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Archive for January, 2019

Vitamin D Deficiency. By Our January Student Pharmacist, Brayson Ramirez.

During the winter months here in Ohio it can be hard to get enough sunlight. The days are short and the weather is usually too terrible to wear shorts or a t-shirt. According to The New England Journal of Medicine, adequate sun exposure is considered direct sunlight to the arms and legs for five to thirty minutes between 10 am and 3 pm twice a week. The weather can be unpredictable, but I know I don’t go outside anywhere close to that much during the winter, even with only my face exposed.

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There are three significant factors that contribute to Vitamin D absorption, or lack thereof:

  • The first factor is skin tone; the darker the skin the harder it is to absorb the UVB rays needed to make Vitamin D.
  • The second factor is weight; the heavier a person is, the less likely they are to produce an adequate amount of Vitamin D.
  • Lastly, age is a contributing factor. Once a person reaches 50 years old, the body doesn’t produce Vitamin D at the same rate.

Rickets, osteoporosis, a weakened immune system, and general fatigue can be caused by a lack of Vitamin D. Each one of these complications is particularly harmful to older adults. Unfortunately, women are prone to bone density issues, such as osteoporosis, so they greatly benefit from maintaining a good level of Vitamin D.

The Centers for Disease Control and Prevention (CDC) reports that at any given time 10% of the population is Vitamin D deficient. In the study where they determined this number, the people they tested were from the northern areas during the summer and the southern areas during the winter. With that selection process in mind, the number of Ohioans during the winter who are Vitamin D deficient is most likely much greater than 10%.

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Taking Vitamin D without an official Vitamin D deficiency diagnosis is okay and recommended by many doctors, but you must make sure to not over do it. If you wanted to take Vitamin D if you know you are not getting enough sunlight, the recommended dosing for an adult is 800 to 1000 units once a day. Doctors commonly prescribe more, but they can run blood tests to have a better idea of how much Vitamin D their patients need.

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When you go to the pharmacy to get your Vitamin D supplement you will most likely come across many choices with many strengths. There will also probably be a Vitamin D2 (ergocalciferol) and a Vitamin D3 (cholecalciferol). Both types are very similar in structure and are safe to use. They are not quite equivalent though. Vitamin D2 originates from plants while Vitamin D3 is what animals, including humans, produce from the sun. Both types are eventually converted by the liver to the same chemical that is used in the body, but some studies show Vitamin D3 produces more of that useable chemical per dose and helps to maintain a higher level in the body. If you are currently using D2 and it is working well for you then there would be no reason at all to change it. When it comes to which one to use, I would pick D3, but if I went to the store and there was a significant cost difference or no D3 options I would go ahead and use D2.

Hopefully, this information can help you understand Vitamin D and why many people are trying to replace it through supplementation.

Continuous Glucose Monitors, a Pharmacy Perspective. By Our January Student Pharmacist, Brayson Ramirez.

Checking blood sugar with finger sticks throughout the day may not be the worst part of diabetes, but it is possibly the most well-known. Finger sticks always have discomfort associated with them and nobody likes to poke themselves to draw blood, no matter how small the sample. The ability to test blood sugar without having a finger stick sounds like a dream solution to a problem affecting such a large number of people. Continuous glucose monitors, or CGMs for short, are trying to offer this option.

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Recently a new product has come to the market and has been gaining popularity in this area, but why? Continuous glucose monitors have been around for a while, but lancets and test strips have not gone away. I wanted to take this chance to look at the continuous glucose monitors from a pharmacy perspective.

There are a couple of very important variables with CGMs that are commonly not considered or well-advertised. The first is the warm-up period of the monitor system. During this time, the sensors are not guaranteed to produce accurate data, so it would not be recommended to use those readings for insulin administration or glucose record keeping.

The second variable is the calibration of the sensors as recommended by the manufacturer. In order to have the most accurate readings, calibration is required. To calibrate a sensor, a traditional finger stick reading is required. In some cases, the calibration finger sticks may be even more poking and prodding than a traditional blood glucose testing schedule.

I went through some of the more popular CGMs and made a quick summary chart of their warm-up and calibration requirements along with their life span. The products listed do not include insulin pumps that can integrate with sensors to get glucose readings.

Chart 1

As you can see from the chart, the Freestyle Libre system is the only one that does not require the user to calibrate, so it is the most likely to reduce finger sticks. All of the systems require a warm-up period. Again, the Freestyle Libre does show a bit of an improvement in this area. It has a one hour warm-up time, but it has a sensor life of 14 days, so that warm-up time will be coming around less frequently.

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When it comes to accuracy with continuous glucose monitors and traditional blood glucose meters, it is very important to understand how each works. Blood glucose meters are basically taking a snapshot of your current glucose level. CGMs measure glucose levels with interstitial glucose that is basically leaking out of your blood vessels, as seen in the above image. Since the interstitial glucose is not a direct measurement of blood glucose, the values are more like delayed blood glucose levels. With this delay, CGMs are not the best in a situation where glucose is rapidly changing, such as a severe high or low glucose reading that you are trying to recover from. In those cases, finger stick glucose readings are going to be more accurate and potentially avoid an even more serious situation.

Continuous glucose monitors have been shown to produce better outcomes overall for diabetic patients due to their more constant monitoring, but it is still necessary to keep a supply of traditional testing supplies for emergencies or sensor malfunctions.

The DASH Diet. By Our January Student Pharmacist, Brayson Ramirez.

At this point, we are a little bit more than a week into 2019. Many people have made New Year’s resolutions and a large chunk of them most likely want to lose some unwanted weight. Weight loss is not a bad idea, but a lot of people do not know how to do it in a healthy way. Some believe eating less is the way to lose weight, but that can be unhealthy and even dangerous.

The best way to lose weight is through diet and exercise, but also keeping in mind what is reasonable and what one is individually capable of doing. Some progress is better than no progress. Some diet changes may show change, but some may just lead to a happier, healthier life.

I recommend focusing on the happier, healthier life and the rest will come with time.

The first place to start a dietary change would be with the DASH diet. This diet has been proven through multiple scientific studies to help lower or prevent high blood pressure and can also help with weight loss and diabetes. The focus of this diet is on foods that have always been considered healthy, such as fruits, vegetables, fish, poultry, and nuts. The DASH diet also tries to keep sodium, sweets, added sugars, and fats in moderation. By adjusting the serving sizes of each group, more nutrients can be ingested while limiting the harmful saturated fats, trans fats, and cholesterol.

Blood Pressure Monitor

To figure out your diet, all you do is check your daily calorie needs for your age and level of activity. Age, is of course self-explanatory, but activity level can be tricky. The DASH diet divides activity level into sedentary, moderately active, and active. Sedentary is only completing your activities to get through the day. Moderately active is walking 1-3 miles a day at a low speed. Active is considered walking more than 3 miles per day and some light physical activity. Females have lower calorie needs on average, as seen in this chart provided by the National Heart, Lung, and Blood Institute (NHLBI).

Chart 1 Calorie Needs

Making this change in diet too quickly can lead to some diarrhea and other uncomfortable problems due to the increase in fiber. Slowly adding a serving or two of vegetables, grains, or fruits each week to transition to the DASH diet can help limit digestive issues and make the change as comfortable as possible.

The hardest part to follow in the DASH diet is knowing the servings needed of each group and what counts as a serving. This is where the diet gets tricky. The NHLBI has a great chart that breaks everything down as shown here.

Chart 2 Food Groups

My advice on this concept is to check out the food groups listed and just try to stay around the top. Maybe try a couple of the meal ideas pre-made on the site or create your own with the recommended food groups. See if there are any meals you enjoy; if you do, start introducing one or two of them every week.

Hopefully, you could get to the point of an all DASH diet approved meal plan, but if you are at least choosing the healthier of two options then that is some important progress. Remember, some progress is better than none and if you are living a happier, healthier life that is most important.


For all my reference material and more information on the DASH diet. And for various resources to use in any dietary adjustments please visit https://www.nhlbi.nih.gov/files/docs/public/heart/dash_brief.pdf


Please Welcome Our January Student Pharmacist, Brayson Ramirez.


This month, we are joined in the pharmacy and lab by Brayson Ramirez, a fourth year pharmacy student from The Ohio State University’s College of Pharmacy. Brayson will graduate in May 2019 and will then take the test to become a registered pharmacist. Brayson will be with us throughout January, so please stop by and meet him while he is in the store. Show him the Plain City hospitality!

Here is what Brayson tells us about himself:

My name is Brayson Ramirez and I am in my last year of pharmacy school at Ohio State. I am from Mansfield, Ohio where most of my family is still located today. I am the first on my father’s side to graduate from college with any type of degree. On my mother’s side, my uncle was the first to attend college. My uncle went to Ohio State for pharmacy, as well, and graduated about 20 years ago. In that time, he has had a huge impact on my life personally and professionally. Growing up, I always looked up to my uncle and, after talking to him many times about pharmacy, I considered joining the profession.

One day when I was in eighth grade, my little sister, who I have always been very protective of, became very sick. She was initially a little sick with strep throat but that appeared to have gone away. She progressively got worse to the point that my mother looked at her once in the morning and immediately took her to the hospital. Some tests were run at the local hospital, but nothing was very clear. At that point, she was taken to Nationwide Children’s here in Columbus. It was determined that she was in diabetic ketoacidosis and that she was a Type 1 diabetic. My family had no idea what any of that meant. All we knew was that my sister looked horrible, could not do anything, and we were all very scared and helpless. One of the first people to stop by and visit my family was my uncle the pharmacist. He explained the disease to my parents and helped assure them that she was going to be okay. Hearing from my uncle provided relief we desperately needed and made me decide I wanted to be equipped with the same knowledge to be able to provide the same relief to others.

Many people came to talk to us over the next few days at the hospital and everything went by so fast, way too fast. In the chaos of the situation, my family felt ill-prepared to handle this disease we knew my sister was going to have to maintain for the rest of her life. We knew there were a lot of pokes and shots but there was no comfort or confidence. It was not until we visited our local pharmacy that we could feel empowerment to take control of the disease. The pharmacist there noticed every new prescription and took the time to show us in a more relaxed setting how each thing worked including how to monitor glucose, inject insulin, carb count, and what to do in situations where glucose was too high or low. At this point, my family was able to overcome our collective fear for my sister and I decided that I wanted to be the one to address situations like that in my community as a pharmacist.

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