthcare reformed and actually going after true HEALTHcare, for a change.  

Well, chiropractic is a big piece of that picture.  And I will elaborate on why that is at another time, but I wanted to tell you now that I have long been an advocate of professional partnerships between provider disciplines.  I use nutrition in my practice for my patients, but I happen to think that once in a while, I need some nutritional advice from someone who's life passion is nutrition.  I once had an allergic skin reaction that I could have tried to treat myself, but an acupuncturist helped me deal with it and I really responded incredibly well.  I exercise, but you know what?  My workouts are more therapeutic if I have them tweaked by a professional trainer once in a while.  The healing touch of a therapeutic massage is incredibly valuable and as much as my spouse is willing, she is no masseuse. And who can heal if their thinkin' is stinkin'?  I know better than to counsel myself (LOL). And I am not an opponent of medical doctors.  I believe that an MD should be part of the team as well, as long as he/she recognizes that healthcare is critically important and that medicine alone is not healthcare - it is sickcare - specifically because an MD has nothing to offer you unless you are sick.

I am currently assembling a professional team of independent local providers that will be all be part of a 100 Year Life PLUS program that will be the true healthcare that YOU need.  And you will not have to choose between your child's college education or your health because I will put it together so that is affordable.  Stay tuned, folks because this is happening, right here in Southern Orange County!!

Chiropractic and Medicare - Solution or Perpetual Colloid?

The entire conversation about Medicare documentation brings up the basic conflict between Chiropractic and the realities of medical insurance.  The truth is that there are two types of chiropractic practice. One is a medical approach in which every patient is being treated for a medical condition through the correction of subluxation. The other is the chiropractic approach wherein the only condition being addressed is subluxation so that healthy function can be optimized through the release of a person's inborn capacity to heal through natural healing processes. No, I am not a stump thumping straight, quite the mixer actually.  But then again, I'm not opposed to medical care just because I am a chiropractor, either.  I just prefer to stick to what I was trained in and leave the heroic chemical infusions and surgical excisions to the boys and girls in the white coats. 

No, the problem that I see is that Medicare (and all insurances for that matter) are, first and foremost, vehicles to finance the delivery of symptomatic medical care.  But there were enough people who wanted a holistic approach, that their cries for alternatives eventually could be ignored no longer. These people realized that non-medically focused care when applied to all the rest of the people who weren't desperately sick yet, could bring about a greater level of health and function in our society than what was erroneously being called "health care". And these people, convinced that they were never going to let themselves get sick that way, insisted that the monies that they were paying into the sick care system should be redistributed in a way that could help to pay for these alternative approaches as well, among them chiropractic. 

But the powers that be, would not let go of their insistence that the medical care monies were for medical care.  So, legislators eventually stepped in to resolve the impasse by observing that chiropractic care works perfectly well in a medical context.  After all, look at how well that sprain/strain did without a medical doctor even involved. See, so let's let chiropractors have a crack at these medical conditions.  But of course, we won't let the chiropractors diagnose anything but musculoskeletal diagnoses. And of course, when it comes to Medicare, we won't pay the chiropractor to examine, diagnose, image or anything other than manipulate.  

And so, the golden 80's came to pass when the square chiropractic peg was legislatviely jammed into the round medical insurance hole, and chiropractors were allowed into the previously exclusive medical billing processes and it was like a kindergarten class in a candy shop... their faces were just smeared with sugar schmutz from ear to ear.  And the medical community hated it.  The money never amounted to anything real significant but the menace had to be contained nonetheless.  And so they decided that the chiropractic profession should be forced to accommodate the billing processes that equated every procedure to a medical diagnosis or else they should be sent back to their pre-inclusion days of cash only practices.  And with the promise that they were going to be paid from the same coffers as the medical doctors, teh chiropractic profession happily did whatever they had to do.  

But in the real medical world, there is no room for "art".  There is no room for "feel". So, in reality, the chiropractors continued to practice chiropractic, but they started to bill physical medicine. If a diagnosis is what they wanted, then by God, a diagnosis is what they would get. Fast forward to today where we find ourselves at another crossroads.  We are being called out on the carpet not based on our results.  We still rank huge in patient satisfaction and outcomes.  The dollars spent on chiropractic care are still spit in the health care bucket of water. No, we are being taken to task because we insist on practicing chiropractic and not physical medicine.  

In my opinion, this doesn't come down to a question of who are the good guys and who are the bad guys.  That is way too simplistic.  What we need to decide is whether our government wants to pay to provide chiropractic and medicine or just medicine.  We are not medical doctors.  We will never be medical doctors.  Let's just lay the cards out and let them fall where they may. Chiropractic will not disappear because insurance doesn't pay for it. But to try to continue to deliver chiropractic in a medical model is not doing the medical community any good, the chiropractic community any good nor the patients any good.  And in the end, Medicare is just another medical insurance company that is going broke.  The problem is that this particular insurance company has the force of the Federal Government behind it.  And this company is using public money and can legislate whatever it wants if it waits until things get desperate enough.  I'm just not sure that I am going to allow myself to get desperate along with them.  How about you?

Medicare Explanation for Chiropractors

Sage Medicare Advice from an Old Chiropractor

aka

Chiropractic Rules of the Medicare Road

First question: Enrolled vs. Not Enrolled

When a chiropractor graduates from college, the first thing he needs to work on is getting his license to practice.  Next, he needs to get enrolled in Medicare.  Why?  Because it is against Federal Law to treat a Medicare beneficiary unless the treating doctor is recognized by Medicare as a provider and they only recognize providers who have enrolled and been approved through their credentialing process.  So, since it would be a Federal crime for anyone uncredentialed to provide medical care to a Medicare beneficiary, unless you are planning to send anyone over 65 years of age down the road to another doc, you have to enroll or you will inevitably end up violating federal law.  Period. Furthermore, if you haven't billed Medicare in over 18 months (you'd have to verify that number), they will drop you as a Medicare approved provider and you will have to re-enroll all over again to restablish your status.

Next question, Participating or Non-Participating

Isn't that the same question as enrolled or non-enrolled?  No.  A participating provider (PAR) is one who will accept assignment of the patient's Medicare benefits for covered services. What this means is that when the covered Medicare patient comes in, you will accept their co-insurance  will bill Medicare for the total amount and then wait for Medicare to reimburse you the balance of the Medicare approved rate later.

A non-participating provider (NON-PAR) is one who chooses to have the patient pay the total Medicare approved rate for the covered service at the time services are rendered and will then bill Medicare for the total amount and let Medicare reimburse the patient Medicare's portion of the Medicare-approved rate for the covered service.  

An important thing to know... a NON-PAR can choose, on a claim-by-claim basis, to accept Medicare assignment and act as if he were a PAR,  taking the patient's co-insurance as partial payment from the Medicare-covered patient at the time of service and Medicare will then send the NON-PAR the balance of the Medicare approved rate later on. This is choice is indicated by checking "YES" in  box 27 on the CMS1500 form that indicates that the provider "accepts assignment." 

So, if I can be a NON-PAR but act as a PAR, why would I consider agreeing to be a PAR?  Well, for one, you get on Medicare's provider list. Woo-Hoo!  What a great marketing tool that is (he said sarcastically).  Also, the medicare approved rate for PARs is about 15% higher than the rate for NON-PARs who opt to bill as accepting assignment. 

Is there any benefit to being NON-PAR? Well, as a NON-PAR who requires full payment at the time services are rendered (in other words, a NON-PAR who does not accept assignment), you can charge more than the Medicare approved PAR rate up to a "limiting charge" which is about 15% higher than the PAR approved rate. This sounds a lot better.  BUT (notice the big but), the rate charged to the Medicare patient must be no more than the lowest rate offered in your office, including any time-of-service discounted rates.  

Covered Services Vs. Non-Covered Services

The Medicare laws only deal with covered services.  In a chiropractor's office, that is simple.  Or at least it should be.  That is because the inclusion law which allowed for Medicare reimbursement for chiropractic specifically allows only for the reimbursement for the adjustment to the spine to correct a subluxation.  So, the only covered CPT  service codes are 98940, 98941 and 98942.  

• No, extra-spinal manipulations are not covered services. 
• No, exams are not covered services.  
• No, x-rays are not covered services. 
• No, physiotherapies (like electric stim, ultra-sound, massage, myofascial release, manual therapy, exercise therapy, neuromuscular rehabilitation, etc.) are not covered services.
  

The only procedure provided by a chiropractor which are covered under Medicare Part B is manual adjustment or manipulation of the spine. Simple, right?  Well, almost.  The truth of the matter is that even that is a covered service only for two select segments of our population over the age of 65 years.  For every other single person on the planet, there are no Medicare covered services at all which are provided by a chiropractor.

The first segment are those seniors who are enrolled in Medicare Part B, and pay a monthly insurance premium to Medicare and only after meeting an annual out-of-pocket deductible. That's right... Medicare Part B is a just a government insurance policy that has a provider panel of particpating doctors, has a $135 annual deductible, a 20% co-insurance, and a fixed monthly premium of $96.40.  If the patient is not enrolled, then they are not covered.

The second segment are those seniors who are enrolled in a Medicare Part C, 3rd Party HMO policy administered by an HMO (like Kaiser Permanente's plans, or some other HMO product) that the chiropractor is independently contracted with.

So, in summary, covered services are 98940/1/2 delivered to Medicare Part B enrollees and Medicare Part C enrollees who selected an HMO Company that the provider has contracted with.

Medicare Provider Obligations

Well, a lot of that is described above, at least indirectly.  But, I will spell it out here... As an approved/enrolled Medicare provider...

1.  You have to provide documentation of your care that meets Medicare guidelines. That is beyond the scope of this blog, but Googling the term "Medicare PARTS" is a good starting point. You should also consult your state chiropractic association.

2. You must bill Medicare for all covered services rendered. If the covered service is medically necessary, you should include a code modifier AT to indicate that this service was delivered under an Active Treatment plan and thus should be reimbursed according to the Medicare policy.

3. You must notify the patient in advance of treatment if their covered services will be denied reimbursement by Medicare by having them complete and sign an ABN form, the Advanced Beneficiary Notice. When billing Medicare for a covered service that will be denied as maintenance care, you must put a code modifier "GA" to indicate that an ABN form is on file. More on that below...

4. You must collect the annual deductible from the patient and thereafter, whatever the patient's financial responsibility is for each visit. Unilaterally reducing the patient's financial obligations under the Medicare rules is considered Medicare fraud, a Federal crime.

5. You may not charge less than the Medicare approved rate unless you are also making this rate available to all of your patient base. To offer special bonuses, gifts, discounts or other incentives greather than $10 in value is an inducement to seek reimbursible care and is considered Medicare fraud.

6. You may not charge more than the respective Medicare PAR or NON-PAR approved rate (when filing as "accepting assignment") or more than the "Limiting Charge" (when filing as "NON-PAR not accepting assignment").  Overcharging is considered Medicare fraud.

7.  Medicare considers services delivered on a maintenance, palliative or non-restorative basis non-medically necessary and thus billing these covered services as medically necessary is considered Medicare fraud.  To make sure that everyone recognizes this distinction overtly, Medicare requires that chiropractors add a modifier "AT" to each billed covered serviced when it is provided in the context of a medically necessary care plan.  "AT" stands for Active Treatment. On the other hand, providers are still required to bill non-medically necessary, but  covered services. But you must drop the "AT" ,  modifier.  You are also supposed to an ABN signed and then you'd  ad a different modifier, "GA" for covered services that are delivered under maintenance care for which an ABN is on file.  The only time a provider can avoid billing altogether is when an ABN is fille out and the patient chooses Option 2.  

Just Give Me The Bottom Line...

All this talk about federal crimes is enough to get a person nervous.  And I hate to admit this, but it has taken me about 7 years to finally get this boiled down, so let's just say I've been nervous for a while. Below are the basic guidelines that I recommend to keep you on the straight and narrow...

1. Enroll: Enroll in Medicare or send everyone over 65 to another office.  Once enrolled, decide for yourself whether you want to participate or not.  The implications are not that significant in terms of your provider obligations so just pick the one that sounds better to you.

2. Document: Learn how to document in compliance with Medicare guidelines. Consider it your obligation to your patient, yourself and your profession.  Just do it right.

3. Intake Paperwork: Add a "Medicare Coverage" Statement: Include a signed acknowledgement in your standard intake paperwork that every patient signs that says that they understand the Medicare pays according to legislated rates only for adjustments to the spine for the correction of subluxation  for Medicare Part B enrolled patients and that payment for any other services are the financial responsiblity solely of the patient.

4. Active Care: If a Part B enrolled patient (Or Part C if you are contracted with the respective HMO) comes in with a new complaint or a re-ocurrence or flare-up of a chronic complaint, document the case properly with an established care plan, collect the patient's portion as appropriate for your provider status, and then bill Medicare with the "AT" modifier.

5. Maintenance Care: If a Part B enrolled patient  (Or Part C if you are contracted with the respective HMO) comes in on a regular basis for maintenance or just to keep from getting worse, inform the patient that this approach is not covered by Medicare, have them complete an ABN form, collect the total fee from the patient in accordance with the allowed PAR or NON-PAR rate or Limiting Charge imposed by Medicare, and then bill Medicare with a "GA" modifier.  If the patient, in filling out the ABN, chooses "Option 2", this is the only instance wherein the provider does not bill Medicare.

6. ABN Forms: Don't get confused...  This is only for covered services and only when they are going to be denied as maintenance care. Some docs think that if they have every Medicare patient complete an ABN form on the basis that they are using it to explain to a patient that non-covered services are not covered, then maybe some patients will choose option 2 and save them the trouble of billing Medicare for all services, including the covered services.  Don't fall for this mistaken line of thought.  In an audit, this will be percieved as inappropriately using an unnecessary form for the express purpose of tricking the patient into electing to deny himself his due benefit.  

7. Don't Bill Medicare for Non-Covered Services: Lastly, don't bill Medicare for non covered services.  They won't pay and it just complicates things. Bill Medicare for 98940/1/2  performed on Medicare Part B enrollees only. If you are a contracted provider with an HMO that has a Medicare Part C plan, then bill 98940/1/2 for those patients also.  Services beyond 98940/1/2 for these patients as well as all services provided for any other patients should be withheld from any Medicare billings and be paid for by the patient at the time of service.

8. One Important Exception to #7: Keep in mind that in very rare cases, a secondary policy may pay for services that Medicare does not cover. So Medicare has a requirement that, at the specific request of the patient, the provider must bill Medicare for all covered and non-covered services so that the billing information may be forwarded for possible compensation by other 3rd party insurance policies. When billing for non-covered services, you should add a "GY" to indicate that this is a service that Medicare does not cover.

Let's sum up the critical points one last time...

• Medicare only covers adjustments. All other services are non-covered.
  
• Medically non-necessary adjustments will be denied. (no "AT" modifier = no "Active Treatment" = non-restorative, preventative or maintenance) 
  
• ABN is only for adjustments that will be denied, if you have an ABN (which you'd better have in this case) then you would bill with "GA" modifier. 
• Never need to include non-covered stuff in ABN forms. 
• No need to bill non-covered stuff to Medicare at all, ever, unless patient asks, then you have to bill everything. 
• No need for ABN unless maintenance care, so don't use to try to get out of billing for covered services. 
• And non-covered services can be charged on a patient pay, cash-basis without any notification required to Medicare.
• This ties it up for me... Oh yeah, and treating a Medicare covered patient ifyou are not enrolled in Medicare is illegal - No opt out available for chiropractors.

That is about it.  I think that short of proper documentation, and a more general discussion about whether chiropractic belongs in Medicare, this about covers Medicare billing. If you have any questions, please contact me at drharriott@gmail.com.  I present this not because I am an insurance or a Medicare expert, but because, like you, I need to know this and why not share what I learn.

Have fun, at least until Medicare folds (currently projected for 2017) 

Mission Viejo Chiropractor Offers More for Less

In Mission Viejo, Dr. Ed Harriott operates Mission Viejo Chiropractic (the practice relocated from the adjacent city of Aliso Viejo and changed the name accordingly from Aliso Viejo Chiropractic to Mission Viejo Chiropractic) and Alliance Diagnostics.  Mission Viejo Chiropractic is a great resource for many area residents for chiropractic care, massage, motor vehicle injury rehab,  nutritional support and with the addition of Alliance Diagnostics, Dr. Harriott can now offer pre-employment physical exams, Commercial Driver's License physical exams and pain-free DNA testing for paternity, heredity, or child safety records.

Chiropractic is an integral part of a healthy lifestyle and any attempt to get or stay healthy will get a tremendous boost by having a licensed chiropractor on your health team.  Let's face it, maintaining optimal function requires purposeful effort and occasional guidance - both on tap in a competent chiropractor's office.

What sets Dr. Harriott apart is his professional focus on leveraging communications technologies in such as way as to keep his overhead, and thus, his prices lower than any other office in the area while maintaining the highest level of service. There is no other office that will let you see online all the appointments available and choose the one you want.  No other office has newsletters, weekly podcasts, blogs, and twitters without obtrusively pushing them on all it's patients.

Go to www.mvchiro.com to schedule an appointment for a free consult or an evaluation and first treatment.  If you mention that you read this offer on my blog, I will provide the exam and the first treatment for the cost normally charged just for a regular office visit.