"Lung Painters"

Sick in the ICU, my patient's heart was beating so fast that her heart, stiff from years of untreated high blood pressure, couldn't keep up.  Her kidneys were starting to fail because the heart couldn't get enough blood to them.  Her lungs were struggling mightily both from emphysema and the fluid building up from her heart.  Wanting to comfort her as well as she could, the nurse, entering the room, asked, "Can I get you anything?"  Without a moments hesitation, my patient responded, "Yeah, get me my cigarette."

My patient did not lack for knowledge in regards to the dangers of smoking.  She knew full well that it was the cause of her emphysema and was the main contributer to her high blood pressure.  The addiction is so powerful, it did not matter to her.  I have spent my career educating my patients to the dangers of smoking and encouraging them to quit.  I am the eternal optimist and will never quite trying.  I am pleased to say that a 95 year old patient of mine decided to quit with my prodding.  I understand, though, that the knowledge of the dangers of smoking will only take people so far.  They need a cheerleader.  They need support at home.  Children are some of my best co-conspirators.  If one of my smoking patients comes in with a child, I will look the child in the eye and commit them to be my partner.  I ask them to hide the cigarettes and watch out for Mom or Dad.  My daughter drew the "Lung Painters" picture as a nine year old.  I have it framed and hung in an exam room.  Many patients have looked at its simple message and given the decision to quit another look.  Who wants to have a "gurntee" to have your lungs turned black?

I'll have to say that my biggest ally in helping people quit smoking has been the government.  I can talk till I'm blue in the face or get on my knees and beg (which I'll happily do if it would work!) but I've noticed that the willingness to quit has increased in direct proportion to how much it costs to buy them.  The cigarette tax works.  I can now tell patients, "It is too expensive to smoke anymore, you need to save your money for gas."  Restricting smoking in public places has also helped.  "I might as well quit," I've heard, "I can't smoke anywhere, anyways."

What is the best way to quit smoking?  The best way is whatever works for you.  There are medications that now directly attack nicotine receptors and work well.  I have seen people do well with hypnosis, with electrical current placed on an ear lobe.  Support groups are good.  The nicotine patches and gum work well. The word is not yet out on the "electronic cigarette" but I say if you want to try it-do it.  Almost anything is better than smoking.  Some can just out and out quit on their own.  My own grandfather had a hard time quitting.  He tried over and over again.  He probably felt as did one of my patients who said, "quitting smoking is easy, I do it every week!"  One of those weeks, he was out plowing his potato field on the tractor.  He took his cigarettes, crumpled them up and threw them in the dirt.  By the time he reached the end of the row he started wanting a cigarette.  Turning around he started scanning for his discarded pack.  When he returned to the area where he had thrown down his cigarettes, he jumped down off the tractor and started digging through the dirt.  Something about a grown man on his hands and knees, digging through the dirt was so ridiculous that he started to laugh at himself.  "How pathetic", he said.  From that moment on he let them lie in the dirt, where they belong.

Medication Mayhem

As a physician who spends much of his day prescribing, renewing or monitoring medications you may find it unusual for me to advocate using less of them.  As with the air we breath, the food we eat, the beverages that we drink and the supplements we consume, we should be mindful of everything that goes into our bodies.  This applies particularly to prescription medications.  There have been wonderful scientific advances in the development of medications.  The incidence of rheumatic heart disease (basically strep throat of the heart valves) is almost nonexistent now.  The incidence of death due to heart disease has dropped dramatically to the point that this number one cause of death is now being rivaled by cancer.  There now exists for cancer, many treatments that can cure or at least greatly prolong life.  Medications have been developed that have transformed the AIDS epidemic from a universally deadly infection to one of managing chronic HIV infection.

As great of an effect that medications can have, there are possible down sides as well.  Some medications which were thought to provide benefit have been taking off of the market when they were later found to increase disease or death in unforeseen matters.  A commonly prescribed group of anti-inflammatory drugs were found to increase the risk of heart attacks.  A diabetic medication was found to cause liver failure.  Devastating birth defects occurred due to an anti-nausea medication used by pregnant mothers.  Certainly, if medications are used they should be used for well established needs in a setting where one is watched and monitored so that the desired effects are achieved and regular reappraisals are made to ascertain if untoward effects are being experienced.  As time goes on, there may be better options available or new information while come to light that would indicate a better coarse of action.

Of particular concern in my mind are medications that are not used to prolong or save life but rather to improve symptoms.  Pharmaceutical companies are particularly interested in developing these medications because they can be marketed to a large number of people.  Immense profits have been made from these drugs.  The marketing of these drugs has advanced the thought that there is "a pill for everything."  The peril comes when a patient takes one medication to assist in maintaining attention and focus only to be stimulated to the point of not being able to sleep well at night.  A sleeping pill may be prescribed only to find that the system as a whole has been slowed down causing daytime sluggishness and constipation.  Similarly, the need for pain medications needs to be monitored closely.  I have seen patients come to the hospital due to life threatening bleeding from stomach ulcers.  Upon further questioning it was found that the patient had ingested a large amount of common, over the counter anti-inflammatory medications to treat chronic headaches.  The medication not only caused the ulcer but in and of themselves were perpetuating the headaches.  In other situations, if narcotic based medications are used for more than a few weeks, the dose invariably will be escalated as the body will build up tolerance to them and they will lose their effectiveness.  In addition to the constipation that almost all who use these medications experience, we are now finding syndromes of inappropriate nerve activations, that can also be debilitating.  If a medication is to be used, it should be given for a clear reason and for a predetermined length of time.

Lastly, if one has multiple chronic medical conditions, I feel that it is imperative that the patient regularly sees a primary care Internal Medicine physician to coordinate care between specialties.  An extreme example is a patient I saw once who was taking over twenty different medications.  The patient was seeing about five sub specialists, each of whom prescribed three or four medications.  There have not been any studies performed with patients in a similar situation.  We have no idea what kind of interactions may occur.  This is especially true in the elderly where medications are not metabolized as efficiently as they are in younger people.  If you are concerned that you may be on too many medications, it is perfectly reasonable to ask your physician if any of them can be cut back or discontinued.  This is especially true if changes in life style can result in reducing the need for many of these medications.  Make sure your medications make a difference, not mayhem!

Drink Up!

One of our staff members one day asked, "I heard that there is a great new drink out for diabetics.  It has no calories and is supposed to be real good for you, did you hear about it?" Passing by, my partner turned to her and said, "Yeah, it's called water."  Yes, water...the forgotten beverage.  Most of the earth is covered by it.  Wars have been fought over it.  More than sixty percent of our own bodies are composed of it and yet the amount of money that is spent and the amount of calories that are consumed in other beverages is staggering.

We are so fortunate to live in a society where we can turn on a tap and receive good, clean water.  There are still many places across the world where that is not the case.  A clean water supply has done more for the health of our society than any other single intervention.  At the level of our own body, water affects every single physiologic process.  The easiest to consider is our blood volume.  The contents of the blood, such as the oxygen carrying red blood cells must travel to every part of the body.  Without water, it is impossible.  The water in our blood stream allows other organs such as the kidney and liver to filter out waste products and toxins that we are exposed to.  The more that can be filtered out, the healthier we are going to be.  A low flow of urine in some people can lead to the formation of tiny crystals.  Over time these can grow big enough to lodge in the tubes that drain the kidneys causing incredible amounts of pain in the form of kidney stones.  Muscles contract according to differing concentrations of calcium and other molecules that flow across cell membranes.  That flow is dependent upon water.  The number one way to decrease painful muscle cramps that some people at night is to drink more water.  In a similar fashion, nerve activation is dependent upon flow of small molecules across cell junctions.  Without adequate hydration, the responsiveness becomes sluggish.  The intestinal tract is dependent upon enough ingested water to safely carry that which cannot be absorbed out of body for elimination.  Can you guess what the number one reason why constipation occurs?  You guessed it, not enough water.  Think about your skin.  How much money is spent on skin moisturizers?  They work by holding moisture in but if we are not drinking enough water to begin with, it won't do any good.

I have been accused, rightly so I may add, that the answer to almost all problems is to drink more water and exercise.  When thought about in regards to how our body works it makes sense.  Water allows all those processes discussed above work better.  Exercise increases the flow of blood throughout the entire body.  It makes sure that the water we ingest gets to all the cells that need it.  I cannot tell you how many times I have seen patients who complain of feeling sluggish, fatigued, achey, etc who come back feeling so much better, and often 15-20 pounds lighter, after having switched from drinking alcohol, soda and tea to simply drinking more water.  I call it "God's Soda," it comes straight from heaven.  Try to get eight, 8 oz glasses of water in a day.  Have a source of it near you at all times. Here's to your health.  Drink up!

How Much is Too Much?

Nothing is quite so controversial as alcohol ingestion.  A small amount of red wine has been shown to improve the HDL (good cholesterol) and is felt to be good for the heart.  I define a "small amount" as four glasses a week for women and six for men.  Given the very real risks of drinking too much alcohol, I feel there is absolutely nothing wrong with complete abstinence.  I have noticed in my practice an interesting phenomenon as I see new patients.  We have them fill out a personal health inventory which includes a family history.  I have yet to see a patient come in and report that they have a problem with alcohol.  Some will report that they had a problem in the past.  It is, however, very common for patients to report that family members have an issue with drinking too much alcohol.  It is easy to deny that there is a problem.  Here is a list of four simple questions.  If you answer yes to any of these, you should speak to your doctor about your alcohol intake.

1. Have you ever felt like you should cut down on your drinking?
2. Have people annoyed you by criticizing your drinking?
3. Have you ever felt bad or guilty because of your drinking?
4. Have you ever taken a drink first thing in the morning to steady your nerves or get rid of a hangover?

It surprises many to learn that the definition of a "heavy" drinker is someone who has three drinks per day.  I remember questioning an older man who when asked if he drank alcohol, he responded "only occasionally."  After further questioning he reported having 4-5 beers a day.  Surprised, I reminded him of his previous response.  He declared, "I'm from South County (home of Anheiser Busch), that is what we drink.  I don't drink alcohol."  He was not pleased to hear that yes, beer counts as alcohol too.  Water remains our best source of hydration.

The adverse affects from alcohol are numerous.  It is well known to be toxic to the developing fetus.  Our brain is affected short and long term.  Chronic balance issues are seen as well as cognitive (thinking/memory) functions.  It can even cause a peripheral neuropathy in our arms and legs (numbing nerve damage).  The majority of all fatal car accidents involve alcohol.  In our digestive tract it is more than just the liver that can be damaged.  Alcohol is tied to acid reflux and esophageal cancer as well.  The pancreas is certainly involved.  The heart can be weakened and it is well known to trigger rhythm problems such as atrial fibrillation.  This is just a short list.  Do you want to be healthy?  Keep the alcohol to a minimum.

Take Your Vitamins

Most of us from an early age remember our mother imploring us to "take our vitamins."  I often get asked by patients what I think about taking vitamins and which ones they should take.  The array of choices is enormous and confusing.  Again, let me try to simplify.

I take vitamins every day.  I take no pills or capsules.  I don't like to take medication if I don't have to.  Now you may say, "Doc, these aren't medication, they are vitamins."  I frankly don't understand the logic of making a distinction between synthesizing vitamins and making them into pills and capsules and synthesizing other materials to be used to treat medical conditions.  Many medications are "natural."  We grind up the foxglove leaf and make something called digoxin.  If used improperly it is a very dangerous medication.  There are chemotherapy agents that come directly from the bark of the Yew tree.  Again, natural but potentially dangerous.  Just because something is purported as natural does not make it safe.  In fact, the vitamin/herbal remedy industry concerns me a great deal.  It is an unregulated industry.  Studies have been done analyzing the exact ingredients in some of these products.  One, claiming to aid in sexual function, found traces of Viagra in the tablets.  Others have found traces of Arsenic and Lead.  In my mind, the best way to take vitamins is in their natural form.  The more colorful your food is, the more vitamins we will get.  Make your goal to eat four to five servings of fruits and vegetables a day.

God's Vitamins

How much is a serving?  The size is relatively small, so this is not as hard as one might think.  It is basically a cup.  That is only six small baby carrots.  Most apples would be a cup and a half.  The CDC has a great website called, fruitsandveggiesmatter.gov.  We can and should receive almost all of the vitamins that we need through our diet.  It is always healthier to ingest the whole food, which includes fiber and other nutrients, than pills and capsules which don't.

Man's Vitamins

Let me discuss a few specifics.  First, what about Calcium?  Recent studies have shown the benefit of getting our calcium through dairy sources rather than supplements.  Most people need about 800-1200 mg of calcium a day.  Each serving of dairy has about 300 mg of calcium.  If extra calcium is taken, make sure it has at least 400 units of vitamin D with it.  Taking supplemental calcium without the vitamin D has been linked to higher rates of heart disease.  Take the calcium with a meal, which will help its absorption.  It does not matter if it is calcium carbonate or calcium citrate as our stomach acid will allow either to be absorbed equally as well.  If you are taking medicine that decreases stomach acid (like Prilosec, Prevacid, etc) then calcium citrate will be a better choice.

Vitamin D helps our body absorb calcium and we are learning of the many other benefits that it has as well.  It comes initially through plant products and most dairy (having been added or enriched).  We should get between 800-1000 units a day.  The active form of vitamin D requires sunlight.  We live in a society where we are getting less and less sun.  We know the dangers of skin cancer are real.  But as little as 15 minutes of sun exposure a day, 3 days a week is sufficient to activate our vitamin D.  The next time you see your doctor, ask if it is appropriate to check your level, especially if you have naturally darker skin.  It is harder for the sun to penetrate in these individuals and they will need more exposure to the sun or may need to take a supplement.

There are many vitamins sold to enhance "prostate health."  This varies from vitamin E to selenium and lycopene.  A very large study recently has shown that selenium is not beneficial.  Lycopene did help but not in the supplement form, only as a dietary source.  Your red fruits and vegetables are the ones that have lycopene.  Again, the more color in your food, the better.

If you have specific vitamin questions, leave a comment.  Remember always to take your vitamins!