Nutritional Advice from Laury for Mother’s Day!

Just in time for Mother’s Day, Laury, our holistic nutritionst is sending over her sound nutritional advice along with the happy holiday wishes!’

The Fit in Your Genes program nutritional focus is key to our success. The blood sugar  and hormonal stabilization are important strategies that work in both genders. However, women especially benefit from the normalization of blood sugar. Women are more prone to the issues caused by fluctuating sugar levels due to less lean body mass and higher visceral adiposity as compared to men. Both of these anatomical differences make the impact of blood sugar more prominent. In fact, among diabetic patients with heart issues, women tend to fare far worse than men. So, as you are celebrating, remember that a lot less sugar will give you a lot more health!

Meal Ideas

Breakfast

  • cottage cheese, berries, ground flaxseed, cinnamon, raw veggies
  • scrambled eggs, sauteed greens, sliced avocado
  • oatmeal, whey protein powder, ground flaxseed, cinnamon, nuts, almond milk

Snack

  • apple, almond butter
  • hummus, raw veggies
  • hard boiled egg, celery sticks

Lunch

  • mixed greens salad, avocado, grilled salmon or chicken, pumpkin seeds, olive oil & lemon dressing
  • lentil, cabbage & tomato dal
  • curry chicken salad on bed of mixed greens

Snack

  • homemade trail mix
  • orange slices and walnuts
  • healthy protein bar

The Fit in Your Genes Program uses medical foods validated at the Joselyn Diabetes Center (Harvard Medical School) to help our patients with weight loss and sugar control. When used in conjunction with sensible diet, results are truly remarkable. Our regimen includes supplements that help with cravings, and restore energy. Follow our posts, and learn about our exciting developments in addressing weight loss and metabolic issues in women (and, of course, men!).

Fit in Your GENES Spring Reset for Wellness

Now that the weather is finally improving, and the  spring flowers are popping up all over, all of us are looking to renew our energy, feel more vital, and lose the unwanted pounds of fat. At the Integrative Cardiology Center of Long Island, we are re-energized and inspired by the continued growth of the Fit in Your GENES program, and are excited to introduce you to our Spring Reset for Wellness!

Fit in Your GENES is a ground-breaking wellness solution to address altered body chemistry that leads to chronic inflammation, the root cause of heart disease, and many other chronic conditions such as hypertension, metabolic syndrome, dyslipidemia and obesity. The opportunity to develop a personalized, genetically-guided  lifestyle plan is now greater than ever. The Spring Reset for Wellness is building on the core features of the program to enhance and fast-forward our weight loss and wellness effort, including a special focus on naturally balancing hormones in women.

We are especially proud to have Laury Anderson, a certified holistic nutritionist, to join our practice. Laury brings a wealth of experience, and a tremendous passion for the “Food as Medicine” philosophy to help our patients get to their goals. She will be available for consults starting April 20th. 

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Laury Anderson R.N., M.A., NC is a Board Certified Holistic Nutritionist who  has a Masters Degree in Human Development, Specializing in Holistic Counseling and a Bachelor of Science in Nursing.  She is a graduate from Bauman College of Holistic Nutrition and Culinary Arts in Santa Cruz, California.  Laury has 20+ years of experience in the health field with an emphasis on holistic approaches to wellness, health education and preventive care.

“Food As Medicine” is the philosophy at the heart of Laury’s practice.  As a Board Certified Nutrition Consultant, Laury’s objective is to assist clients in optimizing their bodies healing power through education and implementation of a “food first” approach to health and wellness. 

Laury believes every person has a powerful and innate ability to heal.  The food we eat is not just food, but information for the body that helps us harness this healing power and help thwart disease.  Laury has additional diversified cooking skills, training and certification from the Natural Gourmet Institute in New York City.  She is a registered member of the National Association of Nutrition Professionals.

We are very excited to welcome Laury to our practice! Please, feel free to contact Kamini at 516-746-1103 for more information.

 

Are You Skinny Fat?

Obesity continues to be strongly associated with multiple chronic conditions, such as hypertension, diabetes, lipid abnormalities, and heart disease. It also strongly contributes to development of certain types of cancer. The rates of obesity are alarmingly high in young children and adolescents, and, unfortunately, continue to rise. According to the AHA/ACC and The Obesity Society Guidelines released in 2013, obesity continues to be defined as measurement of the body mass index, or BMI.  Using BMI, overweight is defined as BMI of 25 kg/m2 to 29.9 kg/m2 and obesity as a BMI of 30 kg/m2 . Current estimates are that 69% of adults are either overweight or obese, with approximately 35% obese. The estimated cost of obesity related complications exceeded $147 billion in 2008.

However, estimating obesity by BMI tells only part of the story. A muscular individual may have a BMI exceeding 30kg/m2, due to a much higher water (and weight) content associated with skeletal muscle. More relevant to the cardiac risk associated with obesity are the measurements of waist circumference. It is generally accepted that the waist circumference should not exceed 35 inches in women, and 41 inches in men. These numbers are 1-2 inches smaller for individuals of European, Asian, or Hispanic descent.

A fascinating and powerful concept in understanding obesity goes beyond  these numbers and involves a  body impedance analysis, or BIA. Using the BIA, a percent of fat deposited in the abdominal cavity (visceral fat) can be distinguished from a more superficial fat distribution. Only visceral fat is associated with elevated risk for heart disease. A 2004 study in The New England Journal of Medicine convincingly demonstrated that removing superficial fat, such as with liposuction, does not alter risks for diabetes or  heart disease. Unlike superficial fat, visceral fat may be present unseen in a skinny person, and increases their risk of insulin resistance and heart disease. The accumulation of visceral fat drives inflammation, contributes to oxidative stress, and disrupts hormonal and immune regulation.

The  diminish visceral fat, an anti-inflammatory diet, supplements, in combination with workouts (moderate intensity but consistent) work to reverse the inflammation, and normalize internal fat metabolism, and, thus, its distribution.  Unfortunately, in our appearance-based society, many fail to see that “skinny” does not always imply “healthy”. Quiet a few skinny people are in fact “skinny fat”, with deposits of visceral fat driving their sugar and lipids into abnormal range. Visceral fat also traps a lot of toxins, including so called persistent organic pollutants (POPs), and this exacerbates ongoing inflammation by disruption of nutrient absorption.

What should you do? If you have access to the BIA machine, often found in gyms or physician offices, consider getting a reading done. A functional medicine physician can perform the BIA, and review the report in conjunction with your blood work. This assessment, while relatively simple, is a crucial step in understanding your metabolic circumstances, and putting your personal genetic information in perspective.

 

Genetic Switches Play a Key Role in The Inflammatory Arthritis and Bowel Diseases

This blog post is the first in the series called “The Inflammation Age”. Follow the series to learn more about functional and integrative medicine approach to heart health, and the impact it may have on your health, vitality and longevity.

 

In the ground-breaking study, researchers at the National Institutes of Health identified DNA elements that function to turn on the genes responsible for chronic and debilitating inflammatory conditions, such as rheumatoid arthritis and inflammatory bowel disease. These powerful switches, called DNA “super-enhancers” are the key finding in unraveling the complexity of environmental-genetic interactions underlying inflammatory diseases:

“Identifying autoimmune disease susceptibility genes can be a challenge because in most cases a complex mix of genetic and environmental factors is involved. Genetic studies have shown that people with autoimmune diseases possess unique genetic variants, but most of the alterations are found in regions of the DNA that do not carry genes. Scientists have suspected that the variants are in DNA elements called enhancers, which act like switches to control gene activities.”

We have known for some time that inflammation is a fundamental common pathway that functions in development and progression of heart disease, stroke, heart failure and even cardiac arrhythmia, such as atrial fibrillation. The genetic “switches” are turned on by the environmental and toxic exposures, lifestyle factors (such as exercise, stress and nutrition) to usher in a cascade of events that eventually results in overt expression of disease. By the time these diseases and symptoms come to medical attention, the changes on a deeper, biochemical level, may have become irreversible, and even heritable. An emerging science of epigenetics and metabolomics is exploring these phenomena. However, even at such a late stage, integrative approach may be of benefit. Focusing on relationships of genetic factors and lifestyle and environmental exposures, and modifying the metabolic environment of the body, is a powerful strategy for prevention AND treatment of heart disease and risk factors.

The metabolic portal provides a unique and powerful solution in identifying and managing your inflammation, and its role on various body systems. Fundamentally, it provides a way to maximize your anti-aging opportunity. Many people mistakenly focus most of their effort on their appearance, whether it includes aggressive workouts and restrictive diets to accomplish weight loss, cosmetic procedures, or using supplements or diets endorsed by various celebrities. While some of these efforts will bear fruit, the long term, durable results are very unlikely. The true anti-aging effort involves intense, coordinated focus on fighting inflammation by identifying and correcting an individual’s metabolic disturbances. Once these corrections take hold, all else falls into place:2491-health-1100024705-10182013 the heroic efforts are not needed, the “yo-yo” weight loss/weight re-gain cycle stops, mood and vitality improve. There is just one catch: this approach requires commitment, persistence, and participation. In the next post in this series, we will explore how traditional and functional medicine models are different in their approach to chronic disease, and how you can find your wellness zone.

 

Join Me to Support American Heart Association Go Red For Women Campaign!

Join me to support American Heart Association  Go Red For Women campaign, and raise awareness about heart disease! Heart disease continues to be a number one killer of women. Major cardiology trials traditionally excluded women, and most of the treatments were validated and investigated in men. American Heart Association supports community effort to increase awareness of the impact of heart disease in women, and provides resources for much needed research into gender related differences in diagnosis and treatment. I am  very excited to bring this first event on behalf of the Integrative Cardiology Center of Long Island to my friends at Equinox of Roslyn,and my patients! Please, click here  to make a contribution to the American Heart Association Go Red For Women Campaign.

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New Year’s Resolution 2015: Find Your Inner Happiness

It is no secret to many of my colleagues and friends that exactly one year ago, I abruptly fell off my professional trajectory. I lost the battle I was fighting-trying to bring new and fresh ideas and a measure of fairness and accountability into a dictatorial academic establishment-and, pretty much, lost the war. The year that followed was a spectacular  ride, filled with new ideas, meeting great people, creating business ventures such as my integrative practice and a start-up company, and relentlessly forging ahead. I listened to my inner voice, and learned that self-doubt is a luxury that I cannot afford. I uncovered the confidence and focus I did not know existed, the clarity of vision, and the guts to convince others in its value. Ultimately, through these efforts, and the unwavering support  of my family and friends, I regained my inner happiness.

Yet happiness is an elusive concept. As the 2015 approaches, and many of us are making the New Year’s resolutions, the very idea of happiness often equates with external values and attributes, the material things, and is devoid of inner focus. This is poignantly expressed by Dr. Robert Oliva in his recent blog post “The Truth About Stress and Its Cure.”

The inner focus may be just what the doctor ordered to cure the pervasive stress, despondency and malaise experienced by many American physicians. One does not have to go far to hear their unhappy voices. Check out the community dialogue on Sermo.com, or a book by my former colleague,Doctored: The Disinlussionment of an American Physician“. There is no question that we are at the most significant inflection point in the history of medicine in this country. Physicians have been marginalized and turned into “providers”, and over the course of several decades, the health insurance corporate tactics enriched the companies while costing us trillions of dollars. Older generations of doctors, our mentors, spent too much time defining their happiness through external attributions, and acquiesced to the troublesome developments even though they were internally unhappy over a loss of autonomy, public trust, and income. The Accountable Care Act, while sorely needed and a very significant step in the right direction, only added to the unhappiness and disengagement already experienced by many.

My resolution and my wish for 2015 is for myself and my colleagues to cure ourselves by finding and growing our inner happiness. Go beyond your professional exterior, your titles, positions and degrees, and focus on listening to your inner voice. In every one of us, there are dreams, ideas and aspirations that hold the keys to fulfillment. The growth of inner happiness is critical to our survival as physicians, and is a catalyst for change from passive observers who are feeling victimized to masters of our destiny.

Happy and Healthy 2015 to all of my colleagues and friends! I want to hear your stories and suggestions on curing the American physicians.

 

Updates to the Fit in Your Genes Program

The Fit in Your Genes program is a remarkable, revolutionary program. Our first 20 participants are well under way in achieving their weight loss goals! The program takes advantage of the genetic blueprint that is unique to each individual. At the core of the program is a full sequencing determination of the genetic makeup responsible for your sensitivity to various types of exercise, macronutrients, nutraceuticals and supplements, and lifestyle measures. The program offers comprehensive testing to determine personalized approach to weight loss. This approach not only functions to keep the pounds off, but promotes wellness from within.

What would be the value of the genetic program in weight loss? After all, there is no shortage of diet and exercise advice. The use of dietary supplements is a booming business, totaling nearly $4 billion annually in the United States. The Internet is saturated with multiple websites, forums, and discussion groups that promote and endorse various products. Physicians, nutritionists, health coaches, and other professionals have created various diets, programs and approaches, some more beneficial than others. Fierce debates continue about merits of diet in various health conditions, including prevention of heart disease and cancer.  Yet, we are in the midst of the most significant epidemic of chronic illnesses. Diabetes, high blood pressure, and elevated cholesterol continue to affect younger and younger individuals. The American population continues to grow progressively more obese year after year. Despite multiple resources, and billions of dollars spent, the solution does not appear to be in sight.

The genetic program offers a unique opportunity. It is a chance to go back to the ground floor. To help you understand how the genetic program for weight loss may be of value, not just in losing weight but also in fostering wellness, consider this. Suppose you decide to build a house. You would ask an architect for a blueprint. The blueprint calls for specific details, provides standardized measurements, defines materials, and ultimately guides the construction. Of course, once the walls are constructed, you put on your personal imprint. This imprint may include your own color palette, choice of finishing materials, even landscaping. It is very common for busy developers to utilize nearly the same blueprint over and over again in construction, making adjustments for personalization or location. Yet, many of these houses, built from similar or identical blueprints, look and feel very different. Your genetic makeup is the blueprint that is guiding construction of your house of wellness and illness. The environment, lifestyle choices, interactions with food, toxins, exercise, medications and supplements all work upon this genetic blueprint to create your personalized imprint. And it is this imprint, the phenotype, or the external appearance is what we often seek to change. However, just as in construction, the external appearance changes do not change the blueprint. To enact a fundamental change, the one that would drastically change the entire house, one would need to take the blueprint into consideration, and act upon it. By determining your genetic blueprint for weight loss, you are enacting a fundamental change that leads to much more than an appearance change. It changes the entire house!

There are several components to the genetic program. The initial testing is carried out by obtaining a small sample of your cells. This is performed by swiping a Q-tip on the inside of your cheek. This sample is sent to be processed in a sequencer. The test result is available in about four weeks. While you are waiting for your test results, you will start with a detoxification phase of the program. Once you test results are received, a recommendation will be made for diet adjustments, exercise regimen, and supplement use.

Each individual starts with a unique blueprint, and the influences of lifestyle and environment on this blueprint are responsible for weight loss, weight re-gain, wellness, and illness. The impact of inflammation in promoting obesity, and related chronic diseases, cannot be overestimated. Thus, the genetic blueprint serves as a fundamental scientific basis for setting goals guiding the weight loss and wellness interventions. It is an objective starting point. The nutritional, exercise, and nutraceutical components of the program are directed to manage much more than the weight loss. The goal is to control inflammation and pro-inflammatory conditions that interfere with weight loss, promote weight re-gain, and diminish organ reserve.

 

Many of our participants are passionate and determined to lose weight and improve their wellness. We are here to help them every step of the way. Our patients success and safety are our primary concerns. The Fit in Your Genes program is a medically supervised program. It requires face-to-face visits with a licensed physician, and offers support through a team of health coaches and yoga instructors. During the detoxification, a virtual video visit is available for additional support. To assure our patient safety, we respectfully ask that patients abide by the following rules of participation:

  • Patients cannot participate in any additional programs if they already are enrolled in the Fit in Your Genes program. Enrollment in another program would preclude detoxification and personalized supplement selection. Patients may be eligible for the Fit in Your Genes program if they discontinue another program for at least two weeks prior to enrollment.
  • Patients taking their own supplements must present them for verification of compatibility with the supplements recommended by the genetic testing. If a full list of ingredients, country of origin, site of manufacture, authenticity, and purity of the supplements cannot be established, the supplements must be discontinued. The supervising physician reserves the right to request that any supplement be discontinued if its safety cannot be ascertained.
  • Patients cannot use additional substances, such as supplements, medicinal foods, herbs, or homeopathic remedies once the program commences unless such substances have been approved by a physician supervising the program.
  • The initial program fee includes a before and after consultation with the supervising physician, performance of the genetic test, and a detoxification kit.
  • The subsequent fees include supplements and nutraceuticals, health coach, and yoga sessions. The first health coach session is complementary to all program participants.

The quest for weight loss is an essential component of vitality and wellness. It is well known that overweight and obesity result in less productivity at work, disturbed sleep, inflammatory state, and early onset of chronic and debilitating diseases. The obesity is a state of chronic malnutrition that is fueled by inflammation, and it adds more fuel to the inflammation fire daily. Billions of dollars are spent annually to treat consequences of obesity and chronic diseases. Pharmacological treatments or drugs are mainstay of these approaches. There are even drugs for obesity, and bariatric surgery is available to help patients suffering from consequences of excessive weight. The genetic program offers an opportunity to address root causes of obesity and chronic diseases.

To Test or Not To Test: Clinical Issues in Genetic Sequencing

The sequencing of the human genome, completed in 2003, opened the doors to providing genetic information for research, and, most recently, made it available directly to the public. Availability of highly precise and efficient sequencers (such as the ones from Illumina) resulted in minituarization of the genetic information, making it available and affordable to look for single-nucleotide polymorphisms, or SNPs, and their association with various diseases. However, as illustrated by the story of the 23and Me, the path to making such information available on-demand is complicated by regulatory and ethical dilemmas. The role of genetic information in clinical decision making is uncertain.

Recently, the New England Journal of Medicine reported on the results of an opinion poll in a case of a hypothetical patient seeking genetic sequencing because of a strong family history of malignancy. The majority of the responders favored genetic testing (60%), with mixed responses as to the extent of such testing to be performed. The authors called for genetic consultations to be carried out by trained geneticists. However, in real-life clinical practice, the statistical and population information provided by such genetic consultations is simply not enough.

As a cardiologist focused on bringing the practice of functional medicine into traditional cardiology domain, I rely on several genetic tests for a variety of reasons. The decisions to test are highly individualized, and have to be made based on patient’s history, objective findings and preferences. In one case, a patient with a distant history of atrial fibrillation sought advice. After normal physical exam and normal echocardiogram, we opted to run a genetic test that may help to determine his risk of atrial fibrillation and stroke. His one and only episode of atrial fibrillation occurred previously while he was treated for hypothyroidism, and has not recurred. Thus, genetic results would be of value in determining if indeed an elevated risk of atrial fibrillation existed independently of hypothyroidism, a reversible condition that could cause atrial fibrillation when untreated.  Detection of a carrier state associated with an elevated risk of atrial fibrillation and stroke would  result in more aggressive surveillance, and, possibly, earlier  treatment.

The decisions get more complicated when genetic testing that identifies a predisposition or likelihood of a disease must be carried out in a context of early disease diagnostic testing. The genetic predisposition as well as early disease may be modified by environmental and lifestyle influences. A patient this week reported that her father died of a massive myocardial infarct in his 40s. How should we proceed? In addition to history, physical exam, electrocardiogram, echocardiogram and possibly a stress test, we can consider imaging for subclinical atherosclerosis, such as obtaining a coronary calcium score. Addition of genetic testing to gauge probability of early myocardial infarction and vascular disease independently of traditional risk factors may be of value if the calcium score is greater than zero. In such circumstances, once sub-clinical disease is identified, a patient who carries a genetic variant forecasting an increased risk of heart disease and its complications may benefit from more aggressive attempt at disease stabilization and risk factor reduction, with supplements, medications, and lifestyle changes. In contrast, for patients with a score of zero (identifying a situation with no discernible vascular disease), detection of a carrier state associated with an increased risk may prompt more aggressive screening, and even result in over-testing.

The applicability of genetic testing is limited by patient acceptance and insurance reimbursement. Many patients view genetic testing as delivering an irreversible verdict, a final “say” about disease and illness. Yet, in most instances, genetic testing presents an opportunity for a change, focused and early intervention, and a possibility for a lifelong commitment to prevention.

A Word About Supplements

The Dietary Supplement Health and Education Act of 1994  (DSHEA) has been an important and, of course, controversial rule released by the Federal Food and Drug Administration. After attempts to restrict supplement industry failed amid intense lobbying effort, FDA agreed to the proposal by Sen. Orin Hatch to provide guidelines for manufacturers and users of supplements. The bill was signed into law by President Clinton in 1994. The bill defines supplements as:

a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin, a mineral, an herb or other botanical, an amino acid, a dietary substance for use by man to supplement the diet by increasing the total dietary intake, or a concentrate, metabolite, constituent, extract, or combination of any of the aforementioned ingredients. Furthermore, a dietary supplement must be labeled as a dietary supplement and be intended for ingestion and must not be represented for use as conventional food or as a sole item of a meal or of the diet. In addition, a dietary supplement cannot be approved or authorized for investigation as a new drug, antibiotic, or biologic, unless it was marketed as a food or a dietary supplement before such approval or authorization. 
 

DSHEA required that supplement labels clearly reflect the ingredients, net weight, source of materials (including parts of plants), disclaimer that differentiates them from pharmacological drugs, and a safety disclaimer. Manufactures could put additional statements at their discretion.

The DSHEA drew criticism nearly immediately for not being restrictive enough. The fact that amount of vitamins or minerals in the supplements was not regulated prompted many to label them as ineffectual and wasteful.

It is true that many supplements have sketchy scientific evidence, and variations in their content make any attempt for evaluation difficult even when ingredients are the same.

At the ICCLI, our philosophy for supplement use is as follows:

-We will only recommend supplements that are manufactured domestically and are in compliance with the DSHEA.

-Supplements are purchased through our virtual dispensary from leading manufacturers that design medical grade formulations for use under physician supervision only. These are high potency formulations known to produce specified desirable effects in scientific studies.

-A detailed electronic prescription is generated individually for each patient, and is attached to their electronic medical record as well as available for personal record keeping. We encourage each patient to have their supplement prescription available for all of their doctor visits.

-A complete list of all active and inactive ingredients is available for all supplements, as well as information on their manufacturer.

-We ask that our patients sign an informed consent that explains uses and limitations of supplements.

Most importantly, the use of virtual dispensary allows Dr. Druz to pass her practitioner discount to her patients.

Feel free to contact us for more information. In further posts, we will explore use of supplements for various conditions, and highlight the most notable of the ingredients and how they can serve you on your way to optimal wellness!

 

 

Medication Safety is Top Priority for NIH

Despite scarcity of funds, NIH announced generous awards that would allow medication testing using human tissue chips. In this unique system, human tissue is arranged on experimental framework material  to mimick interplay of various organs in a body, and determine safety of drugs under development.

This represents one of many advances toward safety and tolerability of medications. At the Over 50 fair today, I gave a talk on the genetic testing for the cytochrome P450 polymorphisms. This system is responsible for processing nearly all of the drugs that are used in clinical practice. The lecture was well attended, and numerous questions at the end were reflective of  the intense interest drug testing and safety generates. The test is performed by swabbing a Q tip inside a patient’s cheek. Results are available in about 2 weeks. Over 280 medications can currently be assessed for safety based on personal genetic variability of the cytochrome P 450 system.

So far, the “med-tuning” using the personalized genetic testing for common alleles of the P 450 system has exceeded my expectations. In one instance, a patient of mine on multiple medications was found to be hypotensive. I stopped one of his blood pressure drugs, and his blood pressure improved. When the genetic testing results became available, the discontinued drug was the safest one for him! I now have the opportunity to readjust his medications so that he achieves optimal blood pressure and heart rate control using the safest medications based on his genetic profile. In another instance, I stopped a water pill for a patient who became dehydrated in a hot climate. Before restarting it, I tested this patient’s P450 system. The drug appeared to be safe for him, and no substitution was needed. He was counselled to maintain his fluid intake in warm weather, and to resume this medications.

The genetic testing for medication safety is an important piece of the medications selection puzzle, and allows a truly personalized approach. Of course, it does not shed light on possible effects (and side-effects) of medications under extenuating circumstances such as diseased states, dehydration, fever. The tissue chip research supported by the NIH will add significantly to the understanding of complex organ- medication interactions.

I encourage all of my patients on at least one medication to have a genetic test for safety and side-effects profiles. All of my patients receive a color-coded hard copy of their results to use as needed during doctors appointments or hospital admissions. Over 100,000 deaths occur annually due to medication toxicity, and the annual cost exceed 182 billion. Medicare and most major carriers cover the test. I negotiated a significant discount for the test for those of our patients not covered by insurance. This simple test, performed once, may be a life-saver!