Options

Today I spent some time chatting with a patient about various options to treat a condition. This disease is slowly progressive and should be treated to prevent complications down the road. If a patient is in good health, it’s especially important to treat since there will be many years in which to develop complications. If a patient has many medical problems and is not expected to survive for more than a decade we can focus our efforts on more immediate concerns.

This patient and I had spoken by telephone after another physician had noted her condition. The other physician had recommended a reasonable course of action but the patient wanted to discuss things with me. The patient and I discussed various options and I encouraged the patient to do her own research and then come in for a face to face meeting.

The first option we discussed is not to do anything. I told the patient that this was not acceptable to me since she was young and in good health: she potentially had forty years to develop the full spectrum of symptoms. The remaining options include three different classes of medications. Each class had its own set of risks and benefits and we discussed them all.

I was very surprised to hear the patient’s initial choice of medication since the risks far outweighed the benefits. When I asked her about the choice, she said that “everyone” said it was the most effective. “Everyone” had problems with the other two classes. And who was everyone? No one that the patient knew or had spoken to – it was all Internet chatter. It was as if there was a Yelp for pharmaceuticals. The comments were almost laughable but were being taken very seriously by my patient and therefore needed to be addressed.

At the end of our conversation we agreed upon an initial three-month plan. If things work out well I hope that she will consider taking medication for a number of years. I directed the patient to some well-vetted medical information sites and asked her to consult with me before making any changes in her medications and not to be distracted by “everyone.”

Five Diets

Healthy eating is key to good health. The following plans can be helpful roadmaps to making lasting changes.

The DASH Diet
The Dietary Approaches to Stop Hypertension is nutritionally complete, can prevent or control diabetes and encourages heart health. The DASH  diet emphasizes portion size, food variety and nutrients.

The Mayo Clinic Diet
This diet uses the Mayo Clinic Health Weight Pyramid as a guide to smart eating and healthy exercise. The  diet is broken into two parts: a two-week "Lose It" phase and a "Live It" phase based on steady weight loss and healthy living. You can preview the book before buying.

The Mediterranean Diet
This diet emphasizes fruits and vegetables, healthy oils, and fish. It limits the in tae of red meat and butter. Research shows the Mediterranean Diet can reduce heart disease risk.

Weight Watchers
Weight Watchers is the commercial plan that has stood the test of time. It is not necessary to buy any of the products to learn how to manage food intake and make wise choices.

TLC Diet
The Therapeutic Lifestyle Changes diet was created by the National Institutes of Health to promote cardiovascular health. The TLC Diet limits calories, consumption of saturated fat and sodium.

Bon Appetit!

This list of diets originally appeared in Medical Economics.

Spring Cleaning

The days are finally getting longer and the sun is brighter – time for spring cleaning! The first warms days are inviting enough to open the windows and get some fresh air into the house. It’s tempting to start a top to bottom, no holds barred project but you will have a better outcome if you choose realistic goals and focus on one thing at a time.

Look around the area in which you spend the most time. Is it the kitchen, bedroom or reading area? Start by taking some photos of the area – the clutter that you no longer see will be obvious in the photo. Get rid of the stuff you don’t use or love. Pretend that you are Martha Stewart and really get rid of the grime. (Martha’s website is an excellent resource). Deep vacuum and clean all surfaces non-toxic cleaners such as vinegar and baking soda. Mr. Clean magic eraser is another good option.

Another spring project is cleaning out the pantry. Check the expiration dates on the canned goods – don’t be surprised to see what went out of date in 2009. Are there purchases that were mistakes? If still good, donate them to the local food pantry.

Being surrounded by a mess is exhausting.  A clean, serene environment is good for mental health. One cannot separate mind from body: it’s easier to make wise health choices when surrounded by beauty. It’s the secret ingredient at the most posh spas.

Sudden Cardiac Death

There is compelling evidence that psychosocial factors can cause sudden cardiac death. Overwhelming emotion can cause arrhythmia and spasm of the coronary arteries; individually or together these could lead to fatal interruption of blood flow the heart muscles.

Like heart attacks, sudden arrhythmias are most likely to occur in the morning with the peak frequency between 8 and 11 am (more specifically, the first two hours after arising). The incidence of cardiac arrests peaks on Mondays and has the greatest incidence in winter.

Intense stressors, such as earthquakes, are associated with increased cardiac mortality. Collected data from implantable defibrillators showed an increase in arrhythmias both in the New York City area and around the world on 9/11. A diagnosis of cancer may increase the risk of cardiovascular death. A cohort study using multiple registries examined the risk in more than 6,000,000 Swedes from 1991 through 2006; compared with cancer-free individuals, patients diagnosed with cancer were six times more likely to die from cardiovascular causes within one week of receiving the diagnosis.

Depression and hostility are behaviors that are associated with an increased risk of coronary heart disease related events. Increased mortality following a heart attack is seen with social isolation and lack of emotional support.

In summary, considerable data supports a role for psychosocial factors in sudden death — both acutely with anger and chronically with states of depression, hostility, and social isolation. Stress management, combined with beta-blockers and aspirin may be helpful interventions.

Exercise

Many people are miserable this winter: feeling lethargic from eating too much junk food, spending too much time in front of screens and catching each cold that comes around. There is a solution to the winter doldrums: more exercise.

The empty calories in junk food don’t provide the nutrition needed for moving large muscles groups and thinking clearly. Too many chips and cookies will make anyone feel like a lump of clay unable to muster the oomph to get going. Thirty minutes of vigorous activity will stimulate the brain chemicals that will improve mood and cognition.

The American Academy of Pediatrics recommends limiting screen time to no more than one or two hours per day. Watching TV develops an appetite for junk food and many people overeat while watching. Screen time results in sleep loss and irregular sleep patterns; both are associated with fatigue and increased snacking. Excessive screen time leaves less time for active, creative play.

There is evidence that moderate daily activity decreases the incidence of colds. In a group of post-menopausal women, those ladies who exercised five times per week reported one-third fewer colds over one year.

Every member of the family will benefit from limiting “sit time.” In addition to limiting screen time, do something active. Challenge each other to see who can do the most pushups during a commercial break.

Even when stuck at home on a snow day, stick with a routine. Get some exercise. Give food the respect that it deserves. Sit at the table and enjoy your food rather than mindlessly snack at the keyboard. Go to bed at a reasonable hour.

Spring can’t get here fast enough.

Tips to reduce screen time. 

If you decide to exercise outdoors or want to stay inside.

Kudos to CVS

Much appreciation to the CVS Pharmacy chain: the announcement that they will stop selling tobacco products is an important step in health promotion. I would like them to continue the good work and stop selling soft drinks, chips, and other items that are contributing to the obesity crisis in America.

Look at photographs taken in the 1940's and 1950's - people were slender. Those were the days that pharmacies sold medicine, bandages and beauty products. It wouldn't be so terrible if both pharmacies and people took a step backward.

Osteoporosis

Osteoporosis is a common problem that results in thin weak bones that break easily. A hip fracture is a sudden event that can have life-changing consequences but not all bone fractures are as dramatic. Small fracture in the spine bones (vertebrae) can result in loss of height, a stooped posture and impaired breathing and digestion due to loss of volume in the chest and abdominal cavities. Both men and women should be concerned about bone health

Osteoporosis prevention starts in the teen years. Key factors are good eating habits, regular exercise and never smoking. The optimal diet to build good bones includes adequate calories and protein and optimal amounts of calcium and vitamin D. The main dietary sources of calcium include milk and other dairy products, such as cottage cheese, yogurt, or hard cheese, and green vegetables, such as kale and broccoli. A rough method of estimating dietary calcium intake is to multiply the number of dairy servings consumed each day by 300 mg. One serving is 8 oz of milk (236 mL) or yogurt (224 g), 1 oz (28 g) of hard cheese, or 16 oz (448 g) of cottage cheese. It’s unclear how much vitamin D a young person should take, but most guidelines recommend 600 IU daily.

Non-drug therapy underlies all osteoporosis prevention and therapy: adequate calcium and vitamin D, exercise, fall prevention, not smoking and limiting caffeine and alcohol intake. Medication may be needed. People with the highest risk of fracture are those most likely to benefit from drug therapy. The decision to add medication needs to be a shared patient-physician since the substantial benefits are associated with substantial risks

The National Osteoporosis Foundation has patient-friendly tips as well as links to new research and recommendations.