Internal Medicine Of Southwest Florida Newsletter
In This Issue
Anitoxidants and Health
Vitamin B12 deficiency
A Recipe Loaded With Antioxidants
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Dr. Raymond Kordonowy MD
Dr. Raymond Kordonowy MD 
Have you been to my blog lately?  Recently the question of postmenopausal hormone replacement has been called back into question. 
Also please be sure to get vaccinated for influenza this season.

Finally, do you wish to become a patient? Learn what distinguishes my practice from the rest.  
Issue: # 17October/November 2012

Greetings!  Due to the summer political season and my participation in the Florida Medical Association annual Delegates meeting, I have been delayed in putting out a newsletter for our readership.  This newsletter is going to focus on nutrition. Nutrition is the cornerstone to optimal health. I have come to realize that most of us our eating a calorically dense but nutritionally depleted diet. As a lipid specialist I am dealing with the calorically dense part of the equation routinely (one of our lipid system's functions is to deliver energy/calories).  I find measurable nutritional deficiencies commonly in my practice. Deficiency is so common that I actually measure serum levels for both vitamin D and B12 levels when I perform complete physical evaluations. Now I can add a new test that conveniently measures another part of a person's nutritional status-the antioxidant level in your skin!
In the past I have written about vitamin D. Recently I have become aware of and have started offering a painless, affordable and reliable method to test a person's antioxidant status. Article one is about that technology and antioxidants. The second piece is about B12 metabolism and deficiency.
In keeping with my newsletter format, I will be offering another healthy recipe to consider in your kitchen. I will remind the readership that there is a fairly large list of recipes archived in the newsletters and you can always go the the archives section and look at the newsletter summaries to find those recipes.
A final comment, while the newsletters are for our entire practice, to date I have been the author of all articles, save Dr. Henricks piece on explaining our HIPAA compliant email service for our patients. This is why I have moved the newsletters to my personal website. I am informing the readership of this minor electronic change for clarification. The comments and information in the newsletters come from me and don't necessarily reflect my partners viewpoints (although we all do practice very similarly and we do collaborate in patient care routinely).
Antioxidants and Health 

Now In My Office We Can Measure Your Antioxidant Status 


Recently in the news and the medical literature there has been positive data correlating antioxidant intake and improved health. Oxidation is an inevitable outcome of burning oxygen, even in our human cells. This process is potentially harmful to our cells due to the release of free radicals which are unstable molecules that damage healthy cells. Free radicals contain at least one negatively charged electron which makes them chemical highly reactive. Antioxidants are positively charged molecules that combine with the free radical containing molecules, rendering them harmless  .

If the balance of free radicals exceed the amount of antioxidants the body becomes more vulnerable to degenerative disorders (From Foods That Harm and Foods That Heal, published 1997). Macular degeneration is now the most common cause of blindness in the United States. This disorder has been proven to improve (dry type) with improved antioxidant intake by either diet or supplements. The retinal specialist doctors recommend various supplement formulas such as the AREDs products and others. If you are presently supplement with these products you can now actually measure your antioxidant status to monitor your product's effectiveness and/or the need to supplement further-using the Biophotonic scanner.

Recently in the literature, research showed a statistically reduced incidence of heart attack in women that correlated with the highest level of dietary antioxidant intake. Also recently, data showed men's stroke rates were inversely correlated with lycopene intake (a potent antioxidant found in tomatoes/red pigmented vegetables and fruits). The more intake the men had the lower the rate of stroke in the time period studied.

As circumstances would have it, I recently became aware of and started providing a simple, affordable test that measures a person's antioxidant status. The ability to measure is what science is all about. This circumstance arose from my chance self introduction to Dr. Corey Howard MD from Naples Florida. Dr. Howard co-chairs the Florida Medical Association annual delegates meeting. As a delegate, I introduced myself to him and told him I practiced nearby.  He and I discussed the fact that we found our practices moving more towards Wellness (mine with Lipidology and his with lifestyle medicine) and he explained to me the availability of this new "life changing" technology.  He came to my office and showed the system to me. Following that I performed due diligence on this scanner and the company behind it and also behind another top notch vitamin/supplement line from this company known as Pharmanex.  

The technology involves something known as Raman Spectroscopy. This Nobel prize winning physics accomplishment proved that chemical structures have signature light reflective properties. A large pool of human antioxidants are stored in the skin. These antioxidants are known as carotenoids and represent a family of compounds including the beta carotene, lutein. Pharmanex owns a patented technology they call the Biophotonic scanner. This device projects a specific blue light frequency into the skin of the hand. Some of this light is reflected back to the scanner with a signature frequency that only carotenoids will create. The amount of reflected light returning then can be correlated to a quantity of carotenoids and thus a measurement score is reported. This technology has been verified to correlate well with a persons overall antioxidant score and has been validated in studies done on retina measurements to study antioxidants and macular degeneration treatment. Dr. Oz featured this technology on one of his programs. Apparently his score was great but the audience overall had a terrible average.  I am finding in my practice so far a wide range of results. The results tend to correlate with anticipated results based upon lifestyle and dietary histories.

The Recommended Dietary Intake for vegetables and fruits is 6-10 servings (2.5 cups of vegetables and 2 cups of fruit). Data also shows nearly no one can meet even this minimal recommendation (let alone optimal dietary intake). Data shows most people take supplemental vitamins. Recently for the first time a study has shown that for adult men, taking a multivitamin (Pfizer's Centrum) resulted in a measurable reduction in cancer compared to nonsupplement users. Multi vitamins vary by product but usually contain some but not all nutritional antioxidants. Now if you are supplementing you can measure whether what you are buying/taking is working or not. Furthermore, you can monitor your dietary changes to see if you are doing a good enough job.  Follow this link to see a list of high antioxidant foods. 

Smoking greatly increases your oxidation status (one of the mechanisms behind the cancer risk associated with this behavior). Sun exposure consumes carotenoids in the skin (this is probably why these antioxidants are stored both in the skin and the retina of the eye (light is a form of UV radiation and this is harmful to cells). Exercise can create higher antioxidant requirements. Weight loss/fat burning markedly increases free radicals and so person's dieting and losing weight need significantly more antioxidants. This is one of the reasons persons losing weight or seeing our Dietitian, Marcy Russo (Registered Dietitian), should consider taking additional vitamin supplementation. You can now monitor your needs and benefits of supplements with periodic scans.  

Pharmanex has a vitamin line that is scanner guaranteed, meaning that Pharmanex guarantees if taken as directed and if purchased using their Automatic Delivery Rewards program (ADR program) if your score doesn't improve at 1 and 2 months they will return your money. Using the ADR program also results in loyalty discounts over time as well as free monthly scans (they pay for your scan). The company actually will email you to remind you to get your score done. By getting the product delivered monthly you are guaranteed fresh product. Antioxidant supplements will degrade/age on the shelf and thus vitamins expire/lose potency over time after production.  All of the above discovery is why for the first time since I started offering vitamin supplements I have added a second supplier/vitamin line. I can't buy and offer the product at my office for less then the ADR program offered to persons buying in the program and thus I won't be supplying this line in the office.  Disclosure: I do receive partial revenue from sales of this product line. This also is true from Pure Encapsulations product sold in my office or from my website store.
 B12 Deficiency, A Common Issue
B12 structure Necessary For Blood and Nerve Function
B12 (cobalamin) deficiency is important to avoid. Humans cannot make this essential nutrient. It is found in calf's liver, sardines, shrimp, scallops and other animal meats.  It can be obtained from Brewer's yeast which is a non animal source.  It takes years of insufficient dietary sources to develop true deficiency. It is very common in true vegetarians after years of dietary restriction.There are several steps involved in extracting B12 from our food. We first need an acid environment in the stomach. Next we need something called intrinsic factor which is produced by a specific cell type in the stomach called parietal cells. The pancreas contributes a protein that must attach to the B12 complex in order to allow a very specific small segment of the small intestine known as the ileum to absorb B12. Any disorder or condition that interferes with any portion of this complex pathway can promote B12 deficiency. B12 is used in the formation of blood. Other cells including the nervous system utilize B12.  The liver stores B12 (as part of something called the reticuloendothelial system).
True B12 deficiency is when a serum level under 200 picograms per milliliter is measured. Relative deficiency is noted when a level between 200-400 pg/ml is measured. Most patients with relative deficiency have no significant complaints.  There are other lab tests that can be run to get further clues as to whether the low normal lab result is already interfering with B12 function/metabolism but I rarely order these tests. I find a moderately high incidence of relative deficiency in my practice, perhaps partly due to the average age of my patients. When this is noted, I recommend patients supplement and do so indefinitely in order to avoid true deficiency.  While people on average use only 6 micrograms of B12 daily, typically supplements come in 1000 to 5000 micrograms. After the storage system is fully restored we urinate any excess B12 that might be taken in. I have found liquid B12 to work the best (other than injections) but many patient do well with simple capsules. Sublingual preparations also work well. This vitamin is readily found over the counter. We do have various options available in the office using the Pure Encapsulations vitamin line. B12 is usually included in multivitams as well. As my prior article indicated, this doesn't necessarily mean the vitamins are well absorbed. Since the potential problems of deficiency can involve memory and nerves and since sometimes replacement may not correct damage already experienced, I recommend identified patients remain on supplementation indefinitely.  I monitor levels at least annually once I have proven their supplement is working.
B12 deficiency can be associated with a lot of various symptoms. Fatigue is a very common complaint in B12 deficiency, so is depression.  Tongue pain and loss of papillae is one physical finding of deficiency (called glossitis).  I have noted patients report muscle cramps when low B12 is found. Generalized small nerve damage called peripheral neuropathy can develop from low B12. Balance problems known as ataxia can be seen in B12 deficiency. Other neurologic symptoms if the problem goes on long or is severe can include frank psychosis (going nuts temporarily), delirium (altered mental status/sudden confusion) and even dementia (more long term confusion). Besides the central nervous system a much more common presentation of B12 deficiency is anemia (low blood hemoglobin) and even fragile red cells which can break up in the circulatory system. When cells break up in our circulation this is called hemolysis. Blood specialist known as hematologists often diagnose B12 deficiency when patients are referred for a diagnosis of anemia.
Blood testing can easily be run to measure B12. If an anemia is noted physician's will often then run tests to rule out nutritional causes of anemia which include not only B12 but also folic acid (folate) and iron deficiency.  As we age, we often develop less than ideal digestive function as well as reduced acid production in the stomach and this can promote B12 deficiency. Commonly prescribed medications known as proton pump inhibitors shut down acid production in the stomach. These medications are used to treat acid reflux, heartburn, ulcers and gastritis. Now we can buy these products over the counter; examples being Prilosec, Prevacid and Zegerid. Other acid suppressors include Pepcid AC and Zantac and these also are readily available over the counter as well.  Metformin,  which is the main medication used in Type 2 diabetes, has also been associated with B12 deficiency.
Do any of you remember the Dracula movies?  I recall the doctor character speaking of the dreaded "pernicious anemia". Pernicious means highly injurious/destructive and so in the movies that seems appropriate. As opposed to blood sucking vampires from the Dracula movies, medically pernicious anemia is attributed to B12 deficiency that is acquired due to a specific cause. The cause is antibodies against a particular enzyme found in specific stomach cells known as parietal cells. If a person has antibodies against this enzyme system then the enzyme doesn't function and this results in B12 not getting absorbed from the diet and into the body. Up until recently this form of B12 deficiency required injections (and sometimes it still does) because even if a tablet of B12 is given the patient may still not absorb the product. With today's liquid products and sublingual products often this form of supplementation can overcome this part of normal absorption and work.  The way to know this is simply to follow the patients B12 level after several weeks of supplementation and from time to time.
If you have had surgery to remove the ileum, you will invariably develop deficiency and thus injections of B12 will be prescribed as a preventative measure. Injections usually are done monthly.  Crohn's disease is a chronic inflammatory condition of the intestinal tract that often attacks the terminal ileum. It is not uncommon for this section of the bowel to required removal in order to control this disease. Other bowel associated disorders that can cause B12 deficiency include: Celiac sprue, pancreas insufficiency, inflammatory bowel disease and bacterial overgrowth of the bowel (which can occur in patients with divertuculosis).
 A Recipe Loaded With Antioxidants
Spinach/Mushroom dise A Simple Nutritious Vegetable Dish
This is a quick, simple but loaded dish. I recommend you use liberal amounts of balsamic vinegar at the end to give it a tasty punch. This is a great way to use up your spinach before it goes bad on you. Patients on vitamin K shouldn't have this dish. There are tons of variations of spinach salad but this one my wife, Margaret, and I "made up" in the kitchen recently.

1 Raw Onion, choice is yours for type, medium to large size

Fresh mushrooms, choice again is yours to type, 1-2 cups raw, sliced

Fresh Spinach, one package (4-6 cups). Cleaned, spun and well drained.

Walnuts; appx 1/2 cup, crushed or sliced

Small amount of olive or vegetable oil, Balsamic Vinegar.


Cut the onion quarters then into moon shaped, larger slices.

Heat 2 skillets. In the first under medium heat saute your walnuts until mildly browned. You may add a small amount of maple syrup or honey to add a natural sweet flavor.  When this is done shut off heat and set aside.

In second skillet under medium high to high heat coat the bottom of the pan partially with olive or vegetable oil. Add the onion and saute until partially clear. Next add your mushrooms and heat/stir uncovered until easily penetrable with a fork.  Quickly and almost immediately after adding spinach, shut off the heat. First though, add all the spinach, add liberally balsamic vinegar and some additional oil, if desired. Using a proper fitted cover for your skillet, quickly "toss" the contents in the heated skillet to mix everything together. Don't overcook the spinach. Add the walnuts, salt and pepper mildly, then transfer to a large serving bowl and serve.
I hope you find this newsletter informative and empowering. While this fellow Internist is happy to diagnose and treat what ails you, I also feel that Wellness and prevention (especially proper nutrition) will result in very cost effective Healthcare to this nation and my practice. Invest in yourself and feel good about it. The revolutionary ability to easily take a "snapshot" of your antioxidant status along with monitoring for anticipated nutritional deficiencies should result in improved quality of life. That is what Wellness is about.

Don't forget your flu shots this season. All of our offices are supplied and ready to provide this service for you.


Raymond Kordonowy MD
Internal Medicine Of Southwest Florida

A New Pneumonia Vaccine

The doctors of Internal Medicine of Southwest Florida now have available the new Prevnar 13 pneumonia vaccine. Recently it is being recommended in persons with certain medical conditions who have already had the long time available pneumovax vaccine. We are also offering the pertussis containing tetanus booster as well (Tdap).
Cut out as a reminder to discuss with your doctor.