WHAT IS “UNNECESSARY” TO MY PATIENT?

This questioning has to do with the article 14 of the Brazilian Code of Medical Ethics. Art. 14. Practicing or indicating medical acts that are unnecessary or prohibited by the legislation in force in the country. In the context, I prescribed a formula for optimization of thyroid hormones, which is not mine by the way. The components of the formula are beta-carotene, copper, L-tyrosine, vitamin A, vitamin C, zinc, selenium, vitamin B12, vitamin B6 and iodine. The “problem” was that this formula contains 300 mcg of iodine, which is an absolutely “normal" dose in our prescriptions as clinical nutrition practitioners. The argument was that since 1953 iodine was added to the cooking refined salt in Brazil  to prevent endemic goiter and now it is "unnecessary" as a supplement. However, Nutrition has greatly changed since. It is widely known that a fantastic revolution has taken place in the XXI century after the conclusion of the Human Genome Project (HGP)  in 2003 [1] notably in the field of Nutrigenomics [2] which, in clinical practice, makes Nutrition much more personalized, particularly if we have the patient’s gene nutrigenomics panel. We cannot totally rely on iodine added to the refined salt nowadays once quite a few people don’t add the referred salt anymore to their cooking - having the opportunity to choose from a variety of other salts, such as spiced salt, sea salt, Himalayan pink rock salt, salt flower, salt from seaweed, Kosher salt and, even for a few that have access to it, the sophisticated Maldon salt, loved by chefs and cooks all over the world. Never heard of it? Never mind. Just realize that we have quite a variety of options, let alone the enormous and surprising variety of spices and seasonings available which also add flavor to our food, such as rosemary, chive, parsley, coriander, dill, mint, basil, oregano, saffron, turmeric, curry, cardamon, star anise, cinnamon, ginger, nutmeg, paprika, chilli pepper, pepperoni pepper, black pepper, cayenne pepper, chimichurri, balsamic vinegar, apple cider vinegar, garam masala, dry garlic sprinkles, concentrated  red onion powder, an endless list of them. They are all there, wide available. So, we can certainly rely much less on the "1953 refined salt" for our daily iodine intake and we might just as well use iodine supplementation, if needed, very easily, prescribing safe doses referenced in the scientific literature [3].

ISN’T IT TRUE THAT THE "BURDEN OF PROOF" LIES ON THE ACCUSER?

In fact, known reference sites (such as the National Health Services - NHS of the United Kingdom) says that taking 500 mcg os less a day of iodine supplements is unlikely to cause any harm [3] and the upper tolerable intake levels (UL) for adults is 1100 mcg daily [4]. Also, if the formula had no name, would it have  brought up all this controversy about some iodine prescription? I wonder.

WHO IS THERE TO JUDGE WHAT IS UNNECESSARY FOR MY PATIENT?

As a clinical nutrition practitioner, shouldn’t I be the one that knows better what is necessary or not for my patient as far as nutrients are concerned, such as vitamins, minerals, amino acids and essential fatty acids? We made the oath when we got our diplomas that we would do our best for our patients and that’s what I do most conscientiously with my work. Before I prescribe, I order a whole laboratory evaluation of the patient’s nutritional, metabolic and hormonal status, particularly - in this case - the levels of TSH, free T4, free T3, vitamin A, copper, zinc, selenium and others that might influence the patient's thyroid function status. Also, I study my patient carefully and follow up his clinical and test results on a systematical basis to analyze the effectiveness of the treatment and check if there is something else I can do to optimize his/her health. Therefore, I feel it is my right to choose whether to prescribe iodine or not, selenium or not, or whatever nutrient I think will contribute to optimize his health.

ANYONE THERE TO SUPPORT ME?

I invite all medical doctors that feel pressured by some "rules" to support me. Rules that limit our freedom to act as we truly believe is the right thing to do as long, we are not going against what is considered "legal" in the normal sense of the word. Situations that expose us like the one I mentioned always cause a lot of stress and, in my case, it is closely connected to my father’s death. Most likely it was his time to die anyway, but, oddly enough, his last message to me was when he was told of what I was going through. He wrote: "Spiritually we have no age. I will always be with you”. I have the feeling that he predicted his own death. But, no drama. I promised you that this commentary would have a happy end. The happy end is simply that life carries on and we might be able to improve our position in the future as healthcare workers. Let’s join our faith and our honest believes to fight for a better practice of the real Medicine - that is, to help our patients to cure themselves. With love and glory.