Sunday, July 28, 2013

Personal Trainers

In an op-ed column in the New York Times, Frank Bruni wrote about the influence of personal trainers. I too have noticed that people will zealously follow every recommendation of their trainers, convinced that following the personalized advice will lead to better health. I am all in favor of better health, but let’s examine who is doing the recommending. As Mr. Bruni points out, all it takes to become a personal trainer is $400 and a pulse. All it takes to be an internist is 8 years of classroom work and at least 3 years of supervised training (and passing nightmarish exams).

The ascension of personal trainers is a direct challenge to evidence-based medicine, the shown to be effective tenet of the conventional medical establishment. In other words, rather than getting the advice that really works the patient would much prefer to get the advice that he or she really wants to hear.  Why actually sweat in the gym – just work on the “core.” It’s much more fashionable to undertake a colon cleanse than to just cut out overly processed food.

I am always pleased when my patients commit to an activity program. It’s a good idea to get some instruction when using a new piece of equipment. However, it should be buyer beware when purchasing nutritional and health advice. The trainer may have the best of intentions – but doesn’t know what he doesn’t know. 

Wednesday, July 24, 2013


Aspirin is the cornerstone of the treatment of cardiovascular disease. Since there can be complications associated with the use of aspirin, we should use the lowest dose known to be effective. For the prevention of heart attacks and strokes, the lowest effective dose is 75 mg. In the United States, the lowest widely available dose is 81 mg, which seems to be an odd amount.

Before the rise of the modern pharmaceutical industry, chemists used the old English system of measurement. The smallest unit of weight is the grain, which is 65 mg. The standard dose of two aspirin was 10 grains. Each tablet was 5 grains (325 mg). It was thought that the appropriate dose of aspirin for a baby was one-quarter tablet (81 mg). An enterprising manufacturer spared the parents of yore from turning aspirin tablets into heaps of powder attempting to quarter them by formulating “baby aspirin.” To make the product more appealing, the tablets were colored and flavored orange.

There can be serious gastric irritation from aspirin. In an attempt to protect the GI tract, what is now called “low dose adult aspirin” is available with an enteric coating. The unexpected consequence of this coating is that not enough of the aspirin is absorbed. The actual delivered dose of aspirin is not 81 mg; it’s not even the 75 mg generally recognized as the minimum dose needed to prevent cardiovascular events.

Equivalent doses of enteric-coated aspirin are not as effective as plain aspirin, since there appears to be lower bioavailability from the coated product. The pseudoresistance may be more marked in heavier individuals.

I recommend that the patient who needs to take aspirin for the prevention of cardiovascular disease take 81 mg of the immediate release product. There appears to be less gastric irritation if taken with a meal. 

Friday, July 12, 2013

The Paradox of Disease Prevention

There is no way to prove that a person’s efforts to prevent disease actually worked. One can assume that a healthy diet, regular exercise and not smoking will prevent a heart attack. But not every fat, sedentary smoker will succumb to heart disease. The outcome of prevention is invisible: it creates an absence of events.  

There is no drama in prevention. Wearing a seat belt that prevents the need for dramatic surgery will never be featured on a television show. The benefit of reducing stress won’t have an effect by the end of the week. The difficult part of healthy behavior is adhering to the healthy decisions day after day.

Avoidable health risks need to exposed as avoidable and we need to establish a culture that celebrates everyday healthy choices.

Dr. Harvey Fineberg of the Institute of Medicine has written an easy to understand discussion on the paradox of disease prevention. Much food for thought.

Monday, July 1, 2013


The first line medication to treat mild to moderate acute pain is acetaminophen (Tylenol). It is generally well tolerated, has few drug-drug interactions, doesn’t raise blood pressure, can be used during pregnancy and is the drug of choice with impaired kidney function. It is also inexpensive.

The side effect profile for acetaminophen is exceedingly good, but there is a relatively narrow therapeutic window (the difference between a therapeutic dose and a toxic dose). The main toxicity, hepatic injury, is a serious concern. Until recently, the maximum daily dose of acetaminophen was 4000 mg daily (12 regular strength Tylenol). Since acetaminophen is in so many over the counter medications there is increasing concerns about unintentional overdose. Government regulators suggest that the maximum dose should be 2600 mg per day (8 regular strength pills).

Although the drug is remarkably safe when taken at usual therapeutic doses, overdose of acetaminophen   has been recognized since 1966 to cause fatal and nonfatal permanent liver damage. It is suspected that even repeated therapeutic or slightly excessive doses can be hepatotoxic in susceptible individuals, such as alcoholics. Acetaminophen poisoning has become the most common cause of acute liver failure in the United States.  

Patients who are older and malnourished appear to be at increased risk for acetaminophen toxicity. Smoking may also be a risk factor. Acetaminophen should not be taken on an empty stomach. 

The most important advice is to carefully read the label of all over the counter medications. Acetaminophen is a component of hundreds of over-the-counter and prescription medications used worldwide. Many patients ingest excessive amounts of acetaminophen because they misunderstand dosing directions or fail to recognize that acetaminophen is found in more than one medication they are using. 

Acetaminophen is a valuable medication but it must be respected as much as any prescription product.