Thursday, December 29, 2016

Vitamin D and Cancer

In a previous post from January 27, 2016  (, it was mentioned that there are associations between vitamin D deficiency and certain types of cancer. This post will explain a little bit more about them.

Regarding colorectal cancer, it was noticed about 2 decades ago, that there is more mortality from colorectal cancer in the northern and northeastern parts of the United States, the ones which receive less sunlight. This in itself is not enough to establish a meaningful association, however, it gave a starting point for research. Then, 2 studies showed that having levels above 30 ng/dL in the blood may reduce the incidence of colorectal cancer by half1,2.

With respect to breast cancer, a recent study found that postmenopausal women may get a benefit from having adequate vitamin D levels in the blood. The risk of developing breast cancer in this particular group of women was lower than in the same group of women with lower vitamin D in their blood3.

Finally, in regards to prostate cancer, it has been found that this cancer is also more common in regions with less sun exposure. In addition, lower vitamin D levels in the blood are related to more aggressive forms of prostate cancer. Last but not least, adequate levels of vitamin D may aid in the slowing of the progression of this type of cancer4.

More research is needed in order to confirm and strengthen these associations. In the mean time, it does not hurt to have adequate levels of vitamin D in the blood, particularly for people living north of the 30th parallel.


1. Serum 25-hydroxyvitamin D and colon cancer: eight-year prospective study. Garland CF, Comstock GW, Garland FC, Helsing KJ, Shaw EK, Gorham ED. Lancet. 1989;2(8673):1176-8.

2. Meta-analysis: longitudinal studies of serum vitamin D and colorectal cancer risk. Yin L, Grandi N, Raum E, Haug U, Arndt V, Brenner H. Alim Pharm Therap. 2009 30(2):113-25

3. Plasma vitamin D levels, menopause, and risk of breast cancer: dose-response meta-analysis of prospective studies. Bauer SR, Hankinson SE, Bertone-Johnson ER, Ding EL. Medicine (Baltimore). 2013;92(3):123-31

4. Association between serum 25(OH)D and death from prostate cancer. Tretli S, Hernes E, Berg JP, Hestvik UE, Robsahm TE. Br. J. Cancer 2009;100(3):450-4.

Marco A. Ramos MD

Tuesday, December 13, 2016

Documenting Malnutrition. Part 1

There are several types of malnutrition. There is protein malnutrition (kwashiorkor), calorie malnutrition (marasmus) and the combined protein calorie malnutrition. In our society, the most common form of malnutrition is the latter and it will be the one most used in the medical records. There are also several degrees of malnutrition, mild, moderate and severe) and they can be associated to an acute or a chronic process. The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines recommends that the diagnosis of malnutrition in the adult patient be supported by the presence of two or more of the following: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized edema, and decreased handgrip strength1. The degrees of malnutrition can be seen in tables, available online

Properly documenting malnutrition requires to have the discipline of always including in the history of present illness (HPI) and review of systems (ROS) a nutritional history. A significant percentage of the disease processes that lead to an admission of a patient to the hospital include a problem with food intake or weight loss. In addition to this, the physical exam can enable us to describe the loss of muscle mass, the loss of subcutaneous fat, the presence of edema and the decreased handgrip strength. The assessment and plan (A/P) should include a nutritional diagnosis (if pertinent) and its chronicity, degree of severity and type.

Lastly, once the diagnosis is established, a plan to deal with it has to be formulated. This plan could be a dietitian consult, a gastroenterology consult for a feeding tube, an interventional radiology consult for TPN vascular access, to cite some examples.


1. White JV, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identiļ¬cation and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-738.

2. Retrieved December 13, 2016

Marco A. Ramos MD
Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement