Using "E-Cigarettes" to quit smoking

As part of my duties as a volunteer teacher at Washington University, I periodically have medical residents (doctors in training) spend a month with me at the office.  I have been fortunate to have Dr. Seema Mahale with me this month.  She will be entering the practice of medicine in a few weeks and has been wonderful to work with.  I invited her to write a post for my blog.  She graciously accepted.  I hope you enjoy!

Dr. Mahale's post:

As I was walking by a kiosk at the mall, I was approached by a salesperson selling E-cigarettes.  While I didn’t buy into the man’s pitch that I will look very sophisticated and cool with an e-cigarette, I couldn’t help but wonder if and how this new device could be used to help people stop smoking. 

First I needed to find out how e-cigarettes work. It turns out there are several different styles available, but the main idea is there is a network of metal filament heated by a rechargeable power source that heats a liquid reservoir. A vapor then is created that the user can inhale. The liquid is made up of water, flavorings and nicotine.

Unfortunately, there have not been many studies done to see the potential beneficial use of E-cigarettes and there are differing opinions. The FDA looked at many different brands of E-cigarettes and studied the content. They found there were traces of tobacco specific impurities that are associated with adverse health effects. Their report also notes there is no way to predict the amount of nicotine actually delivered when inhaled. The FDA also feels E-Cigarettes may even promote younger generations to start smoking since it is a new device. Based on this, the FDA does not feel E-cigarettes can be used for smoking cessation.

However, a small study done by Boston University School of Public Health found that E-cigarettes are much safer than real cigarettes. While E-cigarettes do contain carcinogenic components, the amount is 1000 time less than real cigarettes. The study goes further to suggest that E-cigarettes can be used as an aid to stop smoking as it mimics motions that one does while smoking.

There is no doubt that smoking is bad for you. It increases the risks of several disease such as cancer most notably lung cancer, heart disease, emphysema and poor circulation. However, it is very difficult to stop smoking, as it is one of the most addictive substances available.  Therefore, I feel it is important for one to realize all the different modalities available to help kick the habit. Some combination of counseling, support from family and friends, medications (such as Chantix and Wellbutrin), and nicotine replacement (patches, gums, etc.) are needed for one to be successful to be become smoke free.

I feel E-cigarettes can help people stop smoking and most importantly by using E-cigarettes people are not exposed to such harsh chemicals. The bottom line is a person should pick the method that works for them the best. While it may take multiple attempts, quitting smoking is the most important things you can do for your health. 

Fact or Fiction: High Cholesterol-Part 2

"I was in for my annual physical two weeks ago and the letter you sent me said that my cholesterol reading had increased from 210 to 216 over the last year.  You said you wanted me to come back in 6 months to get retested.  My questions are:

1.       I take one 900 mg fish oil tablet a day - would it be beneficial to double that?

2.       Some of the "natural" remedy information indicates that cinnamon tablets are helpful - any thoughts on that?

3.       My wife wants me to take "Cholest-Off" which is advertised as an all-natural means of reducing LDL numbers - would that be worth trying?

4.       Any thoughts on the Juice Plus program and if that might help?

5.       I eat a fair amount of peanut butter at lunch and drink 2% milk most nights for dinner - is that a problem?

I am eliminating or reducing my favorite vices - brats and ice cream sandwiches - probably  a good thing no matter what my cholesterol number is."  Name Withheld


The last post described what cholesterol is and how it can be damaging.  I want to go back to this email and discuss some of the issues that were brought up.

Let's start with fish oil.  It has been observed that a diet high in fish consumption is protective for heart disease. Now to be clear, seafood itself is not healthy, it is fish.  Crab, lobster, clams and other shell fish are actually bad for us.  It is the fish that swim that are healthy.  For many of us it is tough to eat fish 3-5 times a week.  For that reason it was thought that purifying the oils contained in fish could be used as a supplement.  Sure enough, fish oil has been shown to lower cholesterol, specifically the triglyceride fraction.  Within the last few months a study has come out that looked at whether or not this would lead to a decrease in the rate of heart attacks.  Those in the study had the expected improvement in their triglyceride levels but unfortunately there was no benefit in the heart attack rate.  It is only one study but it is the best information we have so far.  My feeling is that if you sit down to a big steak dinner and pop a fish oil tablet, you are not going to do yourself any good.  One of the good things about eating fish is not just the oil but it is also the fact you will not be eating something else that is not healthy.

What about cinnamon tablets?  Quite simply, I have seen no data in regards to cholesterol lowering effects of cinnamon.  I have seen modest data in regards to lowering blood sugar.  The effect is quite small.  Avoiding sweets will have a much greater effect on lowering blood sugar than ingesting a little bit of cinnamon.

  

Moving on, let's discuss "Cholest-Off."  This is a plant based sterol put in margarine that has been shown to lower cholesterol levels.  It has actually been around for several decades.  The effect is not huge but it has been demonstrated.  If an oil spread is going to be used, it is best to pick one that works for you, not against you.  It has also been put into capsules aswell.  I have no problems with "Cholest-Off."

The next item is "Juice Plus."  The idea behind this product is to get the benefits of multiple servings of fruits and vegetables in a few capsules.  I know of no data showing that it helps cholesterol levels.  It is high in vitamins.  My biggest concern is that people will take these capsules and fail to eat fruits and vegetables.  If so, the food they do eat is more likely to be of a lesser quality.  Eating fruit and vegetables is more than getting vitamins.  It is filling up with good fiber and an excellent source of water.  The more whole food and fruit that we eat, the better off we will be.  I do not endorse this product though it is safe.  Let's make sure and get our 4-5 servings of fruits and veggies in a day.

What about peanut butter and milk?  Peanuts are a decent source of protein but peanut butter is usually about 70% fat by calories.  It is not the worse thing that can be eaten but if one has high cholesterol, there are better alternatives.  In regards to milk, it is all about the fat.  Two percent is better than whole milk but not as good as skim milk.  I drink nothing but skim.  I think it tastes great.  Your taste buds will adjust, you don't need the extra fat.

The last paragraph on this email is my favorite.  Nothing we have discussed so far will make a difference at all if the brats and ice cream sandwhiches are still being eaten.  I can think of nothing worse for cholesterol than brats.  It is like a wrapper for fat.  Ice cream has the distinction of being the deadly double.  It has both fat and sugar in it.  No amount of cinnamon, fish oil, Cholest-Off, red yeast or even Lipitor will negate eating poorly.  It is not rocket science, it is quite straight forward.  If we use our common sense over our taste buds we will be "simply healthy."

Fact or Fiction: high cholesterol

I recently received an interesting email:

"I was in for my annual physical two weeks ago and the letter you sent me said that my cholesterol reading had increased from 210 to 216 over the last year.  You said you wanted me to come back in 6 months to get retested.  My questions are:

1.       I take one 900 mg fish oil tablet a day - would it be beneficial to double that?

2.       Some of the "natural" remedy information indicates that cinnamon tablets are helpful - any thoughts on that?

3.       My wife wants me to take "Cholest-Off" which is advertised as an all-natural means of reducing LDL numbers - would that be worth trying?

4.       Any thoughts on the Juice Plus program and if that might help?

5.       I eat a fair amount of peanut butter at lunch and drink 2% milk most nights for dinner - is that a problem?

I am eliminating or reducing my favorite vices - brats and ice cream sandwiches - probably  a good thing no matter what my cholesterol number is."  Name Withheld

I thought this would serve as a good launching point to discuss cholesterol.  Let me first explain what cholesterol is, what it's function is and how it can cause problems.  

Cholesterol is basically blood fat.  It is made mostly in the liver and is used in the body to create the membranes that keep our cells intact.  There are many different components to it.  The most important to understand are the LDL (low density lipoprotein), the HDL (high density lipoproetein) and the TGs (triglycerides).  The LDL particles are the most atherogenic (meaning they cause blockages in the arteries).  When in excess, they will be deposited in the membrane of blood vessels and start an inflammatory process resulting eventually in build up or "plaques."  They are referred to as the "bad cholesterol."  HDL particles are like tiny little fat vacuums. They circulate and will take up the extra LDL and other fat particles keeping them from forming plaques.  The higher the HDL, the better off you are.  The triglycerides are particles that are less toxic than LDL particles but still harmful.  Together with fatty acids, they will also strain the body's metabolism and increase insulin resistance, which can lead to diabetes.  

The total cholesterol is the sum of the LDL and the HDL and 1/5 of the TG's.  We typically say that the total cholesterol should be less than 200 mg/dl.  However, that depends on the makeup of the other particles.  For example, I just saw a patient whose total cholesterol was 240 mg/dl.  That seems rather high but her HDL was outstanding at 135 mg/dl.  Her LDL and TGs were well within the normal range so her cholesterol  profile was perfectly normal.  I could only wish mine be so good.  We would like to see everyone above 40 mg/dl for the HDL.  As of yet there have been no good medications developed to increase the HDL.  Regular cardiovascular exercise remains the best way to increase it.  That and having good genes.  

The LDL is partly genetic but greatly influenced by the foods that we eat.  The culprits tend to be animal fats (red meat, bacon are the worse).  Butter and other oils which are solid at room temperature are also dangerous.  The LDL in low risk individuals should be under 130 mg/dl.  In higher risk patients it should be less than 100 mg/dl and even some studies show that driving it down to 70 mg/dl gives additional benefit.  Those at high risk are anyone who has had a heart blockage, those who have blood vessel disease elsewhere such as in the neck, brain or legs, and anyone who has diabetes.  I'll talk more about specific dietary recommendations in a future post.  

The triglycerides are the easiest to lower without medication.  They are increased by ingesting too much greasy food, alcohol and simple carbohydrates.  Sugared beverages are some of the worst culprits.  Even the simple carbs in bread and pasta can cause elevated triglycerides.  The TGs should be less than 150 mg/dl.  A level over 200 mg/dl greatly increases one's chance of developing diabetes.  At very high levels, such as 800-1000 mg/dl, pancreatitis can even be triggered.  

With a basic understanding of the cholesterol components, I can now start answering the questions I received above.  Stay tuned next week for some answers!

The Statin Scare

Many of you may have heard the recent news in regards to the FDA updating the risk profile for the common cholesterol lowering medications referred to as "statins."  As portrayed by the media, if you take this medication you are sure to end up with dementia and crippling diabetes.  Let me share my perspective on this situation.

First of all, it must be reemphasized that statin medications have unequivocally resulted in lower rates of death due to heart disease.  Even in the short time that I have been in practice I have seen far fewer patients develop heart disease, suffer heart attacks or had the need for procedures and surgery.  This certainly is not due to the population eating better and getting more exercise since obesity rates have steadily climbed higher and higher over that same time period. It is due to driving down cholesterol levels, largely from statin medications.  This has been quantified to about a 25% decrease chance of death in those who take the medication.  That is very substantial.

Now to the cautions.  I'll be the first one to say that I do not want to take one of these medications.  I put a lot of time and effort into exercising regularly and eating right so that I do not have to.  I have grandparents who had heart disease and stroke.  My father was recently put on a statin medication.  I may have to take one some day but I will do all in my power to lower my risk through non pharmaceutical means first.  If my levels raise despite my best efforts I'll have no second thoughts about trying a statin medication.

The FDA highlighted two main concerns.  The first is the "reports of memory loss."  This sounds like the medicine can cause dementia.  That is as scary a thought as having cancer.  I have dementia in my family as well and have no desire to head down that path.  What has been reported is not dementia but more of a "brain fog." Patients describe this as muddled thinking, not being as sharp.  The good news is that this is totally reversible.  It goes away when the medications is stopped.  It happens quite infrequently but I have seen it in my practice on occasion.

The second concern is for elevated blood sugar readings.  As a prescribing physician I have not seen diabetic patients have problems with their blood sugars after taking the statin medications.  I wonder if this is related to the population becoming more obese.  That would be a reason both for having elevated cholesterol levels requiring medication as well as being predisposed to developing diabetes.  It is important to understand that the lower cardiovascular risk seen in studies using statin are the most robust in the subset of patients who have diabetes.  It is currently considered to be bad practice to avoid statin drugs in diabetics whose LDL cholesterol values are over 100 mg/dl.  Dr. Amy Egan, the deputy director of safety for the FDA's metabolism and endocrinology division summed it by saying, “Clearly we think that the heart benefit of statins outweighs this small increased risk, But what this means for patients taking statins and the health care professionals prescribing them is that blood-sugar levels may need to be assessed after instituting statin therapy” (link here).


If you have concerns, by all means share those with your physician but don't stop taking your medication till you do.  These are life saving medications.  They need to be treated with care, yes.  The risks of not taking them may well be higher than the risk of stopping them.  

Managing Medications

I hold out hope that some day, I'll be able to send my patient to the lab for a "hypertensive DNA genotype array" which will check a person's genetic makeup and tell me why an individual has high blood pressure and which medicine will work the best for that particular patient.  We have learned much in the last 50 years in regards to why people have high blood pressure but we do not have a simple way as of yet to apply that on an individual basis.  As of right now when a patient needs medications to control their blood pressure, we as physicians use our knowledge, experience and our best guess as to what will work for a given person.  Trial and error is inevitable.  Some patients may require three, four or even five separate medications to control their pressure.  Others may be able to do it with life style changes alone.  Each medicine may have side effects that might limit its usefulness.  One may need to be stopped and another started.  As discussed previously, though, it is essential to get the blood pressure down and to keep it down.

I want to reemphasize that it is always better to be on less medication if possible.  I talk to all my patients with high blood pressure about their salt intake but very few of them really take me seriously.  I believe that it has a much greater influence than most people realize.  I came across a study some years back where researches studied a primitive island population in the Pacific.  They grew and or gathered almost all of their food.  Their diet was high in potassium given the high fruit content and it was extremely low in sodium in comparison to ours.  The astounding aspect to me was there was not a single person on the island that had high blood pressure.  Not even one.  Surely, I would suspect that someone would have a genetic defect giving them hypertension but it was overcome by a much healthier diet.  As stated in last week's post, it is essential to keep the sodium level under 2000 mg a day.

Some medications can be taken as needed.  Allergy medications, pain relievers or acid reducers can all be taken sporadically.  High blood pressure medications may not be used now and then.  They must be taken every single day.  The medicine will only work when it is taken and will have no lasting effects if doses are missed.  In fact, beta blockers if used inconsistently will trigger the blood pressure to spike to potentially dangerous levels.  I encourage all of my patients who are on daily medications to use a weekly pill box.  Many don't want to do so, saying they are not "old and senile."  We all will make mistakes if we are taking medicine from a bottle.  We can easily become distracted and then not remember if it was taken.  If we are using the pill box we will know for sure if it was taken or not.

Make sure you set up a routine.  Many patients will say that they remember their morning medications but often forget in the evening.  Put the medicine next to your tooth brush (which you should be using every night !), set an alarm if you need to.  Leave a note next to your bed stand to remind you.  Make sure you are consistent.

I want to finish with a word about side effects.  The printout given by the pharmacy is rather daunting.  It lists so many possible problems that most feel rather timid about taking any medication.  In general, medicines have 2-3 potential side effects that are more common.  If you think you are having a side effect to a medication, ask your physician.  Don't just stop the medicine and tell him three months later.  It is not always easy to tell if a symptom is related to a medication or not.  Remember that uncontrolled high blood pressure has side effects also.  The risks of both need to be weighed prior to making changes.  Your doctor is your health partner.  Don't leave him or her out of your important medical decisions.

Harnessing Hypertension

Does having hypertension automatically consign one to taking medications for the rest of one's life?  What about all of the side effects of taking medications?  Aren't they bad for you?  Knowing the risks posed by high blood pressure (see my previous post), what can be done to keep the pressure down?  answers to these questions are not always straightforward and can only be answered correctly on an individual basis.  Let me discuss some generalities first.

It is always better to control blood pressure without medications.  Always.  It may not always be possible to lower blood pressure enough with healthy living alone, but doing so will certainly decrease the number and or the dose of medications needed to keep it under control.  There are four basic precepts to keep in mind in harnessing hypertension.

First, if you smoke you must quit.  Nothing else you do will matter much if you keep smoking.  You may have a perfectly normal blood pressure, controlled with medications but your risk of heart disease and stroke will not go down significantly if you keep smoking.  Nicotine is a vasoconstrictor.  This means that it narrows the blood vessels.  Think of your garden hose.  If you want to increase the pressure in the hose to wash off your deck you apply a device at the end of the hose that narrows it.  Every time a cigarette is smoked the blood vessels narrow for about twenty minutes.  I see this all the time in my office.  A patient will come in with a higher than normal blood pressure.  One quick sniff tells me that they likely had one last cigarette before walking in the door.  At the end of the visit, I'll recheck the blood pressure and it will have come down.  In the beginning these changes are reversible.  With time, the stress on the walls of the blood vessel cause it to become thickened.  This is like taking that garden hose and turning it into a pipe.  As there is no elasticity or give in the blood vessel wall, pressure shoots up even more.  This whole cascade is caused from cigarette smoking.  I know that it is hard.  You must quit smoking.

Second, regular cardiovascular exercise is as good as taking a medication.  The side effects are much better.  It will not give you a cough, make your ankles swell or take away your sex drive.  It will give you more energy, relieve stress and help you sleep better.  The biggest side effect from exercise is injury, of course.  Start slow and gradually build up.  Consistency is the key.  To effectively lower blood pressure some sort of exercise needs to be done at least four days of the week.  During exercise, the blood pressure will actually go up.  This is normal.  The muscles need more blood flow during exercise to provide fuel and oxygen to the muscles.  The heart responds by contracting more quickly and with a greater force.  As the heart itself gets in better shape, it pumps more efficiently.  A well conditioned athlete will have a very low heart rate and excellent blood pressure readings. This is a sign that the blood vessels are relaxed and the heart is not burdened.

If you want to avoid taking medications or limit the number that you need, make sure that the fuel you give your body is of the highest quality.  In particular, limiting the salt content in your food will help your blood pressure.  The sodium in salt causes your body to retain more water in the kidneys.  This is equivalent to turning up the knob on the garden hose.  The higher the volume in the tubes, the higher the pressure.  You must first break the habit of salting your food.  This includes tomatoes and cantaloupe.  In addition, much of the food that we eat has a lot of salt in it to begin with.  Make the effort to look at everything that you eat in a day.  Look at the labels, find out how much sodium is in all that you eat.  Your total sodium intake in a day should be less than 2000 mg.  It is easy to find a website to tell you how much salt is in common foods (here's one).  If it is in a package, a wrapper or a can, it likely has salt in it.  If it says "low fat" it likely has salt in it.  Guess what has not salt in it at all?  Fruits and vegetables.  In fact, fresh fruits and vegetables are naturally high in potassium.  When potassium is delivered to the kidney it exchanges with sodium, excreting it in the urine.   By eating fruits and vegetables you are actually getting rid of salt.  The best diet to lower your blood pressure is the DASH diet (dietary advice to stop hypertension).

Lastly, limit the toxins in your system.  Admittedly this includes nicotine and salt but those two are so important they get their own category.  In addition, alcohol can be an issue.  Up to four glasses of red wine has been shown to have a beneficial effect on cholesterol levels but not more, and not any other kind of alcohol.  No amount of beer, vodka or other forms have been shown to have any beneficial effect.  The alcohol molecule itself can have adverse effects on the heart.  Alcohol also contains sodium and "empty calories" (they don't do your body any good).  Caffeine is not as bad as nicotine but it is a stimulant.  It will artificially raise the heart rate.  The only safe way of doing this is through exercise.  Just this week I saw a patient in follow up who has dramatically reduced his blood pressure by eliminating soda, coffee and adding exercise.  Many medications can make blood pressure worse.  Anti-inflammatory medications such as Aleve (naproxen) or Advil (ibuprofen) can have a deleterious effect, especially in older individuals. ADD drugs such as Aderall and Ritalin can also raise blood pressure.  The anti-depressant Effexor also must be used with care in addition to the migraine medications like Imitrex.  Decongestants are especially bad for hypertension and should not be used.  This is just a sample.  Look on the labels of anything that you take and make sure it does not give warning in regards to high blood pressure.

In summary, I have not given any advice in this post that I have not given previously.  I have tailored it specifically to high blood pressure.  The advice remains simple, putting it into practice is difficult.  Choose on thing that you can do better and work on that.  Make a positive step in your health today.

Earning My Ice Cream

If you have read many of my posts you must wonder if we even own an ice cream scoop.  I am constantly talking about fruits and veggies.  I extoll the virtues of avoiding processed foods.  Fats and sugars?  Must stay away at all costs.  What could be worse for you than ice cream?  It is loaded with sugar and is full of fat.  I tell my patients that it is the diabetic double whammy.  My daughter, a competitive swimmer is achieving her best times ever this year.  I asked her what was going on, "did you give up ice cream?" It truly is not good for you.  All true, but...I love ice cream.  I admit it.  In fact, I must give ice cream credit for much of how I view health and nutrition.

If ever my family had any reason to celebrate, ice cream was involved.  Sporting events, good grades, giving a talk in church, all were a reason for ice cream.  Anyone ever eat the cylindrical scoops from Lucky's?  Keeping the triple decker upright was always tricky.  We could never get Mom and Dad to spring for the triple, though, that had to be from paper route money.  Ice cream never lasted more than a few days in our home.  With three boys and my father (the biggest sneak of us all), the carton never lasted long.  Now mind you, we would get in trouble if found skimming off the top.  We all thought we had mastered the art of taking a spoon and taking off only the top layer so as to avoid detection.  No obvious divots could be found.  Oh, how sneaky we were!  Sure.  I have no doubt that Mom knew exactly what we were doing.  Especially, since you could never really just take off the top layer.  Once started, the layers quickly started to add up.

As I grew older and started to buy my own food, I started talking myself into the Bill Cosby rationale of healthy eating.  Let's see, ice cream has milk.  We all need milk every day.  It has calcium.  It is good for our bones.  It must be something that I should have every night.  It would "settle my stomach."  And so for several years I ate ice cream pretty much every night.  I reasoned that it was better than being addicted to heroin.  As the waist began to expand, my energy level start to sag, I had to admit that perhaps the ice cream was not helping me out.  I decided to give it up.  That lasted until the next time it was offered to me.  Like a chain smoker I would quickly go back to a bowl every night.  As I kept trying to stop my habit but failing, I finally settled on a dietary plan that I could stick with and still have my ice cream.


I decided that instead of feeling guilty for eating ice cream, I would go back to my childhood and use it as a reward.  I decided that during the week I would eat healthy.  I would eat at least 4-5 servings of fruits and vegetables a day.  I would not eat candy, treats, dessert, soda or even my beloved....ice cream.  I decided that if I did this in conjunction with exercising at least four days during the week I could eat whatever I wanted on the week end.  In the beginning I craved the treats so badly I would get headaches, sweaty and a bit dizzy.  When the weekend would come I ate way too much.  By Sunday night I was bloated, had a headache and couldn't wait for Monday to begin so that I had a reason to regain my will power.  With time, I learned to control myself better.  I now may enjoy a bowl of ice cream (which I did while writing this post!) but since I behaved during the week, I can savor it.  I enjoy it.  I've earned it.

Care With Caffeine

The road proceeds straight off in the distance tapering to a fine point on the horizon like the tip of an arrow.  Mile after mind numbing mile, the Kansas landscape passes broken only by the highway patrolmen stationed every fifteen miles to ensure that the state coffers don't run dry.  It starts as a few blinks but then the eyelids began to gain weight.  Gravity takes over and they start to sag.  The blinks become longer and I break down and realize that it is time to use some caffeine.  In my mind there are only two reasons to ingest caffeine: to keep my family alive on a long car trip across the country and to occasionally treat a headache.

First off, let us understand and realize that caffeine is a drug.  I have talked to many patients who are appropriately leery of taking prescription medications but don't think twice about the amount of caffeine they ingest.  One patient responding to how much caffeine he typically drinks by saying, "two a day."  I answered, "well, that's not too bad."  He looked down and a bit sheepishly clarified, "two....pots"  Well, that explained his chronic headaches, his indigestion and having to urinate constantly.  Caffeine is chemically in the xanthine family of drugs.  You can buy caffeine in pill form.  Just because it is also found in some of the food and beverages that we drink does not make it any less of a drug.  Remember, at one point cocaine was in Coca Cola.

As a medication, then, what effects does it have on the body?  Its two major effects is as a stimulant and a vasoconstrictor.  It causes blood vessels to tighten and the heart rate to speed up.  It acts quickly but tolerance develops after just a few days.  This is why it both treats and causes headaches.  Through its vasoconstricting effects on the blood vessels of the scalp and face, vascular headaches (such as migraines) can be aborted.  However, if used on a regular basis, the body will no longer respond or will respond just transiently and then be followed by a rebound phenomenon, triggering more headaches.  The same is true for its effect on fatigue.  The quick surge of wakefulness rebounds into lethargy and the dreaded brain fog.  Many respond by redosing the caffeine, making matters even worse.  My philosophy is to keep my system as free from caffeine as possible so that when I want to use its effects to my benefit, it will work for me.  I try not to use a medicine containing caffeine (like excedrin) more than three times a month.

One of caffeine's effects that has been used to our advantage is its ability to relax the airways in asthmatics.  However, given its short duration, its deleterious effects on the heart,  and the fact that we now have better, less toxic agents to achieve the same goal, it is no longer used for that purpose.  In regards to the heart, caffeine may increase the blood pressure a bit but mostly it causes the heart rate to speed up.  This accounts for the "buzz" from energy drinks.  Potentially dangerous heart arrhythmias may result.  This metabolic stimulation is used by manufacturers to promote products for weight loss.  Echinacea falls in this same category.  Many think that if it is "natural" it is safe.  Not so.  The only safe way to increase your body's metabolism is through cardiovascular exercise.  Any weight loss achieved through caffeine will come right back as soon as the product is stopped.

In addition to its affect on headaches, promoting chronic fatigue and over stimulating the heart, caffeine can also contribute to heartburn by affecting the sphincter muscle of the lower esophagus.  This muscle normally constricts when we are not swallowing, keeping acid in the stomach where it belongs.  Caffeine weakens that muscle.  Lastly, caffeine is a bladder irritant and a mild diuretic.  Bottom line?  If you are running to the bathroom more than you think you should, pay attention to how much caffeine you are ingesting.

In summary, just be careful with this medication.  Used sparingly for infrequent periods, it may have beneficial effects.  If used on a regular basis, it is likely to cause problems.  Here is a quick test to know if you are using too much caffeine.  If you ever refer to your caffeinated beverage by using a possessive pronoun such as "my coffee" or "my diet coke," you need to cut back.

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.

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.

The Simvastatin Story

This week the FDA released new guidelines in regards to the use of the very common medication, simvastatin, which is used to lower cholesterol and thereby decreasing the risk of heart attack and stroke.  The reason for the guidelines change was due to new information that has been received from their Adverse Event Reporting System.  They found that there was an increased incidence of problems with muscles at the highest dose, 80 mg.  The incidence for this was much higher during the first year that a patient took the drug and was much more so in combination with certain other medications.  The most common are the calcium channel blockers used to control high blood pressure (diltiazem, verapamil).  They recommend that no more than 20 mg of simvastatin be taken in combination with these drugs and 20 mg with a similar medication, amlodipine.

Simvastatin 80 mg pill

You may ask, if there are serious risks to taking this medication, why wasn't it just pulled off of the market?  The reason is that for many people the risk of not taking the medication is higher than the risk of taking it.  In the last twenty five years, the incidence of heart disease has decreased dramatically.  Most researchers feel that it is due to the beneficial effects of the statin medications.  Their effects on the liver and on muscle tissue is well known.  When it is watched for and monitored, the medication is safe.  Simvastatin in particular is useful because it is the only statin on the market that is both potent and available in a generic form.  In my opnion, lovastatin and fluvastatin have more incidence of muscle pains.  Pravastatin is quite safe, has fewer muscle problems but is not very potent.  Basically, three options remain: Crestor, Lipitor and Vytorin.  Crestor and Lipitor will both be quite a bit more expensive.  The incidence of muscle problems is likely to be lower but the potential still exists.  Vytorin is simvastatin, together with a medication called ezetimide (Zetia).  It works by blocking the absorption of cholesterol in the intestines.  It shows great reductions in cholesterol levels but there is some debate over whether that translates into fewer cardiovascular events (heart attacks).

Where does this leave you?  It depends on your individual situation.  Step one is to estimate your cardiovascular risk.  If you have known vascular disease (atherosclerosis-partial blockage in any of your arteries), it is imperative that your LDL, bad cholesterol, be less than 100 mg/dl.  This is unlikely to be achieved by diet alone. A statin drug has the best data in regards to lowering your future risk.  If you have diabetes you fall into that same risk category.  If neither of the two are present, go to the Framingham Risk Calculator (click here) and if your risk is above 10%, you should be on a statin.   If it is lower you need to ask yourself if you are truly doing everything you can in regards to diet and exercise to ensure that you remain healthy.   Healthy living is preferable to medications any day of the week as long as the proper levels are attained.

If you need to take a statin medication, the good news is that if you have been taking simvastatin at 40 mg or less and are doing well on it, there is no concern about staying on that dose.  If you take 80 mg of simvastatin or you are also taking any of the medications that interact with it, you should discuss this with your physician.  For a detailed summary from the FDA and a list of all medications that can interact with simvastatin (click here).  If you have any questions, feel free to ask in the comments.  I'll be happy to respond.  Remember, these medications are there only to assist your own efforts in eating right and getting plenty of exercise.  They do not take their place.  Let's just simply be healthy!

A Salty Study

I received an email recently from a patient wanting to know what to do in regards to salt intake in light of a study which was released this month from the Journal of the American Medical Association.  There has been long standing consensus that too much salt in the diet raises blood pressure.  High blood pressure (hypertension) indisputably increases the risk of both heart attacks and strokes.  The study looked at a group of people for eight years and followed them till they were 49 years old.  The Centers for Disease Control made a public statement expressing concern over the study's findings and reiterated their support of the stand of the World Health Organization and the American Heart Association that sodium be limited to 1500-2300 mg a day.  Interestingly, the Salt Institute, was the lone organization that hailed the study.

One of my big concerns about the study is how young the patients were.  The chance of dying of heart disease before the age of fifty is quite low.  The fact that they could measure a statistically significant difference surprises me.  It makes me wonder if those who died had preexisting heart disease.  They would be much more likely to be on low salt diets because that is what their doctors would have told them to do in order to minimize their risk.  If that were the case, it would not be salt restriction which caused them to have more adverse events, but rather their underlying heart disease.

Tropical fruit high in potassium with no salt!

Some of the best information we have in regards to sodium restriction come from studies done in relation to the DASH (dietary approaches to stop hypertension) diet.  It is sponsored by the National Institutes of Health (NIH).  Recent studies are summarized on their website at www.dashdiet.org.  Some years back I came across a study from a remote pacific island.  The population that lived there did not have access to processed foods.  The amount of sodium in their diet was exceedingly low and the amount of potassium was quite high due to a high intake of the native tropical fruits and vegetables.  The astonishing finding to me was that they did not find one single person with high blood pressure.  Not one!  I would have thought that someone would have had a genetic aberration that would have caused their blood pressure to be high.  To me, this study stands as a testimony of what eating the right foods will do for us.  Remember, if it sounds too good to be true, it usually is.  Leave the salt in the cupboard.

"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!

Making Diet a Way of Life

The desire for weight loss has spawned innumerable diets. Most gain popularity for one or two years only to be discarded as they are abandoned. You may have heard of "The Zone Diet," "The Cabbage Diet," and even the "Atkin's Diet." The "yo-yo" effect of going on a diet only to revert to old ways and regain all the weight, is well documented and is dangerous to one's health. If a dietary change for weight loss is not permanent it will always fail. The newest fad is the "HCG Diet." I feel this is one that is particularly dangerous. It calls on taking the pregnancy hormone HCG (human chorionic gonadotropin) and limiting daily calories to 500 a day. Of course this is not sustainable and it will fail. I have repeatedly seen people regain weight after stopping this diet.  Let me discuss several programs or ideas that can be sustained life long and thus have merit.  There are links to their respective websites by clicking on the highlighted titles.

Weight Watchers:

The evolution of Weight Watchers through the years has been interesting to follow. In its current form, I feel that it is a great way to learn how to eat. It is a "points" system. An individual is given so many points per day. One can choose any food that they want but the least healthy foods are awarded more points. Most fruits and vegetables are "free." You can get more points through exercise. The program works because it is sensible, but it must be followed and all the "points" must be counted. There are new smart phone aps which make keeping track of everything so much easier. I highly recommend it.  It is a great way to learn how to eat healthy for the rest of your life.

South Beach Diet:

The low carb craze heralded in by the Atkin's diet (see below) got smarter with the South Beach Diet. I especially think that the maintenance phase of the diet is quite healthy and is a great way to make good food choices. It is especially beneficial for people who have elevated triglyceride levels, have diabetes or are borderline for such. First, a few facts about carbohydrates (carbs). This is prevalent in much of the processed food discussed previously. It is converted into blood sugar quite readily by our digestive tract and will raise blood sugar if we are prone to such. It is also what is the common denominator for "comfort food." If we are feeling lonely, angry, down or blue carbs will give us momentary pleasure. Our bodies acquire a physical dependence to them. Cutting back on them is hard since there will be actual withdrawal symptoms when one cuts back. They can also be eaten in large quantities before our hunger center tells us that we are full. This makes it much easier to over eat. Foods high in fiber are filling. Greasy foods, though not healthy, are harder to indulge on in large quantities. Most people need to get control of their carbs and the South Beach Diet helps do just that.

Lastly, the South Beach Diet allows for the ingestion of "healthy carbs." These are the ones found naturally in fruits and vegetables. There are three reasons why they are healthy. First, natural sugar comes in a compound that is just half of the glucose of table sugar. Secondly, fruits and vegetables have that filling fiber making them harder to be over eaten. Thirdly, fruits and veggies contain the essential vitamins necessary for basic bodily functions.

Mediterranean Diet:

This has been studied fairly extensively and has been found to significantly lower one's risk for heart disease. It is not as popular here as it is in Europe, though there are many more people learning of its benefit. . Similar to what has been stated above, it is a diet high in fruits and vegetables. Meat is limited and most all fats are converted to olive oil.

DASH Diet:

This is an acronym which stands for "Dietary Advise to Stop Hypertension." This is a specific diet for high blood pressure but it is quite healthy for anyone. Again, focusing on fruits and vegetables is essential. There is also a strong focus on limiting salt intake, which is very important for lowering blood pressure. There will be more about that later.

Atkins Diet:

I include this diet as it has remained popular for many years. It has shown to be effective in modest weight loss, however, recent research has shown that the risk of heart disease is unchanged and may be slightly higher. In the immortal words spoken at Curley's funeral in the movie, City Slickers: "He ate bacon for breakfast every day....You just can't do that!"