Dem Bones Dem Bones

I have received a request to discuss the treatment for osteoporosis, so here are my two or three cents.  Feel free to make additional requests.  You can leave a comment on this blog or send an email to me at mpf9973@bjc.org.

During our younger years most of us take our bones for granted.  They carry us from place to place remarkably well.  They are quite resilient and only give way under a significant amount of stress.  As we get older that changes.  I have had a patient break their pelvis by nearly bending over to pick up a load of laundry.  Slips and falls can easily lead to broken hips, collar bones or arms.  The back bones can spontaneously implode on themselves like a stepped on soda can.  Not only are all these situations extremely painful, they are dangerous as well.  If an 80 year old falls and breaks a hip, there is a 50% chance that they will no longer be alive within six months.  It takes longer to heal at that age.  The immobility will predispose one to blood clots.  Pneumonia is more common.  The physical stress of the fracture may trigger a heart attack.  Muscle wasting occurs, making future falls even more likely.  This is the reason why physicians are so concerned about your bones.

Osteoblast: Bone Builder

Osteoclast: Bone Eater

The time to act is now, not after a fracture has happened.  By that time the bones are already brittle and weak.  To understand the different therapies used to improve bone strength, let me first explain bone metabolism.  One of the reasons why bone is so strong is that it is constantly being remodeled.  You can think of bones as scaffolding composed of calcium deposits.  There are two types of workers on the scaffolding, osteoblasts and osteoclasts. The osteoblast is the builder cell.  He is your brick mason, so to speak.  The osteoclast are the low paid college kids who come in and tear out the old bone that is showing signs of decay.  Think of calcium as the bricks used to build up the scaffolding.  The reason why people develop thin bones is because of an aberration in one of these three areas.  First, the youthful demolition workers may be over active.  Second, the deliberate mason builders may work too slow to match the demolition done by their younger counterparts.  Third, there may be a deficiency of material to work with (not enough calcium).  An example of the first are people given anti-inflammatory steroids such as prednisone.  This turns on the osteoclasts and bone destruction is accelerated.  Women in menopause who lack the estrogen of youth have a decrease in the activity of their osteoblasts (mason workers).  Patients with Celiac disease don't absorb calcium as well and lack the material used to make the bones.  The same is true for patients taking long term anti-acid suppressant medications or patients with vitamin D deficiency.  An overactive parathyroid gland will result in pulling calcium out of the bones and into the blood stream.  Understanding the cause of why someone's bones are thin is important so as to recommend how to counteract those effects.

The most important way to improve bone health is to be on them and be active.  There will never be a better solution than regular weight bearing exercise.  In as little as six weeks, well conditioned, young astronauts in space will begin to lose strength in their bones.  The same happens to anyone confined to bed for an illness.  Self imposed inactivity (nice way of saying "laziness") has similar effects.  When we are active and up on our feet our bones feel that pressure.  The mechanical reaction stimulates our osteoblasts to action and they get to work building more bone.  This won't do you any good if there is not adequate calcium to work with.  Calcium is mostly found in dairy products.  It is recommended that we obtain 1000-1200 mg of calcium a day.  Each serving of dairy contains approximately 300 mg of calcium.  The absorption of calcium is enhanced by the effects of vitamin D.  Vitamin D is activated by sun light.  As little as 10 minutes of sun exposure three days a week will suffice (see "Good Rays or Bad").  If you are not getting enough calcium through your diet, it is good to supplement that with a combination calcium-vit D tablet.  I recommend using 600 mg of calcium combined with 400 units of vitamin D, 1 or 2 tablets a day depending on your diet.  If you take a medication to block the acid in your stomach, using calcium citrate, which is absorbed better in an acid free environment than is calcium carbonate, which requires acid for absorption.

Regardless of what conditions affect your bones, adequate exercise, the appropriate diet and just enough sun exposure will help.  In a future post, I'll discuss how bone strength is measured and medications used to treat brittle bones.

From Darkness into Light

Orion

Orion stands sentinel over my house in the morning as I wait for my 15 year old son to back out of the garage and we head off for the day.  He still is peaking over my shoulder as I get to the gym.  It is hard enough to exercise when it is dark, harder still when it is cold.  The initial chill of jumping in the water for my swim work out is an added jolt.  Thankfully, as I head out the door, the sun has decided to finally rise and Orion has gone to hunt in other lands.  My days are busy and long.  The winter time viruses are in full swing as well as the hustle and bustle of those who have met their deductibles for the year and want to make sure they get in their physicals.  By the time I sit down to finish up my calls and go through all my paperwork, I glance out the window to see that dusk has already settled on my world.  By the time I come home Mars has already climbed high in the sky and it is dark again.

These winter days of starting and ending my day in the dark can cast a shadow over my mood.  Medically we refer to this as seasonal affective disorders or "SAD."  For most of us, we muddle through and pull out fairly well.  A small minority just lose their ability to function altogether.  What is one to do?  How can this be combated?  First of all, on the days when the sun is shining, put on a coat and get outside.  Even if it is just for ten minutes.  The sun is a healing force, both physically and mentally.  Even artificial light helps.  Turn on the lights at night.  It will help your energy level and brighten your spirits.  Stay involved with other people.  Finding ways to help others will make it easier not to worry so much about our own problems.  Above all, stay active.  Gaining weight will only make one sink deeper into the dark abyss.  Some may need to seek help from a physician.  Medications may help.  There are actually light boxes constructed for this very purpose as well.

 Try to stay positive.  A gratitude journal may help remind you of the good in your life.  Jot down the good things that transpire in your day.  It will help you look for the good around you.  As we do so, we will see the beauty of the heavens instead of the darkness of the sky.  It will remind us that we truly are being watched over and that in due course light will shine forth again in our lives like the promise of spring.

Anguish over Antibiotics

Having suffered with a bad chest cold for the last week, I figured this would be a good time to discuss the appropriate use for antibiotics in regards to upper respiratory infections.  By this, I refer to infections of the sinus (sinusitis), throat (pharyngitis), upper airways (bronchitis) or of the lung itself (pneumonia).  The common cold is usually referred to as rhino-sinusitis or infection of the nasal passages and sinus.  Over 90% of these infections are due to viruses.  The most important fact to understand is that antibiotics do not treat viral infections.  They treat bacterial infections.  There are times when it is appropriate to use them but for the most part they are to be avoided.

Now, one may ask, "What is the big deal about taking antibiotics?"  I have often heard, "I just get this twice a year and if I get my Z-pack, I do well."  However, after talking to the patient, I often come to the conclusion that their infection is likely viral.  I can assure you, that my life would be much easier if I just sent out the prescription for an antibiotic.  I have often wished I could give someone "placebocillin."  I would tell my patient to take these sugar pills twice a day for ten days and I know that chances are they will be feeling quite well by then.  There are three reasons to be wary in taking an antibiotic.  The first is a chance that you may develop an allergy to the medication.  Rarely can this be life threatening.  The second is the risk of developing diarrhea associated diarrhea, the worst of which is called, clostridium dificile colitis which is triggered by taking antibiotics and can be very difficult to clear and very serious.  The last is the risk that bacteria can develop resistance patterns due to being overexposed to antibiotics.  This is already began to be a problem.  We may not be too far away from a time when certain infections will have no available antibiotics that can be used to treat them.

What, then, are the symptoms which would suggest that antibiotics are appropriate?  First strep throat requires the use of an antibiotic.  The symptoms are fever and a sore throat.  Strep does not cause a cough. There is not much sinus involvment either. If you have a fever and a sore throat with a bad cough, that is not strep.  Bacterial sinusitis is characterized by a fever, sinus related facial pain in the prescence of yellow or green secretions.  Usually, these infections are secondary, meaning that they begin as a virus but with time (usually 10-14 days) bacteria can get trapped in the sinuses and start a new infection.  Commonly, a patient will tell me that they started with a cold, started to improve and then got worse again.  It is also important to know that colored secretions in and of themselves do not indicate a bacterial infection.  In fact, such are expected starting about 4-5 days after the beginning of a cold.

Resistant Bacteria

Bronchitis only requires antibiotics in the setting of an asthmatic, smoker or certain other lung diseases.  Such infections are quite common and can last a very long time.  Patience is the key.  If one is making gradual improvement, even if painfully slow, it is imperative to wait it out, letting our body clear the infection on its own.  Now if one developes chills, fever, pain with breathing or shortness of breath, it is time to go see your doctor and make sure pneumonia has not developed.

Lastly, pneumonia almost always requires an antibiotic.  Even if it is precipitated by a viral infection, it is common that pneumonia develops into a secondary bacterial infection.  The prime example of this is seen with influenza.  The deadly epidemic of 1918 was fueled mostly be pneumonia from staph that came after the influenza was contracted.  If you have symptoms to suggest pneumonia as listed above, it is always appropriate to be evaluated by a physician.

Holi-DAYS

The holidays are upon us.  Thanksgiving is just a few days away.  This is often the beginning of hibernation for too many of my patients.  However, I do not care for bears.  We humans have no physiologic need to store fat to make it through the long dark winter.  Remember, bears do this due to a lack of access to food during the winter.  We do not have this problem.  Now, we will, like hibernating bears, grind our metabolism down to a halt if we allow ourselves to slip into a pattern of inactivity, only getting up to forage in the refrigerator.

What are good ways of staying active in the winter time?  It will likely involve exercising indoors.  If you do not have your own treadmill, exercise bike or other equipment, consider joining a gym.  Many are relatively inexpensive.  The malls are open early for those who want to walk in them.  Put on a coat and take your walk.  Don't let the winter doldrums keep you from being active.

In regards to eating habits, this is the time of year I refer to as "the danger zone."  There will be plenty of opportunities to eat the wrong types of food.  You need to make up your mind now how you are going to respond when something really tempting crosses your path.  Many of my men patients will tell me, "if she wouldn't buy/make those cookies/cakes, I wouldn't eat them."  This is a weak excuse at best.  We must be firmly responsible for the decisions we make.  Make a resolution now and stick with it.  Don't wait until the first of the year and you've put on ten extra pounds.  Watch yourselves every day.  Get on the scale daily if you need to.  Be strong.

Lastly, I fully understand that during the holidays we are going to eat food that is not healthy.  There are three simple hints that can help keep things under control.  First, earn your calories.  Get up early on Thanksgiving and go for an extra long walk.  Play football with the kids (this may have other adverse health outcomes, though).  Go to the gym and stay longer.  If you are going to eat more, burn more.  Secondly, realize that there will be far more choices than normal.  It is all right to eat from all of them if the portions are much smaller than what you would normally take at a normal meal.  If there is something that isn't your favorite, skip it.  Don't dish it up just because it is the next item in the line.  Lastly, remember that these special days are just that..."days."  They are not holi-weeks or holi-months, they are holi-DAYS. Enjoy yourself.  Taste all the goodies.  Don't fret about feeling guilty all day but when the day is over it is OVER.  Get back on track the next day.

Colon Cancer Concerns

Colon cancer is one of the more dangerous forms of cancer, in fact it is the second leading cause of deaths among cancers.  Fortunately, it has a precancerous phase that can be detected.  These early growths can be removed, preventing this deadly disease.  Detection occurs through a procedure called a colonoscopy.  Now, I realize that contemplating a scope being inserted into the colon is not a pleasant experience.   It is not quite as bad as the imagination would suggest.  The procedure itself is done under sedation and is tolerated well.  The worse part of the test is getting cleaned out the night before.  The good news is that if the test is normal and there is no family history of colon cancer, it need not be repeated for ten years.

Now, surely, you ask, there must be a better way.  How about those virtual colonoscopies I heard about on T.V.?  This can be done, but here are the details.  The preparation is the same.  It is done by a CT scanner after dye and air have been forced up into and through the colon.  This does not feel good and no sedation is used.  If anything abnormal is detected, a full colonoscopy will need to follow so that a biopsy can be obtained.  Personally, I would rather have the better test and be done with it.  What about using those little cards to detect blood in the colon?  The problem with those is that there is a pretty high false positive rate.  It also misses many precancerous growths.  If the polyps do not happen to cause bleeding, nothing will be protected.  Is a colonoscopy really necessary?, my patients ask.  I respond that I cannot remember having diagnosed a patient with colon cancer who has been screened.  As opposed to screening for breast or prostate cancer which hopes to detect cancer at an early stage and cure it, screening for colon cancer finds growths before they have turned cancerous and thus the disease never develops in the first place.

When does screening begin?  A person at average risk should be screened beginning at age 50.  If someone has a family history of cancer or precancerous polyps in a first degree relative (parent or sibling), they should be screened starting 10 years prior to their affected relative or by age 50, whichever comes first.

Most agree that a diet high in natural vitamins and fiber decrease your risk of colon cancer.  There are, of course, found in fruits and vegetables.  Genetics play an important role as well.  Make sure you ask your family members if they have been screened and if any polyps were found.  Make sure you get screened.  Talk to your doctor about your individual risk.  It may well save your life.

The Problematic PSA

There has recently been much debate and discussion as to whether or not the PSA blood test should be used in screening for prstate cancer.  The PSA is a blood test.  It stands for "prostate specific antigen."  Protein particles in the prostate gland are released in small quantities into the blood stream and have found to be elevated in prostate cancer, a state in which prostate cells are multiplying and dividing at an accelerated rate.  Since the development and routine use of this test, the detection of prostate cancers has increased dramatically.  What is not clear, though, is whether increased detection has led to saved lives.  Let me discuss further some of the controversies that surround the issue.

First, the test itself is not a perfect test.  Cancer is not the only cause of having an elevated blood test.  A lower urinary tract infection may also elevate the test.  Some may have a low grade inflammation of the prostate gland (chronic prostatitis) that will lead to having an elevated PSA.  Recent sexual intercourse can cause transient elevations in the PSA as well.  If an abnormal result is found, it is important to repeat the test in 6-12 weeks prior to considering a prostate biopsy, a rather invasive and not so pleasant procedure.

Proper interpretation of the PSA is very important.  The test itself is not dangerous, but an elevated result may lead to a path consisting of first a biopsy and, if cancer is found, to possibly surgery, castration chemotherapy or radiation.  Any of these three may carry adverse effects ranging from urinary incontinence, urinary frequency, impotence and bloody diarrhea.  Though prostate cancer is the leading cause of cancer, it is far from the leading cause of cancer death.  Most prostate cancer is a slow growing process that most people will die with rather than from.  However, there are cases that can be more rapidly progressive and deadly.  In this form, the cancer can spread to other organs in the abdomen and into the bones.  At this stage, the cancer is quite difficult to treat.  The demise is usually slow, painful and progressive.  When looked at as a whole, the vast majority of patients will not have this deadlier version.  Some will interpret those statistics in such a way as to conclude that early detection of prostate cancer is not worth the complications attendant to its treatment.

What is really needed is a way to determine who will progress to the deadlier form of disease and who will not.  In such an instance, treatment could be safely withheld from those who do not need it but could be aggressively applied to those who do.  We do not as yet have such markers.  Strides in this area are being made in relation to breast cancer but are lacking as of yet for prostate cancer.  In the meantime, proper interpretation of the PSA test can help guide decision making.  This should be done on an individual basis between each patient and their physician.

I personally feel that it is appropriate to screen patients with a PSA level in their forties, especially if there is a family history of prostate cancer.  If in the forties, the PSA is low (below 1.0 ng/ml) waiting an additional five years to repeat the test is reasonable.  I recommend yearly testing in someone who is in their 50's.  In the 40's and 50's, an elevated test should first be repeated to make sure that it is accurate.  I am more aggressive in this age group since detection is much more likely to result in meaningful treatment.

As a patient enters their 60's and 70's, I look less at the absolute value of the test and more at how it is changing.  The PSA will rise with age just due to the fact that the prostate never quite stops growing.  If, through the years, there has been a slow gradual increase, I am not nearly so concerned as someone who suddenly has a steep spike in their value from one year to the next.  If repeat testing at a shorter interval shows progressive worsening, that is likely a sign of progressive disease and warrants consideration for a biopsy.  In a patient in his 80's or 90's, I would only use an elevated PSA if I thought there was progressive disease as manifested by symptoms of urinary blockage or evidence of cancer in the bones.

One comment.  The above discussion applies only to patients not previously known to have prostate cancer.  In a patient with known cancer, who has been treated, the PSA is a good marker of disease activity and there is no controversy as to its use.

Lastly, a word about treatment.  Hormonal based treatments definitely have symptoms of weakness, fatigue and hot flashes that likely will occur.  Radiation treatments have evolved so as to be more precise and involve less damage to other nearby organs (such as the large bowel and bladder).  In this instance there is less diarrhea, rectal bleeding and frequent urination.  Surgical techniques have changed considerably.  Many urologist have become quite proficient in the use of robotic procedures.  Since the prostate lies deep in the pelvis, former surgical techniques did not allow the surgeon to always see what was being stitched or cut, but was done by feel alone.  The robotic techniques allow for much better visualization of the area and much more precise stitching.  In the right hands, such a surgery has a very low incidence of impotence and incontinence.  Further studies are being done to determine if these better techniques can result in prolonged life without sacrificing the quality that we want.

In conclusion, using the PSA test to screen for prostate cancer is not a black and white issue.  Ask your doctor for his opinion.  Consider your options and choose the course that you feel most comfortable taking.

Treating Neck Pain

There are five basic components to getting better when suffering from tight muscles in the neck and shoulders.  Posture prevention.  Simple Stretches.  Helpful Heat. Meaningful Massage.  Consistency is Key.

Posture Prevention:
As mentioned in last week's post, if the head is maintained in a forward position for an extended period of time the muscles will become overworked, tight and they will spasm.  When sitting in front of a computer screen, watching television, reading a book or even knitting a scarf, take care to keep you head back so that it is being supported by the bones in your spine, not the muscles of your neck.  If you are sitting in the same position for more than thirty minutes, take a few seconds and move your neck.  Do some simple stretches (see below).  In addition to your head position, make sure that your shoulders are in a neutral position during your activity.  If your keyboard is too high and you type with the shoulders hunched up, even just a fraction of an inch, the muscles will be overworked.

Simple Stretches:

Trapezius Stretch

These are examples of three simple stretches that can be done repeatedly through the day to loosen up your muscles.  They can be done in just a minute or two.  You can do them right in your chair at work.  There are many ways to stretch.  Most of them are quite acceptable.  First, listen to your body.  If the activity causes pain which is more than simple muscle stretching, don't do it.  In the neck, especially, be careful with spinal manipulation.  If you are older or have any risk factors for hardening of the arteries, consult with your physician prior to considering treatment consisting of neck manipulation.  It can result in disruption of the blood vessel in the neck.  Though quite rare, it is a potentially devastating complication.  You Tube has many videos demonstrating how to stretch the neck and shoulders.  An example of simple neck stretching is found here.  I enjoyed another one entitled, "Yoga Spine Exercises."  In fact, signing up for a Yoga class would be a great way to learn new techniques and enhance your flexibility in general.  Another form of exercise with great results for the spine is Pilates.  An example of some basic Pilates stretching is found here.

Helpful Heat:

Tight muscles in spasm tend to stay in spasm.  Heat helps to soften them up by increasing blood flow to the area.  Ice will contract the muscles and will make it worse.  Ice is best used when there has been an injury and swelling needs to be controlled.  For stiff muscles, heat is the best.  A great way to deliver heat is a "U-shaped" pack.  They may be filled with rice, barley, corn or other materials which can then be microwaved and will retain their heat for about 10-15 minutes.  This is just the right amount of time to apply it.  When is the best time to use heat? There is no bad time to do it.  Most people get lazy and don't do it enough.  Put it around your neck as you drive to work.  Put it on as you go to bed.  Using heat prior to stretching and massage is especially helpful.


Meaningful Massage:
Massage can release the painful knots or triggers that keep the muscles tight.  Certainly, going to a massage therapist is the best way to get relief.  A good physical therapist will also utilize massage in his/her treatment plan.  Lower cost alternatives may involve a close friend or family member.  Even if untrained, you can point out where the knots are.  A golf or tennis ball can be rolled over that area.  Even a rolling pin can work!  The vibrating massage balls sold in stores are not a bad idea either.

Consistency is Key:
Our bodies have a remarkable ability to heal themselves when given the chance.  We all have a tendency to ignore aches and pains knowing that eventually we will feel better, the body will take care of itself.  However, if you have reached the point where your neck and shoulder muscles are in a state of constant tightness and spasm,  those symptoms may last for a very long time.  By consistently following the simple steps listed above, the cycle can be broken and you can get back to feeling normal again.  It takes effort, but most of all it takes persistence.  Don't give up and get discouraged if you do not have immediate results.  You will feel better, but it takes time.

A Pain in the Neck

No, I'm not talking about your boss, your homework, being stuck in traffic or even all the things on your to do list.  I'm talking about the tightness between your shoulders that can cause pain up into your head, down your arms, sometimes in your chest and can even feel like a sharp pain deep in your inner ear. To explain how and why this happens, let me start with an anatomy lesson.

The main muscle group involved is called the trapezius.  It is so named due to its trapezoid shape, like a kite.  It attaches high up in the neck on the scull, extends down the spine to the mid back and flares out across to the edges to the shoulders.  The upper edge that is marked with an "X" is an area where trigger points can develop.  You know these better as "knots."  They are balled up areas of spasm that make life miserable. 

Underneath the trapezius are the scalene muscles.  They hold your head up straight and get overworked when our posture is bad.  At the bottom edge of these muscles is the brachial plexus.  This is a group of blood vessels and, more importantly, nerves that go down into the arm.  Enough spasm in the scalene muscles will cause pain, tingling and even numbness down the arm that feels similar to a bulged disc in the neck.

The sternocleidomastoid muscle group attach to the skull just behind the ear and attaches to the collar bone and breast bone.  These are the muscles that turn your head from side to side.  When they are in spasm one may feel a burning pain from the shoulder into the neck and side of the head.  This is the muscle that can make it feel like there is a sharp pick down in your ear.  This can especially be bad in those who spend a long time on the phone, holding it without hands between the ear and shoulder.

The levator scapulae muscle lifts up the shoulder blade to which it is attached.  It is responsible for shrugging your shoulders.  It is well known for knotting up on people who spend much of their time in front of a key board, especially if it is too high.  Steadily holding the shoulders in a shrugged position while typing creates constant tension in this muscle group.  It is not uncommon for me to see patients who come in complaining of a deep pain in their chest and are worried that they are having heart pains.  As I talk with them I'll hear clues that this is not their heart.  As I examine them, it becomes readily apparent that they are knotted up in the trapezius and especially the levator scapulae muscle.  I say to myself, "A ha!"  for I know that when there is a spasms in that location, it puts traction on the shoulder blade, pulling it upwards.  This then puts pressure on the other muscles which are attached to it, in this case the pectoralis minor muscle.  This is a small muscle of the chest that sits under the well known pectoralis major muscle, or "pecks."  As seen in the picture, the pectoralis minor attaches to the front of the shoulder blade and extends straight down to the rib cage.  Traction on the shoulder blade then causes a reciprocal spasm in this muscle and results in chest pains.

The number one reason for tightness and spasm in these important muscles is posture.  The head weighs about 20-25 pounds and is built to be supported by the bones in our spine.  If we are hunched forward, even just an inch or two, now those 25 pounds are being supported by the muscles of the neck instead.  I am seeing more and more patients with these problems and it is mostly due to the fact that we spend more and more time in front of a computer screen typing.  I have also seen this in patients who have bad posture while reading, sewing, quilting and even wood carving.  Tune in next week and I’ll discuss ways to help you get rid of your “pain in the neck.”

Aspirin Anguish

A report this week came to my attention that has linked a higher rate of macular degeneration with those who take aspirin on a regular basis.  Macular degeneration is a slowly progressive disease leading to blindness.  It is due to abnormal blood vessels in the back of the eye and becomes worse with age.  It is a frightening diagnosis to receive.  The news media seems to have very little interest these days in education and is rather more concerned about sensationalism.  This is the type of story that they love to scare people with.  I feel this deserves more thought and consideration.

The first issue lies in the fact that the study under consideration is retrospective.  This means that they took people who have the condition and looked back at factors that could be associated with it.  These types of studies are useful for generating questions for further study but are not in and of themselves definitive.  A prospective study is much better.  In this case, a group of people would be defined and divided into two groups.  One group would receive aspirin and the other would not. After a specified period of time, the two groups would be compared to see if one developed macular degeneration at a faster rate than the other.  This is not how the current study was performed.  Looking backwards can identify associations more so than establishing cause and effect.  One needs to ask, is aspirin the cause of the macular degeneration or could there be a different association.  As macular degeneration is a vascular (blood vessel) disease, I wonder if aspirin was just a marker for those who are at higher risk for vascular disease in general.  Aspirin has been shown conclusively in men over 45 and women over 55 to lower the risk of heart disease and stroke.  This is especially true in those who have risk factors such as high blood pressure, elevated cholesterol, smokers and diabetics.  Those at higher risk for vascular disease are likely to have a higher risk for macular degeneration as well.  Given their risk factors, such patients are more likely to have aspirin recommended to them by their doctors.  It is quite possible that if the patients who are found to have macular degeneration are taken off of their aspirin, they could have worsening of their macular degeneration.  They will certainly be at higher risk for the life ending complications of heart attack and stroke.

Aspirin use in the appropriate setting has been ranked by the U.S. Preventive Task Force as the single most effective way to save lives of any measure that we currently employ to prevent diseases.  This includes mammograms, pap smears, colonoscopies, blood pressure control, cholesterol management, etc. The single most effective!  Remember, your vision won't help you if you are dead.  Further studies are in order to determine the exact nature of the relationship between aspirin use and macular degeneration.  In the meantime, if you have risk factors for blood vessel disease, please talk to your doctor prior to considering stopping a potentially live prolonging medication, your simple aspirin a day.

Facts About Flu

This is the time of year when flu shots are administered.  It seems that you can get your flu shot just about anywhere.  The good news is that the shot is the same, no matter where you go.  Get it where ever it is most convenient.  That said, I did once ask a patient never to return to the location where she received hers.  It wasn't that I was afraid that the vaccine that she received was not effective.  It was that she received it at Krispy Kreme doughnuts.  I have a serious problem with my patients receiving their health care at such an establishment.  It just sends the wrong message.  She didn't even get out of her car.  She just rolled down her window, signed a form, stuck out her arm and picked up a doughnut.  

Why is it important to be vaccinated for flu?  First of all, many confuse a viral stomach bug as flu.  This is incorrect.  Though such an illness will make one quite ill for a few days, it tends to be short lived and not serious.  In such a case, it would not be necessary to be vaccinated.  However, flu stands for influenza.  This is a respiratory illness characterized by high recurrent fevers, shaking chills, and horrible muscle aches.  What makes it especially risky is that there is a significant risk for pneumonia to develop.  Not uncommonly this is due to staphylococcus aureus, the most deadly bacteria to cause pneumonia.  Those at particularly high risk are those at the extremes of ages-the very young and the elderly.  The illness tends to last at least 7-10 days and is quite incapacitating.

So who should get vaccinated?  Those who are over 65 years old definitely should.  Also, those who have chronic diseases should as well.  Repeated studies have shown that vaccination in these patients saves lives.  Those who work with or are in contact with such people should also strongly consider being vaccinated.  In fact, anyone who wants to avoid being out of commission for at least a week should be vaccinated.  This includes school children as well as those of you in the work force.  There is a reason why many employers provide the vaccination for free.  It is well worth the investment to keep people productive at work.

Unlike many other vaccines, the influenza vaccine must be given each year.  This is because the virus interchanges its components, evading our immune's system memory.  Certain combinations of these components are more dangerous than others.  The H1N1 epidemic (swine flu) two years ago is a good example of this.  One of our big worries is if the "bird flu" (H5N1) becomes easily transmissible to humans.  That particular strain has a mortality rate of nearly 70% in healthy adults.  Such an epidemic would decimate every community in which it traveled.  One of the reasons why it is good to get your flu shot every year is that it gives your immune system more chances at reacting to future viral rearrangements.

"I don't want to get a flu shot.  Every time I get a shot, I get sick."  I have two responses to this concern.  First, illnesses that occurs after receiving the vaccination are not influenza.  They are coincidental colds.  I realize that no one believes me when I say this.  The real consideration is to know that the flu shot is now a totally killed virus.  Past vaccines were partially live viruses which may indeed cause one to feel feverish and achy for a few days after.  That is no longer the case.  The shot is exceedingly safe with minimal effects.  Flumist, the vaccine given through the nose is partially live.  If you are concerned about feeling ill after the vaccine, get the shot.

In summary, protect yourself, protect your loved ones, protect your community.  Get your flu shot.  This is the best time to do it.  Please, just don't go to the doughnut shop!

Diabetic Macrovascular Damage

Macrovascular disease is damage due to large blood vessels.  There are basically three types of disease that are caused from large blood vessel damage.  They are blockages in the legs (peripheral arterial disease), blockages to the brain (stroke), and blockages in the heart heart arteries (heart attack).  Whereas microvascular damage tends to cause damage that makes life miserable, macrovascular damage results in conditions that cause the majority of deaths in diabetic patients.

All three of these conditions share similar features.  Unlike microvascular disease, strict blood sugar control by itself has not been shown to greatly decrease the risk of having these conditions.  A multi thronged approach is essential.  Controlling high blood pressure is critical.  Having both diabetes and high blood pressure more than doubles the risk of these conditions.  As such, the blood pressure goals in a diabetic are lower than for others.  Ideally, the blood pressure should not exceed 130/80.

Similar to hypertension, elevated cholesterol levels are more dangerous in diabetics as well.  Upper limits for the LDL (bad cholesterol) levels are 100 mg/dl.  This is the same goal as for those patients who already have established disease in their coronary (heart) arteries.  In fact, the risk of a heart attack in a diabetic patient is the same as for a patient who already has established heart disease.

Lastly, avoidance of cigarette smoking is critical in any patient but even more so in diabetics.  In regards to peripheral arterial disease (PAD), the only patients we see with this disease who are not diabetic are smokers.  Those with both conditions are at especially great risk.  PAD, in combination with neuropathy (see Diabetic Microvascular Damage) makes it extremely difficult to heal wounds, leading to sores and ulcers.  This may even lead to gangrene requiring amputation.

I hope that your understanding of what can go wrong with diabetes will be a stimulus to act now to prevent diabetes from progressing.  Consider the consequences above.  If a person with tendencies towards diabetes progresses to the point that their Hgb A1C is above 7.0% and requires medication, it will triggers a cascade of additional medicines.  Even at the beginning, a patient is likely to require a medicine for diabetes, an aspirin a day to prevent heart attack, a blood pressure medication and a cholesterol lowering medication.  At a minimum that is four medications.  Many patients require two, three or even four medications for the diabetes alone, three to five medicines for blood pressure and sometimes two medicines for cholesterol.  That is a lot of pills.  Not only will that be extremely expensive, there are possible side effects with all of those.  Don't wait till your doctor tells you have diabetes to take your health seriously. We all should be "on a diabetic diet."  We should all be exercising.  Now is the time to act.

Diabetic Microvascular Damage

Part of controlling diabetes is understanding the possible complications that comes from not keeping the blood sugars in check.  These complications all arise from damage to blood vessels due to elevated blood sugar levels.  Every organ system in the body can be affected.  Broadly speaking these complications are divided into two groups: macrovascular ones (large vessel) and microvascular ones (small vessel).  This week I'll be discussing the small vessel damage.

Microvascular Effects:
These changes have been shown to be closely linked with diabetic control.  Those who keep their hemoglobin A1C levels below 7.0%, do not for the most part develop these problems.  Let me discuss them in more detail.

Neuropathy: This is caused from damage to nerve fibers due to the diseased blood vessels that supply them.  The result is decreased feeling in the feet and poor wound healing.  A small pebble in the shoe which would be immediately taken out in a person with normal feeling may fester in a diabetic and cause a sore.  These sores can enlarge and get deeper.  If severe enough, infection can begin first in the skin (cellulitis) and later it may even reach the bones (osteomyelitis).  Bone infection is nearly impossible to cure with medications alone and can lead to amputation.  This often starts in the toes, continues in the forefoot and can lead to amputation above and below the knee.  Those with diabetes should inspect their feet each and every night prior to going to bed.  A tiny sore can be cured if caught early, evading the dreaded complications listed above.  Once a year, your physician should check the feeling in your foot using a simple filament test shown above.


Nephropathy: This is kidney damage.  In the United States diabetes is the number one reason for hemodialysis. Not only is hemodialysis inconvenient, it will greatly affect one's quality of life.  The chance of dying is five times higher in those who are on dialysis compared to those who are not.  Early diabetic kidney damage can be found by screening for protein in the urine.  In addition to keeping the blood sugars down, there are medications (ACE inhibitors and ARB's) that have been shown to slow the progression of diabetic kidney damage.  The urine should be checked at least once a year with your physician.

Retinopathy: The membrane in the back of the eye that allows us to absorb light and is responsible for vision is called the retina.  Blood vessel damage causes this important membrane to become thin and degenerate.  What is the number one cause for blindness in our country?  You guessed it, diabetes.  There are early changes that can be seen in the eye by an ophthalmologist.  Each diabetic should see an eye doctor once a year to be checked.  If damage is found, laser surgery can slow down this destructive process.  In the absence of good blood sugar control, though, it is usually a losing battle.


Arthropathy: This is a less well known complication of diabetes.  It is the slow destruction of the joints, often in the feet.  The delicate arch collapses and becomes deformed.  Together with neuropathy, dangerous pressure points develop that lead to ulcers and sores.  Specialized shoes can help off load these pressure points.  Once again, good blood sugar control will completely prevent this problems.

Your Diabetic Report Card

Everyone who has elevated blood sugars should be familiar with what the normal ranges of blood sugar are as well as the ranges for the hemoglobin A1C.  These are the markers that will tell you and your doctor what kind of control is being achieved and what your risk of future problems will be.

Let's start with your blood sugar.  In a normal individual a fasting blood sugar (defined as first thing in the morning prior to eating) should be less than 100 mg/dl.  In a diabetic, the goal is to keep that level below 120 mg/dl.  Certain medications used to treat diabetes can lower blood sugar too much, such as insulin.  A level below 70 mg/dl is too low.  Levels in the 40's or 50's can be dangerous.  Low blood sugar reactions can cause spikes in blood pressure, induce heart attacks or even seizures.

Blood sugar levels after eating in diabetic patients should be less than 150 mg/dl.  The best time to check the level is two hours after a meal.  If it is checked too soon, the level will be uninterpretable.  Diabetics tend to have levels that both spike too high after eating and go down too slowly.  Some diabetics may have normal readings in the morning but higher levels after eating.  If the sugar is checked only in the morning, that may not be picked up.  Others may have readings that are higher in the morning but normal after eating.  This is due to an abnormal release of glycogen (long chains of glucose) from the liver at night.  Both conditions are bad but may be treated in different ways.

Over the last twenty years a test has been developed and validated that has greatly enhanced our ability to both detect and treat diabetes.  It is called the hemoglobin A1C.  Whereas instant blood sugar readings tell us the state in the blood vessel at any given instant, the hemoglobin A1C (hgb A1C) gives us an overall view of how the blood sugars have been over the previous three months.  The test has been validated both as a marker of control and detection of diabetes.  Every diabetic should know what their number is.  The test is a measurement of sugar molecules that form on the surface of hemoglobin (the protein that carries oxygen in red blood cells).  The life span of this protein is 3-4 months.  These short chains of glucose are measured in percentages.  A normal person will have a hgb A1C of 4.5 to 5.9%.  Early diabetes starts at 6.0%.  Levels above 7.0% are dangerous and require medications.  Repeated studies have shown that maintaining a level under 7.0% greatly diminishes the chances of diabetic complications.  That said, the time to action is not when it reaches 7.0% and beyond but the moment that it is found to be 6.0% or higher.  This is the time when diabetes can be reversed through diet and exercise.

Know your numbers.  If you are seeing your physician for an annual physical examination, your blood sugar will be tested.  It is my practice to then check an hgb A1C in anyone whose fasting glucose is above 100 mg/dl.  If you wait till you have symptoms of diabetes to be evaluated, it is too late.  Excessive thirst, hunger, weight loss, blurred vision and the like will only occur after the sugars have gone above 250 mg/dl.  The time for action is now, don't wait to get checked.

Diabetes Prevention-Earning Your Calories

Michael Phelps at work

It should be pretty clear from the last two posts that sugar in the blood stream leads to the dangerous complications of diabetes.  Just as important as what is delivered to the blood vessels is how it leaves. The greatest source of energy demand is from the muscles.  If we don't use our muscles, they won't use up the sugar.  It is that plain and simple.  Conversely, when we actively use our muscles we turn into a blood sugar burning machine.  Well conditioned athletes use up a huge amount of sugar.  In the last Olympics, it was well documented that Michael Phelps, our gold medal, world record breaking swimmer, consumed around 9000 calories a day.  Most of those were in the form of carbohydrates.  That would put many of my diabetic patients in the hospital in a diabetic coma.  He had to consume that much to keep up with the amount of calories that his muscles were consuming due to his intense training.  However, I have witnessed many swim coaches who are over weight and at risk for diabetes.  The reason?  While they were actively training they developed a habit of heavy caloric intake which was not adequately scaled back when their training decreased.  The point is that exercise allows us to be able to eat more food.

One need not be an olympic swimmer to increase his ability to burn sugar.  Intensity matters but consistency is the key.  In the days when most of our population worked on farms, type II diabetes was not very common.  Today, where many of us work at computer screens or sitting down, the incidence is sky rocketing.  That is not a coincidence.  If you are not a construction worker or a farmer, you likely need more exercise.  I've discussed this in previous posts, but it does not matter what sort of activity you engage in as long as you are moving your muscles and getting your heart rate up.  The heart rate is an indicator that the muscles have used up their store of fuel and are calling out for a new delivery.  Whatever you choose to participate in, do it regularly.  It would be nice to be able to exercise just once a week for three hours and call it quits.  If we just ate once a week, I suppose that would work, but as long as we are putting fuel in the body, we need to keep the engine running.  I recently saw a patient in the office and I told him, "I'll make you a deal...you only have to exercise on the days that you eat."  The glimmer of hope that shone in his eyes as I started my sentence quickly turned to despair as he realized the point I was making.


I enjoy eating as much as anyone else.  I love ice cream.  I have been known to have a certain fondness for M&M's.  I realize that eating such items on a regular basis is a recipe for disaster.  Some years back to curb a nearly nightly habit of having ice cream, I put together my rules for eating.  I have followed these rules now for 15 years and I'll have to say that it has worked well for me.  During the week, I make sure and eat my five servings of fruits and vegetables a day.  I avoid all sweets, junk food, and yes, even ice cream.  On the weekends, I can eat anything I want, if and only if, I have exercised at least four days during the week.  I'll admit that in the beginning, I over did it on the weekends.  By Sunday, I would often feel bloated, lethargic and I often battled headaches.  Monday would be a relief.  I now no longer go crazy and feel much better for it.  It is nice to be able to sit down and have a milkshake without guilt.  I view it as a reward rather than a transgression.  Since I have burned it, I earned it!

Diabetes Prevention-The Right Fuel

Though there is not yet a cure for diabetes, type II diabetes is certainly preventable in most people.  Yes, some inherit a genetic tendency towards diabetes but that is not a guarantee of getting the disease.  As discussed in last week's post, the key to keeping diabetes at bay is to keep down the abdominal fat stores so that the pancreas does not become overworked.  Quite simply, if you are overweight you must burn more than you take in.  I realize that this is easier said than done.  I've discussed diet and exercise before but will readdress these topics with a specific emphasis on how diabetes is impacted.  I'll start with food intake and will discuss exercise next week.

First, let's talk about what is coming in.  If the goal is to minimize the amount of glucose (sugar) that reaches the blood vessels, sweets must be avoided. Table sugar is sucrose which chemically is composed of two glucose molecules stuck to each other.  It takes nearly no effort to split them in two.  Compare that to fructose, the molecule that fruit contains.  It is composed of one glucose molecule and another called galactose.  For the same amount of food ingested, there will be half as much sugar in whole fruit than in sweets.  In addition, fruit contains fiber, vitamins and other nutrients all of which are healthy.  The fiber makes the body work harder to digest the food and thus delays how quickly the nutrients reach the blood stream.  In addition to sweets, some foods have a much higher glycemic index than others.  Think of the glycemic index as how much sugar a given food delivers to the blood vessels.  Cereals are notoriously high, though the higher fiber cereals are much better than the others.  Bread, pasta and potatoes are also high glycemic foods.  Whole grains are always better than processed ones.  The bran and fiber in whole grains makes it harder to digest and will therefore deliver less sugar to the blood stream.  For more details about the glycemic index of specific foods, click here.

In addition to the types of food we eat, the amount eaten is just as important.  Our body uses sugar to meet its metabolic demands.  If too much glucose is delivered, it will get stored either in the liver as long chains called glycogen or be processed into fat stores.  If small amounts of food are eaten frequently, total calorie consumption will not need to be decreased in order to keep the weight stable.  In fact one of the worst things someone can do when trying to lose weight is to skip meals.  When going too long between meals, the body does not receive the nutrients that it needs so it enters starvation mode.  Signals are then sent throughout the body to turn down metabolism, lessening energy demand.  In addition, cortisol is released from the adrenal gland.  One of its effects is to decrease the sensitivity to insulin, thus raising blood sugar. It is best to have healthy food nearby during the day.  Just a few grapes or a bite or two of carrots will keep down hunger and maintain the metabolism.  Keep it small and keep it healthy.  

Lastly, eating a large meal late in the evening prior to going to bed is a recipe for disaster.  Very few of those calories will be metabolized.  The exception is if you chose to exercise in the evening before eating.  Exercise turns on a muscle enzyme called alcohol dehydrogenase.  It is quite good at burning up glucose.  It stays active in the muscles for 2-3 hours after exercising.  If you are going to have foods with a higher glycemic index, the time to eat them is during this window of opportunity after exercise.

Defining Diabetes

Diabetes is becoming more and more prevalent.  If you do not have diabetes, I am sure that you know someone who does.  As of yet, there is no "cure" for diabetes.  However, diabetes can be prevented and controlled.  Patients with controlled diabetes can live a normal life span.  The key to controlling and possibly preventing diabetes is to understand its cause.  With proper understanding it becomes easier to adhere to the practices and treatments that will keep diabetes in check.

In our body, sugar or glucose is used by our cells, especially muscle cells, for fuel.  This is the main reason why we eat, to provide fuel for our body.  Glucose is delivered to our cells by way of our blood vessels.  Elevated levels of sugar in the blood stream cause damage.  Since we have blood vessels going to every organ system of the body, diabetes can adversely affect them all.  I like to think of Insulin as a key that unlocks and opens the doors from the blood stream to the cells.  This allows glucose to exit from the vessels to be used for fuel.  Diabetes occurs when there is too much sugar in the fuel lines instead of in the cellular engine.  There are two types of diabetes, type I and type II.  Patients with type I diabetes have an absolute lack of insulin.  This is usually due to a destructive immune response.  It is felt to be triggered by a viral infection and it results in the destruction of all the cells that make insulin.  A patient who has had their pancreas removed surgically would functionally have the same disease.  These patients must take insulin.  I will not discuss this type any further but will now focus on type II diabetes.

This is the type of diabetes that is taking our country by storm.  It is truly reaching epidemic proportions.  It is closely related to being overweight.  It is caused by a resistance to the effect of insulin initially and then a gradually increasing lack of it as the disease progresses.  The problem originates because of abdominal fat stores.  These stores release short fatty acids, which like glucose can also be used for fuel and enters the cells through the same doors.  It is like a bus load of students who have arrived at a museum.  Once they are in line to enter if another bus load arrives and mixes with them it will take much longer for them to all get inside.  The only was to get them in quicker is to open up twice as many doors.  If you have equal amounts of glucose and fatty acids competing to get into a cell it will take twice as much insulin to open enough doors for the glucose to exit out of the blood vessels.  For a time the pancreas just spits out more and more insulin to keep the blood glucose level normal.  Over time, though, the pancreas is no longer able to produce a sufficient amount of insulin to keep up with the demands and the blood sugar begins to rise.  When the pancreas completely burns out, it becomes functionally like type I diabetes.

Diabetes does not begin when the blood sugar rises but many years before that.  If you have more than an inch or two extra around your waist, you are putting stress on the pancreas and increasing your chance for diabetes.  Though there is no cure for diabetes, most of type II diabetes can be prevented.  It is all about the supply and demand for blood sugar.  What we eat greatly influences how much sugar is delivered to the blood stream.  How much we exercise is the major determinant in how much sugar the cells use up for fuel.  In a person who is prone to diabetes the proper diet and adequate amounts of exercise during the time when blood sugars are still normal will completely prevent diabetes for developing.  Waiting until the blood sugar rises may be too late.  We all need to be concerned with this whether or not we have been told that we have a problem.  With this definition in mind, stay tuned as I discuss the treatments for diabetes in more detail next week.

Sleeping Soundly

We all know how wonderful a good night's sleep feels.  It is hard to beat the feeling of waking up, feeling refreshed, and being ready to tackle the day.  For many, such a morning is more a dream than a reality.  Too many wake up feeling sluggish, tired and ready to go back to bed.

Poor sleep has been linked to poor health.  For those that snore and wake up tired, ask your spouse or family member if they ever see you stop breathing between snoring.  You could have a condition called obstructive sleep apnea.  It not only will give you a headache on waking up, it will make you tired during the day.  It has even been linked to an increased risk of having a car accident.  It puts a stress on the heart, raises blood pressure and increases the chance of having a stroke.

Most of us know what stress will do to our sleep.  When the heart is pounding, our limbs are shaking and our mind is racing, it is hard to fall into the calmness of sleep.  What we really need is not to just get to sleep but to sink into a deep sleep.  Medically we refer to that as "REM" sleep.  During this stage our muscles become so relaxed that they are essentially paralyzed.  This is what makes sleep so refreshing.  Most researches feel that patients with fibromyalgia are not able to get into that deep stage and thus wake up feeling stiff, sore and tired.

The drug companies would have you believe that the cure for insomnia is to simply take a pill that will allow you to flit off into dreamland with the butterflies.  Sedative medications do make one feel sleepy but they do not induce REM sleep.  What research I have seen in regards to a patient's ability to function the next day universally shows that people who use sleeping pills score more poorly on their ability to perform tasks than those that do not.  To truly help insomnia, the underlying cause must be found and corrected.  If it is due to obstructive sleep apnea, your physician can order a sleep test to diagnose and guide treatment.  If it is due to side effects of medications, those can be adjusted.  If acid reflux is the cause, there are treatments for it.  The same is true for those getting up frequently to urinate.  Some may have uncontrolled pain from arthritis or other conditions.  The majority of patients I see likely suffer from stress that affects their sleep.  Many don't want to acknowledge that their stress is affecting them in this way.  I have many patients who would be willing to take a "sleeping pill" but not to take a medication to control their anxiety.

Lastly, our behaviors can make sleep both better or worse.  There is something to be said for having a bedtime.  Getting off schedule can be a serious problem as any shift worker can likely attest.  Keeping stimulation low prior to going to bed is helpful.  This is a good time to stay off the computer, put down any work and let the mind relax.  Stay away from food and beverages prior to bed, especially anything with caffeine.  Never use alcohol to help you sleep.  It may make you calm as you go to bed but invariably it will trigger you to be more alert and awake four hours later when you need to be in that deep stage.  Regular exercise is so important. By working your muscles earlier in the day, they are much more likely to relax later.  If you do wake up at night resist the urge to turn over and look at the clock.  When your mind is asked to look at the numbers, compute what that means and elicit a negative response to having only slept till 2:00 AM, you have now activated your brain to the point that makes it even harder to fall asleep.  Keep your eyelids shut.  Focus on calm, regular breathing.  More often than not you will be able to drift back to sleep.  In the morning you will be ready for a brand new day!

How Hard to Push

It is not uncommon that I am asked about exercise.  Am I working out hard enough? How much is too much?  We have all heard of people who have gone out to exercise and had a heart attack and died. What is one to do?  How should one start and with how much intensity?

First of all, make sure that you meet with your doctor prior to starting an exercise program.  For the vast majority of people it will be quite safe to start exercising without any further testing. There are some patients who will need to make sure that there are no blockages in the heart arteries prior to beginning.  Your doctor will make that judgement.

The best way to start exercising is slowly and gradually.  It is more important to build a habit in the beginning than it is to build muscles and endurance.  The worst thing that can happen is to jump into a program aggressively and get injured.  That will just lead to discouragement, making it even harder to get back into a regular regimen. I would start just three days a week.  It may be for only 5 or 10 minutes.  Every day build it up little by little.  Ultimately, you want to be doing some sort of exercise for 45 minutes at a time, four days a week.  That is the goal.  More is even better.

The intensity with which you work out will vary depending on the activity.  In the beginning, I do not suggest that you track your heart rate.  Again, it is more important to just make the habit of exercising.  Certainly if you feel short or breath or dizzy, stop exercising and check your heart rate.  To calculate your heart rate, count the number of beats in fifteen seconds and multiply that by four.  If you feel your pulse and there are 20 beats in fifteen seconds, your heart rate is 80 beats per minute.  The maximal predicted heart rate for steady cardiovascular exercise can be calculated by subtracting your age from 220 and taking 80% of that.  If someone is 56 years old, 220-56 is 164.  My way of figuring out 80% is to take 10%, double it and subtract it again.  In this case 10% is 16, doubling it is 32; 164-32=132.  This is not a number that if surpassed will lead to immediate death.  It is just a recommendation to keep you at a steady level.  If short burst of exercise raise your heart rate above this level and do not cause dizziness, excessive shortness of breath or chest discomfort, that is acceptable.

If during exercise you start to feel any of the above mentioned symptoms, it is not time to panic.  It is time to stop and let your heart recover.  Lay down so that blood will get to your head.  Get some fluid in you.  Make sure you stay well hydrated during your work out. If you exercise for more than 30 minutes, you need to have a water bottle with you.  If you go for more than 45 minutes, you should add carbohydrates and electrolytes such as a sport drink or energy bar.  If resting for five minutes does not result in feeling better, you should get assistance.  Remember, keep moving but let's make sure to use common sense.

What is Health?

I came across an interesting article in the New England Journal of Medicine this week that gave me cause to think about health in general and how it is measured.  The study was looking at asthma and studied it in two ways.  The first was by measuring the amount of air a person exhales in one second.  This is quite standard and is used frequently to see how well one is doing with their disease.  The second measurement was to simply ask the patient if they were feeling short of breath or not.

There were three groups of patients.  One group received an inhaler containing albuterol.  Again this is a very standard medication used to treat asthma.  It relaxes the muscles that surround the airways allowing for improved passage of air.  Another group received acupuncture and the third group received a fake treatment-or placebo.  In regards to the air measurement, the medication was overwhelmingly effective compared to the other two arms.  However, by symptom scores the acupuncture and the medication were rated the same.  The question then is asked, which group was healthier?  It is easy to say that it is the group with the best airway measurements but that is not why patients come to see the doctor.  They do not come and state, "doc, I just don't feel like I am getting enough air out of my lungs in the first second that I breath."  They say, "I am short of breath."  From a doctor's standpoint, what recommendations do I give my patients?  I would enjoy hearing what you think about this.

As I have contemplated this further, I have thought that we cannot just go by how a patient is feeling.  There are plenty of medical conditions that can be detected at an asymptomatic state.  If nothing is done at the time, the disease can progress with possible deadly consequences to follow.  For example, why would anyone agree to undergo screening for colon cancer?  This requires taking medication to flush out the colon, go to a facility where powerful sedative medications are given so that a scope can be inserted into the colon.  None of that is going to make a patient feel any better.  However, if a polyp is found, cancer is averted.  The consequences of not finding colon cancer at an early stage are far worse than what it takes to have a colonoscopy performed.  Another example is hypertension.  It is called the silent assassin for a reason.  For many years there will be no symptoms in patients with elevated blood pressure.  Eventually, though, the heart will either weaken, develop arrhythmias or succomb to a hear attack due to blood vessel blockages.  Strokes can occur in the same fashion.  Therefore, the answer to the question, "why would a doctor recommend that a patient who feels fine take a medication that may have side effects?" is that it just may save their life.

Continuing with the theme of hypertension, let me ask: Who is healthier?  A patient with a blood pressure of 120/78 who is taking three medications to keep his blood pressure down, is overweight, does not exercise and eats out about twice a week? or a patient with a blood pressure of 120/78 who is on no medications but exercises five days a week, keeps his weight down and watches what he eats?  The answer seems obvious does it not?  However, I frequently see patients who will look at the number, take the pills and make no effort to do more on their own feeling that everything is just fine.


In summary, health, I believe is more than how we feel, though that is an important component.  Health is also how we live.  Health is more than the absence of disease.  Healthy living lowers our risk for future disease as well.