Patients today often are overfed but undernourished. A growing body of literature links dietary choices to brain health and the risk of psychiatric illness. Vitamin deficiencies can affect psychiatric patients in several ways:

• deficiencies may play a causative role in mental illness and exacerbate symptoms
• psychiatric symptoms can result in poor nutrition
• vitamin insufficiency—defined as subclinical deficiency—may compromise patient recovery.

Additionally, genetic differences may compromise vitamin and essential nutrient pathways.

Vitamins are dietary components other than carbohydrates, fats, minerals, and proteins that are necessary for life. B vitamins are required for proper functioning of the methylation cycle, monoamine production, DNA synthesis, and maintenance of phospholipids such as myelin (Figure). Fat-soluble vitamins A, D, and E play important roles in genetic transcription, antioxidant recycling, and inflammatory regulation in the brain.

Figure: The methylation cycle
Vitamins B2, B6, B9, and B12 directly impact the functioning of the methylation cycle. Deficiencies pertain to brain function, as neurotransmitters, myelin, and active glutathione are dependent on one-carbon metabolism
Illustration: Mala Nimalasuriya with permission from DrewRamseyMD.com

To help clinicians recognize and treat vitamin deficiencies among psychiatric patients, this article reviews the role of the 6 essential water-soluble vitamins (B1, B2, B6, B9, B12, and C; Table 1,1) and 3 fat-soluble vitamins (A, D, and E; Table 2,1) in brain metabolism and psychiatric pathology. Because numerous sources address using supplements to treat vitamin deficiencies, this article emphasizes food sources, which for many patients are adequate to sustain nutrient status.

Table 1

Water-soluble vitamins: Deficiency, insufficiency, symptoms, and dietary sources

Deficiency	Insufficiency	Symptoms	At-risk patients	Dietary sources
B1 (thiamine): Glycolysis, tricarboxylic acid cycle
Rare; 7% in heart failure patients	5% total, 12% of older women	Wernicke-Korsakoff syndrome, memory impairment, confusion, lack of coordination, paralysis	Older adults, malabsorptive conditions, heavy alcohol use. Those with diabetes are at risk because of increased clearance	Pork, fish, beans, lentils, nuts, rice, and wheat germ. Raw fish, tea, and betel nuts impair absorption
B2 (riboflavin): FMN, FAD cofactors in glycolysis and oxidative pathways. B6, folate, and glutathione synthesis
10% to 27% of older adults	<3%; 95% of adolescent girls (measured by EGRAC)	Fatigue, cracked lips, sore throat, bloodshot eyes	Older adults, low intake of animal and dairy products, heavy alcohol use	Dairy, meat and fish, eggs, mushrooms, almonds, leafy greens, and legumes
B6 (pyridoxal): Methylation cycle
11% to 24% (<5 ng/mL); 38% of heart failure patients	14% total, 26% of adults	Dermatitis, glossitis, convulsions, migraine, chronic pain, depression	Older adults, women who use oral contraceptives, alcoholism. 33% to 49% of women age >51 have inadequate intake	Bananas, beans, potatoes, navy beans, salmon, steak, and whole grains
B9 (folate): Methylation cycle
0.5% total; up to 50% of depressed patients	16% of adults, 19% of adolescent girls	Loss of appetite, weight loss, weakness, heart palpitations, behavioral disorders	Depression, pregnancy and lactation, alcoholism, dialysis, liver disease. Deficiency during pregnancy is linked to neural tube defects	Leafy green vegetables, fruits, dried beans, and peas
B12 (cobalamin): Methylation cycle (cofactor methionine synthase)
10% to 15% of older adults	<3% to 9%	Depression, irritability, anemia, fatigue, shortness of breath, high blood pressure	Vegetarian or vegan diet, achlorhydria, older adults. Deficiency more often due to poor absorption than low consumption	Meat, seafood, eggs, and dairy
C (ascorbic acid): Antioxidant
7.1%	31%	Scurvy, fatigue, anemia, joint pain, petechia. Symptoms develop after 1 to 3 months of no dietary intake	Smokers, infants fed boiled or evaporated milk, limited dietary variation, patients with malabsorption, chronic illnesses	Citrus fruits, tomatoes and tomato juice, and potatoes
EGRAC: erythrocyte glutathione reductase activation coefficient; FAD: flavin adenine dinucleotide; FMN: flavin mononucleotide Source: Reference 1

Table 2

Fat-soluble vitamins: Deficiency, insufficiency, symptoms, and dietary sources

Deficiency	Insufficiency	Symptoms	At-risk patients	Dietary sources
A (retinol): Transcription regulation, vision
<5% of U.S. population	44%	Blindness, decreased immunity, corneal and retinal damage	Pregnant women, individuals with strict dietary restrictions, heavy alcohol use, chronic diarrhea, fat malabsorptive conditions	Beef liver, dairy products. Convertible beta-carotene sources: sweet potatoes, carrots, spinach, butternut squash, greens, broccoli, cantaloupe
D (cholecalciferol): Hormone, transcriptional regulation
≥50%, 90% of adults age >50	69%	Rickets, osteoporosis, muscle twitching	Breast-fed infants, older adults, limited sun exposure, pigmented skin, fat malabsorption, obesity. Older adults have an impaired ability to make vitamin D from the sun. SPF 15 reduces production by 99%	Fatty fish and fish liver oils, sun-dried mushrooms
E (tocopherols and tocotrienols): Antioxidant, PUFA protectant, gene regulation
Rare	93%	Anemia, neuropathy, myopathy, abnormal eye movements, weakness, retinal damage	Malabsorptive conditions, HIV, depression	Sunflower, wheat germ, and safflower oils; meats; fish; dairy; green vegetables
HIV: human immunodeficiency virus; PUFA: polyunsaturated fatty acids; SPF: sun protection factor Source: Reference 1

Water-soluble vitamins

Vitamin B1 (thiamine) is essential for glucose metabolism. Pregnancy, lactation, and fever increase the need for thiamine, and tea, coffee, and shellfish can impair its absorption. Although rare, severe B1 deficiency can lead to beriberi, Wernicke’s encephalopathy (confusion, ataxia, nystagmus), and Korsakoff’s psychosis (confabulation, lack of insight, retrograde and anterograde amnesia, and apathy). Confusion and disorientation stem from the brain’s inability to oxidize glucose for energy because B1 is a critical cofactor in glycolysis and the tricarboxylic acid cycle. Deficiency leads to an increase in reactive oxygen species, proinflammatory cytokines, and blood-brain barrier dysfunction.2 Wernicke’s encephalopathy is most frequently encountered in patients with chronic alcoholism, diabetes, or eating disorders, and after bariatric surgery.3 Iatrogenic Wernicke’s encephalopathy may occur when depleted patients receive IV saline with dextrose without receiving thiamine. Top dietary sources of B1 include pork, fish, beans, lentils, nuts, rice, and wheat germ.

Vitamin B2 (riboflavin) is essential for oxidative pathways, monoamine synthesis, and the methylation cycle. B2 is needed to create the essential flavoprotein coenzymes for synthesis of L-methylfolate—the active form of folate—and for proper utilization of B6. Deficiency can occur after 4 months of inadequate intake.

Although generally B2 deficiency is rare, surveys in the United States have found that 10% to 27% of older adults (age ≥65) are deficient.4 Low intake of dairy products and meat and chronic, excessive alcohol intake are associated with deficiency. Marginal B2 levels are more prevalent in depressed patients, possibly because of B2’s role in the function of glutathione, an endogenous antioxidant.5 Top dietary sources of B2 are dairy products, meat and fish, eggs, mushrooms, almonds, leafy greens, and legumes.

Vitamin B6 refers to 3 distinct compounds: pyridoxine, pyridoxal, and pyridoxamine. B6 is essential to glycolysis, the methylation cycle, and recharging glutathione, an innate antioxidant in the brain. Higher levels of vitamin B6 are associated with a lower prevalence of depression in adolescents,6 and low dietary and plasma B6 increases the risk and severity of depression in geriatric patients7and predicts depression in prospective trials.8 Deficiency is common (24% to 56%) among patients receiving hemodialysis.9 Women who take oral contraceptives are at increased risk of vitamin B6 deficiency.10 Top dietary sources are fish, beef, poultry, potatoes, legumes, and spinach.

Vitamin B9 (folate) is needed for proper one-carbon metabolism and thus requisite in synthesis of serotonin, norepinephrine, dopamine, and DNA and in phospholipid production. Low maternal folate status increases the risk of neural tube defects in newborns. Folate deficiency and insufficiency are common among patients with mood disorders and correlate with illness severity.11 In a study of 2,682 Finnish men, those in the lowest one-third of folate consumption had a 67% increased relative risk of depression.12 A meta-analysis of 11 studies of 15,315 persons found those who had low folate levels had a significant risk of depression.13 Patients without deficiency but with folate levels near the low end of the normal range also report low mood.14Compared with controls, patients experiencing a first episode of psychosis have lower levels of folate, B12, and docosahexaenoic acid.15

Dietary folate must be converted to L-methylfolate for use in the brain. Patients with a methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism produce a less active form of the enzyme. The TT genotype is associated with major depression and bipolar disorder.16 Clinical trials have shown that several forms of folate can enhance antidepressant treatment.17Augmentation with L-methylfolate, which bypasses the MTHFR enzyme, can be an effective strategy for treating depression in these patients.18

Leafy greens and legumes such as lentils are top dietary sources of folate; supplemental folic acid has been linked to an increased risk of cancer and overall mortality.19,20

Vitamin B12 (cobalamin). An essential cofactor in one-carbon metabolism, B12 is needed to produce monoamine neurotransmitters and maintain myelin. Deficiency is found in up to one-third of depressed patients11 and compromises antidepressant response,21 whereas higher vitamin B12 levels are associated with better treatment outcomes.22 B12 deficiency can cause depression, irritability, agitation, psychosis, and obsessive symptoms.23,24 Low B12 levels and elevated homocysteine increase the risk of cognitive decline and Alzheimer’s disease and are linked to a 5-fold increase in the rate of brain atrophy.26

B12 deficiencies may be seen in patients with gastrointestinal illness, older adults with achlorhydria, and vegans and vegetarians, in whom B12 intake can be low. Proton pump inhibitors such as omeprazole interfere with B12 absorption from food.

Psychiatric symptoms of B12 deficiency may present before hematologic findings.23 Folic acid supplementation may mask a B12 deficiency by delaying anemia but will not delay psychiatric symptoms. Ten percent of patients with an insufficiency (low normal levels of 200 to 400 pg/mL) have elevated homocysteine, which increases the risk of psychiatric disorders as well as comorbid illnesses such as cardiovascular disease. Top dietary sources include fish, mollusks (oysters, mussels, and clams), meat, and dairy products.

Vitamin C is vital for the synthesis of monoamines such as serotonin and norepinephrine. Vitamin C’s primary role in the brain is as an antioxidant. As a necessary cofactor, it keeps the copper and iron in metalloenzymes reduced, and also recycles vitamin E. Proper function of the methylation cycle depends on vitamin C, as does collagen synthesis and metabolism of xenobiotics by the liver. It is concentrated in cerebrospinal fluid.

Humans cannot manufacture vitamin C. Although the need for vitamin C (90 mg/d) is thought to be met by diet, studies have found that up to 13.7% of healthy, middle class patients in the United States are depleted.27 Older adults and patients with a poor diet due to drug or alcohol abuse, eating disorders, or affective symptoms are at risk.

Scurvy is caused by vitamin C deficiency and leads to bleeding gums and petechiae. Patients with insufficiency report irritability, loss of appetite, weight loss, and hypochondriasis. Vitamin C intake is significantly lower in older adults (age ≥60) with depression.28 Some research indicates patients with schizophrenia have decreased vitamin C levels and dysfunction of antioxidant defenses.29 Citrus, potatoes, and tomatoes are top dietary sources of vitamin C.

Fat-soluble vitamins

Vitamin A. Although vitamin A activity in the brain is poorly understood, retinol—the active form of vitamin A—is crucial for formation of opsins, which are the basis for vision. Childhood vitamin A deficiency may lead to blindness. Vitamin A also plays an important role in maintaining bone growth, reproduction, cell division, and immune system integrity.30 Animal sources such as beef liver, dairy products, and eggs provide retinol, and plant sources such as carrots, sweet potatoes, and leafy greens provide provitamin A carotenoids that humans convert into retinol.

Deficiency rarely is observed in the United States but remains a common problem for developing nations. In the United States, vitamin A deficiency is most often seen with excessive alcohol use, rigorous dietary restrictions, and gastrointestinal diseases accompanied by poor fat absorption.

Excess vitamin A ingestion may result in bone abnormalities, liver damage, birth defects, and depression. Isotretinoin—a form of vitamin A used to treat severe acne—carries an FDA “black-box” warning for psychiatric adverse effects, including aggression, depression, psychosis, and suicide.

Vitamin D is produced from cholesterol in the epidermis through exposure to sunlight, namely ultraviolet B radiation. After dermal synthesis or ingestion, vitamin D is converted through a series of steps into the active form of vitamin D, calcitriol, which also is known as 25(OH)D3.

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Okay, short history lesson — don’t let your eyes glaze over. Have you heard of the 80/20 rule? It’s also called the law of the vital few and was originally called The Pareto Principle. It started way back in the early 1900s when Vilfredo Pareto discovered that 80 percent of the land in Italy was owned by 20 percent of the people. Am I making you feel like you are back in school? Stay with me!

Soon people saw how this rule played out in business. More often than not, 20 percent of your customers lead to most, or 80 percent, of your sales. Today the 80/20 rule has all sorts of cool interpretations.

To use the 80/20 rule for business, you focus on the 20 percent of your best customers who are giving you 80 percent of your sales.

To use the 80/20 rule to manage your time, you focus on the 20 percent of the things you do that really move the dial for you or your business. In other words, your highest-valued activities.

Here’s the kicker! When it comes to your health, you gotta flip the 80/20 rule and focus on that 80 percent. You know you can achieve a healthy lifestyle when the majority of your choices are healthy. See? It’s not rocket science, but it can really change how you think. 80/20 is a universal rule, and it applies to everything. Spend the majority of your time making the right decisions, and you will love your results.

It’s not about circumstances, it’s about choices.

A healthy lifestyle is achieved by the sum total of all of your choices. Losing weight, getting healthier or becoming more fit is not a quick fix or a gimmick; it’s the culmination of your habits and your daily decisions. This rule is about moderation. Yes, you can have that dessert. No, you cannot have dessert every night. Yes, you should work out most days. No, you don’t have to beat yourself up if you skip a day.

Always strive to have most — at least 80 percent — of your choices be healthy.

You know what’s so great about this rule?

You can use it for eating.
You know it’s challenging to eat clean all the time. Work parties, BBQs, cookouts, pot-luck gatherings, cocktail parties, restaurant temptations, travel… all those things make clean eating a bit of a challenge. But if you can work toward eating clean the majority of the time (lots of real foods from the produce aisle!), you are going to see a difference in your body and in how you feel. (Hello, energy, there you are!) If you go for portion control moderation more often than not, you can effectively manage your weight!

You can use it for exercise.
Yes, it’s easy to fall out of your workout routine when you travel, or you have family in town, or a rerun of  Real Housewives has you captivated to the TV, but get right back in the saddle and get back at it. Don’t let a break from your exercise routine become a break-up from exercise. Push toward that 80 percent. (P.S. Remember my two-day rule? I never go more than two days in a row without a workout. It’s my little game I play to keep consistent at least 80 percent of the time.)

It’s easy to remember.
When things are easy to remember, they are easy to do. Plus, you can easily turn this rule into a question to keep you on track: Are the majority of my choices today healthy? If they aren’t, start making some healthy decisions pronto. If they are, terrific! Better yet, put a Post-it note on your bathroom mirror to remind you each morning to make it an 80/20 day.

It’s a lifestyle rule, not a fad.
You know what I dislike about diets? People are either on or off diets. Diets come and go, and actually now people aren’t doing “diets,” they are doing “cleanses” — the same thing in many ways. The 80/20 rule is a lifestyle gauge. It isn’t a quick fix or a weird gimmick. You aren’t on it or off it. You just lean toward health. Each day try and get more of your choices to favor your health. Wake up tomorrow and try again. Take a nod from one of my favorite authors, Michael Pollen, who says, “Eat food, not too much, mostly plants.” Bingo, easy to follow.

You don’t have to be perfect.
Okay, I had a green smoothie for breakfast, my FitBit says I’ve walked 10,000 steps and it’s only lunchtime, I ate a salad for lunch with lots of veggies… I think it’s okay to eat this afternoon cookie.

Or, I ate a big muffin for breakfast. I am going to hit the gym after work and I’ve been drinking lots of water today, but I think I will skip the birthday cake for my coworker.

See how it plays out? You just lean toward healthy the majority of the time.

You can be human.
One of the funniest things about being a fitness trainer and health coach is other people think I only eat foods from the produce aisle and I never have a bite of chocolate or a glass of red wine or (gasp!) sugar. Yes, I probably lean more toward 90/10 with my healthy habits, but I do allow myself some room to enjoy indulgences from time to time. (Did someone say ice cream?) Let the 80/20 rule give you permission to sometimes just enjoy the things you enjoy in moderation. Don’t serve yourself up a giant helping of guilt and remorse with that small dish of ice cream or that cone. It falls into your 20 percent and it’s OKAY. Breathe.

You can save time.
You don’t have to weigh your food, count calories or do anything else that takes up time you don’t have. Maybe tracking every morsel of food you eat just doesn’t jive with your lifestyle or what you like to do. While tracking what you eat can be extraordinarily helpful, you don’t have to do it if you use the 80/20 rule. You know when the majority of your decisions are healthy and when they aren’t. Work slowly toward getting more of your choices into the healthy camp! I always suggest getting familiar with what portion sizes look like and then get good at eyeballing them. Bottom line, another way to describe the 80/20 rule when it comes to food is portion control.

It works.
I guarantee if you exercise on most days and eat clean most of the time, it will work. You will be at the weight you want to be at and you will be healthier. The 80/20 rule is a doable, healthy lifestyle plan that you can enjoy! Try it and let me know what you think. I’d love to hear from you. Drop me a comment below!

Joy Dubost, registered dietician and spokesperson for the American Dietetic Association

The science shows that overall, regular ingestion of vitamin C had no effect on the common cold, as far as in the incidence (or how common colds are). Now, most of these studies looked at people who took more than 2,000 mg of vitamin C, which is a very large dose.

The recommended dietary allowance, or RDA, is 75 mg for most adults, and 2,000 mg is the upper limit — you don’t want to go over that because you’ll have gastrointestinal distress.

[Vitamin C] does support a healthy immune system. So if you’re not getting enough vitamin C, you will be more susceptible to colds. If you are taking vitamin C while you have a cold, it could prevent complications such as pneumonia by boosting your immune system.

****

Dr. Mark Levine, chief of molecular and clinical nutrition in National Institute of Diabetes and Digestive and Kidney Diseases

For the average person, vitamin C supplements for colds don’t do much of anything, and I don’t recommend them. After I say that I like to explain why: There are a lot of trials on vitamin C and colds, of variable quality and people analyze these, so there are analyses of analyses.

You can take vitamin C to prevent colds, or you can take vitamin C once you have a cold to treat it. The treatment trials show a modest benefit. But the reality is in terms of that effect, I don’t think it has clinical meaning. In the prophylaxis trials — and prophylaxis means to prevent — the prophylaxis trials [show] in the average person, [Vitamin C doesn’t] prevent colds.

Our bodies are configured to keep vitamin C levels within a particular range… As you take in more vitamin C, the amount you absorb from each dose goes down. Then once it is absorbed and goes in the blood, there are proteins on the cell that bring vitamin C into the tissue, and those proteins can’t work any faster. Then the excess vitamin C is excreted through the kidneys.

Overall, I say eat more fruits and vegetables.

****

Dr. William Schaffner, chairman of the department of preventivemedicine at Vanderbilt University School of Medicine in Nashville, Tenn.

In terms of vitamin C for colds, we need to separate prevention from treatment. On the prevention side the studies are clearly divided. There are some studies that show that taking Vitamin C – usually in fairly large doses – provides some protection against the common cold. But there other studies that show no effect. There are studies of different sizes and quality on both sides of the conclusions. So we (as doctors) have not voted on that one yet.

But, I would say this: that the people who usually advocate taking vitamin C usually advocate taking it in fairly large doses. If you take vitamin C in fairly large doses you’re going to excrete a lot of it out in your urine. And if you’re dehydrated, that vitamin C is going to form little crystals, which can be painful. So make sure you’re drinking lots of water if you are taking vitamin C.

In terms of treatment – there’s no evidence that it shortens the course or reduces the symptoms. In other words, there’s no evidence that it makes your cold feel better.

***

Dr. Aaron E. Glatt, spokesman for the Infectious Diseases Society of America and professor of clinical medicine, NY Medical College in Rockville Centre, NY

The general answer is probably not a lot. Vitamin C has a checkered history in terms of some studies showing mild benefits, while other studies do not show benefits for upper respiratory viral infections like the common cold. On the whole, I don’t think that vitamin C is something people should be jumping to take beyond the regular dietary recommendations.

When you deal with any supplement and you are taking very large doses, it can potentially be problematic. There have been reports of complications and side effects from high doses of supplements, and studies have never demonstrated that super-pharmacological doses are helpful for any disease. In essence, by taking such large doses you are just potentially taking health risks and having an unnecessary expense.

I just tell people to have a normal diet, and drink a glass of orange juice or two if you like. I do not recommend taking high doses of any supplements.

***

Shelley McGuire, national spokesperson for the American Society for Nutrition and an associate professor of nutrition at Washington State University

What we know is that people who eat a lot of naturally occurring vitamin C in foods, do have a lower risk for the common cold. However when scientists isolate just vitamin C and do studies, they’re very rarely able to show vitamin C reduces the incidence (how often someone catches a cold) or the severity of a cold.

There is some evidence that people who are in stressful situations — and by that I mean people who are marathon runners, soldiers or people training in the arctic — may benefit from some sort of vitamin C supplementation in terms of incidence of their colds. That may be because their vitamin C requirements may be higher.

So it’s kind of a mixed bag. The problem with science sometimes is that we try to reduce these foods down to a specific nutrient and it’s probably way more complex than that. Nutrients don’t work in isolation, they don’t, they work with other nutrients.

Networking has long been recognized as a powerful tool for business people and professionals.  Knowing more people gives you greater access, facilitates the sharing of information, and makes it easier to influence others for the simple reason that influencing people you know is easier than influencing strangers.  The creators of LinkedIn, Facebook, and Twitter have built their empires on the presumption that their social networking tools help people build their networks and remain better connected than ever.  Does it follow, then, that social networks, by making connectivity easier, make leaders more powerful?

The answer is no.  Clearly, social networks allow you learn about other people you might never have known of otherwise.  On LinkedIn, you can build awareness of your products or services, join groups of people with similar interests, search for job opportunities, or look for people who might be qualified to fill a position in your company.  And Facebook enables you to find long-lost classmates or share with friends what you liked about a new film, what you saw during your trip to Venice, or what you ate for breakfast.

But these benefits of social networking, while valuable to some degree depending on how robustly you use these networks, miss the essence of what makes networking such a powerful tool for leaders and other highly influential people.  The research on power and influence shows that people who are well networked are three times more influential than people who aren’t.  But their power is based on the social capital they have developed in building relationships with the people in their network—and you can’t build sufficient capital with people by merely “friending” them on Facebook or accepting an invitation to connect on LinkedIn.

Network power depends on how strong your relationships are, on how much attention you command when you engage people in your network, and on how attractive you are as a member of other peoples’ networks.  If you are known as a source of deep expertise, for instance, and people can rely on you for expert solutions or creative ideas, you will be a more attractive network partner than someone who lacks that expertise.  If you know other powerful people and can access them whenever you need to, you will be a more attractive network partner.  Similarly, if you are in a position of authority in your organization and can make things happen, you will be a more valued network partner.  Finally, you will have more power in your network with the people you know best—with long-time colleagues, close friends, and others with whom you have developed mutual trust and respect.

It may be possible to build those kinds of relationships with people you meet on social networks, but it’s unlikely unless you sustain contact with them over an extended period, have meaningful exchanges with them, disclose a lot about yourself and learn much about them, and build the kind of trusting relationships that normally occur when you have worked with someone successfully over a period of time.

I have more than 500 connections on LinkedIn.  At least two-thirds of those connections are with people who asked to be connected with me and whom I’ve accepted even though I’ve never met them.  They might have been friends of friends or colleagues in my company whom I’ve spoken to on the phone but don’t know well.  Or they might be people who have read my profile and thought it would be useful to them to be connected to me.  In all these cases, my power with these people is limited by the fact that I have relatively little genuine social capital with them (and vice versa).

Networking can be a powerful tool.  It can enhance your ability to lead and influence other people—but only when the people in your network value being connected with you—and value you for more just being just one of the hundreds of people in their network.  The power of networking lies in how well they know you, how much they trust you, how much they gain from having you in their network, how frequently you communicate with them, and how many other powerful people there are in your network.

Social networks like LinkedIn are useful, but they are no substitute for direct personal connections and the kind of history you develop with people when they have known you for a long time, when they have learned to trust you, and when they have come to value the relationship.

The Medical Supplies Industry is essentially a growth industry. Value Line divides the group into Medical Supplies Invasive and Medical Supplies Non Invasive. Although many of these businesses have been around for quite some time, they are constantly seeking avenues of expansion, such as new products with next-generation technologies and overseas markets. Medical Supplies companies manufacture and distribute a broad range of items, from surgical and dental instruments to elective laser surgery equipment to orthopedic products. The two major classes of customers served are hospitals and doctors offices.

There are several strategies for members of this industry to optimize profits. Companies that supply low-tech items, such as surgical gloves and syringes, do not require substantial amounts of capital outlays. Profitability is dependent upon procedure volume, particularly in hospitals. Those with highly complex operations, including orthopedic and interventional cardiology device manufacturers, require extensive capital spending, and cash generation is vital to survival. Their products are high-tech, and ample research and development spending is needed to maintain a steady rollout of new offerings.

The Medical Supplies Industry is competitive. Primary drivers of demand are demographics and advanced, effective products. Large companies strive to manufacture and distribute top-quality products across a broad territory. Their smaller peers are more likely to specialize in a particular market segment, thereby optimizing operating potential. Typically, the stocks of the bigger players in this sector offer investors solid long-term growth and income potential. Small companies often rely on one or just a few very complex or specialized product lines, and their shares usually appeal to venturesome, risk-tolerant market participants seeking above-average appreciation potential.

Top- and Bottom-Line Influences

Medical Supplies companies are fairly well insulated from negative macroeconomic factors, since the need for treatments is rather constant. But, they are by no means immune to harsh cyclical downturns. In challenging periods, hospitals will attempt to delay purchases of the most expensive capital equipment. Too, during times of high unemployment, patients, with limited disposable income and dealing with rising health insurance costs or loss of coverage, might put off treatment for as long as possible. Those companies providing products and services for elective surgeries (e.g., laser, cosmetic) are vulnerable. Reduced procedure volume can hit top and bottom lines particularly hard. Too, manufacturers of orthopedic equipment often suffer in a weak economic climate.

Intense competition can significantly pressure operating performance, as well. This is evident, for example, in the ICD (implantable cardioverter defibrillator) and stent segments. Products that are not protected by patents are open to competition. Barriers to market entry can be somewhat easy to overcome. Commonly, competitors will develop improvements to items already on the market. Faced with more competition, companies will frequently cut prices on legacy products to hold on to business share and support production volume and net profit. Also, they might boost R&D spending to overcome any technology shortcomings.

Product recalls are difficult to avoid and can have a substantial impact on results. When products cause patient injuries or fatalities, companies will voluntarily pull them from the market or regulators may compel a suspension of sales. Not only are sales and earnings affected in the short run, as companies act to resolve the problem, but operations could suffer for an extended period because of the wariness of hospitals, doctors and patients to return to a previously recalled offering. Companies endeavor to limit the number of recalls to protect their reputations.

Product development and market expansion, most notably in developing nations, are major facilitators of sales and net-income growth for these companies. Acquisitions provide a means to this end. A business purchase will allow a company to better penetrate the global market, eliminate a competitor, bring a new technology in house, and/or enlarge the customer base.

Regulatory Considerations

The U.S. Food and Drug Administration (FDA) is the primary regulator of the Medical Supplies Industry in The United States. An FDA branch, the Center for Devices and Radiological Health, has responsibility for devices. Product approval depends, in part, on the level of risk, I, II or III. Level I is perceived as having the least risk, and such products do not require FDA approval. Levels II and III pose greater risk and require pre-clinical testing, which, alone, can take three to six months. Products sold overseas may be subject to additional oversight. In Europe, a key market, sanctioned independent organizations review products, determining their efficacy, and make recommendations. Frequently, the FDA and foreign regulatory boards will update and alter approval guidelines, creating a measure of uncertainty; further review and testing is sometimes ordered.

Additionally, changes in healthcare legislation, related to Medicare reimbursements and excise taxes, for example, can influence the operating strategy and performance of Medical Supplies companies.

Companies that succeed in this diverse, competitive industry are able to keep pace with developing technologies and accurately anticipate the needs of hospitals, doctors and patients. They are also able to properly allocate cash among R&D, ongoing-operation maintenance, and expansion efforts in a way that maximizes long-term sales and earnings results.

The following tables show the 2015 VA compensation rates for veterans with a disability rating 10 percent or higher. (Effective Dec. 1, 2014)

Dependents Allowance:

In addition veterans entitled to compensation whose disability is rated as 30 percent or more, shall be entitled to additional compensation for dependents as follows (monthly amounts):

Without Children:

Disability Rating: 30% – 60%
Disability Rating: 70% – 100%

With Children:

10% – 20% (With or Without Dependents)

Percentage	Rate
10%	$133.17
20%	$263.23

30% – 60% Without Children

Dependent Status	30	40	50	60
Veteran Alone	$407.75	$587.36	$836.13	$1,059.09
Veteran with Spouse Only	$455.75	$651.36	$917.13	$1,156.09
Veteran with Spouse & One Parent	$494.75	$703.36	$982.13	$1,234.09
Veteran with Spouse and Two Parents	$533.74	$755.36	$1,047.13	$1,312.09
Veteran with One Parent	$446.75	$639.36	$901.13	$1,137.09
Veteran with Two Parents	$485.75	$691.36	$966.13	$1,215.09
Additional for A/A spouse (see footnote b)	$44.00	$59.00*	$74.00	$89.00

70% – 100% Without Children

Dependent Status	70	80	90	100
Veteran Alone	$1,334.71	$1,551.48	$1,743.48	$2,906.83
Veteran with Spouse Only	$1,447.71	$1,680.48	$1,888.48	$3,068.90
Veteran with Spouse and One Parent	$1,538.71	$1,784.48	$2,005.48	$3,198.96
Veteran with Spouse and Two Parents	$1,629.71	$1,888.48	$2,122.48	$3,329.02
Veteran with One Parent	$1,425.71	$1,655.48	$1,860.48	$3,036.89
Veteran with Two Parents	$1,516.71	$1,759.48	$1,977.48	$3,166.95
Additional for A/A spouse (see footnote b)	$104.00	$118.00	$133.00	$148.64

30% – 60% With Children

Dependent Status	30%	40%	50%	60%
Veteran with Spouse and Child	$491.75	$699.36	$976.13	$1,227.09
Veteran with Child Only	$439.75	$630.36	$890.13	$1,124.09
Veteran with Spouse, One Parent and Child	$530.75	$751.36	$1,041.13	$1,305.09
Veteran with Spouse, Two Parents and Child	$569.75	$803.36	$1,106.13	$1,383.09
Veteran with One Parent and Child	$478.75	$682.36	$955.13	$,1202.09
Veteran with Two Parents and Child	$517.75	$734.36	$1,020.13	$1,280.09
Add for Each Additional Child Under Age 18	$24.00	$32.00	$40.00	$48.00
Each Additional Schoolchild Over Age 18 (see footnote a)	$78.00	$104.00	$130.00	$156.00
Additional for A/A spouse (see footnote b)	$44.00	$59.00	$74.00	$89.00

70% – 100% With Children

Dependent Status	70%	80%	90%	100%
Veteran with Spouse and Child	$1,530.71	$1,775.48	$1,995.48	$3,187.60
Veteran with Child Only	$1409.71	$1,637.48	$1,840.48	$3,015.22
Veteran with Spouse, One Parent and Child	$1,621.71	$1,879.48	$2,112.48	$3,317.66
Veteran with Spouse, Two Parents and Child	$1,712.71	$1,983.48	$2,229.48	$3,447.72
Veteran with One Parent and Child	$1,500.71	$1,741.48	$1,957.48	$3145.28
Veteran with Two Parents and Child	$1,591.71	$1,845.48	$2,074.48	$3,275.34
Add for Each Additional Child Under Age 18	$56.00	$64.00	$72.00	$80.52
Each Additional Schoolchild Over Age 18 (see footnotea)	$182.00	$208.00	$234.00	$260.13
Additional for A/A spouse (see footnote b)	$104.00	$118.00	$133.00	$148.64

FOOTNOTES:

• A. Rates for each school child are shown separately. They are not included with any other compensation rates. All other entries on this chart reflecting a rate for children show the rate payable for children under 18 or helpless. To find the amount payable to a 70% disabled Veteran with a spouse and four children, one of whom is over 18 and attending school, take the 70% rate for a veteran with a spouse and 3 children, $ 1,642.71, and add the rate for one school child, $182.00. The total amount payable is $1,824.71.
• B. Where the veteran has a spouse who is determined to require A/A, add the figure shown as “additional for A/A spouse” to the amount shown for the proper dependency code. For example, veteran has A/A spouse and 2 minor children and is 70% disabled. Add $104.00, additional for A/A spouse, to the rate for a 70% veteran with dependency code 12, $1,586.71. The total amount payable is $1,690.71.

These rates were provided by the Department of Veterans Affairs. The original copies can be found at:http://www.vba.va.gov/bln/21/Rates/comp01.htm.

VA Travel Reimbursement

Reimbursement for mileage or public transportation may be paid to the following:

1. Veterans with service-connected disabilities rated at 30% or more;
2. Veterans traveling for treatment of a service-connected condition;
3. Veterans receiving a VA pension;
4. Veterans traveling for scheduled compensation or pension examinations;
5. Veterans whose income does not exceed the maximum VA pension rate;

Mileage Reimbursement is at the rate of 41.5 cents per mile. These milieage subject to a deductible of $3 for a one way trip, $6 for a round trip, with a maximum of $18 per or the amount after six one-way trips (whichever occurs first) per calendar month. However, these deductibles can be waived if they cause a financial hardship to the veteran.

The deductible is also waived for veterans traveling for scheduled compensation or pension examinations.