The Road to Success

Is it quitting smoking?  Losing weight?  Giving up ice cream?  Starting an exercise program?  What is your new year's resolution?  We all want to improve but the lack of results can be frustrating. "The road to hell is paved with good intentions."  This was apparently penned in 1855 by Henry G. Bohn.  If you are like me, the list of things in your life that need improving is rather daunting and yet every year we try again to improve.  How can we make lasting change?  How do we keep our latest resolution from adding to the cobblestones on the road to failure?

You may have noticed that this is not being posted on January 1st.  My resolution this year is to update my blog once a month.  What can I say?  At least it is not January 31st.  The first key to lasting change is to pick a reasonable and achievable goal.  Planning to exercise every single day for an hour would be ideal for all of us....but achievable for almost none.  Make sure there is enough flexibility to achieve the desired outcome.  I have resolved in the past to not eat any ice cream.  Those resolutions clearly failed but I found a way that works for me (see my post "Earning My Ice Cream").  It is also important to tackle our shortcomings one step at a time.  Choose just one and work on it first (see "Make Every Step Count").  Take a bite out of it and chew it one day or week or month at a time.  There are many people who need to lose fifty pounds to be healthy.  That is a big number and seems so unattainable that most will not even try.  Breaking down the goal helps to realize how to achieve it.  Over a year, losing one pound a week will result in a fifty pound weight loss.  That is even giving you two weeks of no weight loss!  To lose one pound a week requires a 500 calorie change each and every day.  That means eating less or exercising more but the difference needs to be 500 calories.  Setting the goal to lose fifty pounds is admirable but it is doomed to failure if one does not start each and every day with, "How can I get to get rid of 500 calories today?"

Broadcasting your resolution is another way to aid in your success.  Tell everyone around you what you are doing.  Yes, it is scary but it holds us accountable.  Not being willing to share your resolutions is the first sign of failure. In fact, it is planning to fail before you even begin.  Instead of shaking in fear that you might disappoint a loved one, use them for support.  They will encourage you, be more patient with you and help you.  In fact, finding a resolutions that can be done with a partner will increase your chance of success (see "The Buddy System").  I am grateful to my patients who have said, "We miss reading your blog."  It has given me the encouragement to make the time to start writing again.

Ultimately, if lasting change is going to be implemented, the resolutions have to be meaningful enough to change who we are.  The resolution must invoke a revolution.  Temporary change will not suffice.  We need make the leap of faith from saying, "I want to quit smoking," to "I am a nonsmoker," or from "I want to exercise more" to looking in the mirror and affirming, "I am an exerciser."  For me, it is changing my mindset from being a doctor that occasionally writes in a blog to being "A blogger." This does not happen over night and requires persistence.  Failure will happen; we will stumble and fall.  Falling is not failing.  Quitting is failing.  Those on the road to success have one thing in common, they have all gotten up after having fallen and continued the race.

Big Brother

On the eve of our national elections many are pondering the role of government in their lives.  We rely on our government for many of the basic necessities of life.  I am grateful to never have gone to bed at night worried that I could be bombed.  Likewise, the ability to turn on a tap and drink clean water is a privilege I take very seriously having lived for a year in Guatemala when younger.  The roads I travel, the electricity I use almost constantly, the schools my children attend are all a result of my citizenship in this great country of ours.  Additionally what makes our country great are the freedoms we are granted.  I am free to pursue whatever path of education and vocation I desire.  I am free to live wherever I want.  I can write such a blog as this and not worry about voicing my opinion.  That said, the delicate balance between taking care of its citizens and granting them freedom can at times be a tricky one to maintain.

Let me illustrate.  As a country the freedom of being able to drive wherever we want is tempered by speed limits, stop lights, qualifications of sobriety, seat belts and the mandate to have car insurance.  What may be viewed as protective laws by one could be construed as invasive antidemocratic abuses by another.  Such debates and concerns are also being raised in regards to the health of the population.

There are many social, moral and even economic reasons to improve the health of our citizenship.  A healthy society is a more productive society.  Disease and disability is a significant financial drain on the government. Achieving health reaches in to all areas of government.  More than delivering health care to the sick, health is fostered by reducing poverty, improving education and maintaining a safe water supply.  Do we as a society have a moral obligation to care for the sick?  What if it is illness that could have been prevented by healthier life styles?  Who bears the burden of such choices?  Those are not always easy questions to answer.

An obvious example is tobacco use.  By now, I would hope that we all know the dangers of smoking cigarettes.  I feel the government has done a good job of educating the public whether it be through packaging requirements, advertisements and to the youth in schools.  I, myself, spend a fair amount of time educating about its dangers as well as encouraging patients to quit and assisting them do so.  I have noticed, however, that the success of my efforts improves according to the price of a pack of cigarettes.  More heed my words when there is an economic reason to do so.  Is it right for our government to impose extra taxes on substances that degrade health?  Before all you nonsmokers cry out, "Yes!," think of proposals to tax sugared beverages.  How far can this be carried?

Is the health of our population the responsibility of society or the individual?  Certainly, as stated above, our society has a stake in our overall health.  Is it possible to legislate health?  How is that balanced with the freedom of choice?  Is it more important to safeguard the best interests of society or the freedoms we enjoy even if that means allowing the citizens to make choices may not be in the best interest of society?  There is a movement afoot that is shifting the personal responsibility of health from the individual to his or her physician.  In the past, we doctors, were viewed as personal healthy consultants.  Advice is given to patients for healthy living all the time but the consequences rested solely on the patient.  A diabetic patient who does not check blood sugars, does not follow a proper diet and takes the prescribed medication only sporadically, will suffer the consequences by developing the consequences of the disease.  Society, however, is coming to the understanding that the cost associated with a poorly controlled diabetic is born not only by the individual but also by the insurance agency and those who must pay the premiums.

These agencies are now shifting the cost of the disease to providers.  There is both a carrot and a stick approach.  We currently are rewarded when a high percentage of our patients achieve measures showing good diabetic control.  We lose that bonus when that number drops lower.  It is pretty clear that in the future, reimbursement from insurance agencies will be dependent upon these markers and that doctors will have to give money back to these agencies if the population of patients they care for are not doing well.

I have chosen the term insurance agency very carefully.  There are measures within "Obama Care," that encourage just what I have described.  However, before, we cast a disparaging vote in regards to the tyrannical oppression of our government, I think it is important to realize that these ideas are being espoused and acted upon with insurance companies as well. Regardless of the outcome of this week's election, such measures will be enacted.  I suspect that as a consequence, some patients will find it harder to find a doctor. Many physicians, tiring of the excessive regulations and now financial risk, are moving to non insurance models such as concierge medicine.  In such a model the patients are back to assuming the risk for their own health.  These are interesting times in which we live.  Your health is assuming a bigger audience than you ever imagined.  How we decide to cope with these issues as a society is likely to be debated for many years to come.

The Glycemic Index

This is a term used fairly frequently but is not often understood.  Simply put, it is a measure of how much sugar gets into the blood stream for a given food.  The scale is set by pure sugar, or glucose itself which is given the value of 100.  Other foods are rated in comparison to it.  Table sugar, which is sucrose, is composed of two glucose molecules bonded together.  Therefore, on a per molecule basis it would have a glycemic index of 200.  The glycemic index should also be viewed in the context of the glycemic load.  This is the actual amount of sugar that one ingests.

Let me illustrate an example.  A typical soda contains about 39 gm of sugar and has a glycemic index approaching that of pure glucose.  Fruit also has a high glycemic index but the sugar found in fruits and vegetables is from a molecule that has one glucose molecule bonded to a galactose molecule.  Only half of the amount of glucose is delivered to the blood stream as regular sugar.  In addition, fruit has vitamins, fiber and water to go along with the ingested carbohydrate, all of which is healthy.  A typical orange has 12 gm of sugar.  It is unlikely that someone will eat three oranges at a sitting, but that is what it would take to equal the glycemic load of one soda.  It is, therefore, important to interpret the glycemic index appropriately.  I give my patients free range on the amount of fruits and vegetables they eat.  Even my diabetics.  It is hard to ingest enough fruit to cause any significant damage.

Apart from fruits and vegetables, the glycemic index can be very helpful.  Most foods are fairly obvious.  Starches can be a big source of dietary glucose.  Potatoes, bread, rice and pasta need to be watched closely.  Many breakfast cereals are quite high on the glycemic index.  As a rule, the heartier grain, the coarser the starch, the better.  Brown rice is healthier than quick, white rice.  Seven grain breads are much better than processed white bread such as Wonder Bread.  It makes sense.  The harder it is for the body to digest the food, the less sugar gets delivered to the blood stream.

Now that you know the basics, head off to a web site and start looking up foods.  There may be a few surprises for you there.  Remember to keep it simple.

Harnessing Hay Fever

The itchy eyes, sneezing, nasal drip and tickle in the back of the throat are all well known to sufferers of hay fever or "Allergic Rhinitis."  What is not commonly understood is how fatiguing this condition can be as well.  People suffer from allergies because their immune system recognizes a foreign substance (antigen) that usually enters the body through the nose and mouth.  A primed immune system will bind that antigen by a histamine receptor to what is called a Mast Cell.  The interaction causes the Mast Cell to release histamine into the blood stream, resulting in an immediate release of inflammatory products which trigger swelling of the lining of the nose, throat and eyes.  This is what causes that runny nose and watery eyes.  The work required to create this inflammation is very fatiguing.  In fact, any medical condition that causes inflammation will cause fatigue.  Sufferers of Multiple Sclerosis, Rheumatoid Arthritis or Chron's Disease know this well. In fact, it is very common for a patient with pneumonia to still feel fatigued weeks after the cough has gotten better.

Most sufferers of allergies do just that; they suffer through it.  I'll admit that I am usually one of them.  Keeping them under control, though, can help you feel more energetic and less miserable.  Let me explain the different treatment options and the rationale for each so you can decide what is best for you.  The most commonly used medicines are the antihistamines.  This includes Claritin (loratadine), Allegra (fexofenadine), Zyrtec (cetirizine), and Benadryl (diphenhydramine) to name the most common ones.  They block that initial triggering event discussed above.  Logically, the sooner they are used, the better they will work.  If you wait till you are full of fluid, they will keep your allergies from getting worse but they will not help for what you have already been exposed to.  The horse is out of the barn in this case and it is too late to close the door.  During a bad season it may be best to take the medicine on a daily basis.  They can work quite well intermittently if given prior to an exposure.  I have used them effectively prior to wood working, mowing the lawn or going to a friend's house who has a cat.  The medicines are all available over the counter now and most have a generic form which makes them less expensive.  The main draw back is that they themselves can be fatiguing.  The least sedating is Claritin and Allegra, followed by Zyrtec.  Benadryl is the most sedating.  There are also antihistamine nasal sprays and eye drops.  Those are not sedating at all but have to be used more frequently.

Nasal steroids reduce the inflammatory response from the histamine release.  They can be used with or without the antihistamine.  Since they are absorbed right in the nasal passage, almost none of the medicine enters the bloodstream, making them quite safe.  The draw back to these medications is that many people do not like squirting medication in their nose and they are quite expensive.  Thankfully, one of the best ones, Flonase (fluticasone) is now available in generic form.  They do all require a prescription.  If used daily over many weeks or months, the lining in the nose can become too thin and result in nose bleeds.  Stopping the medication for 1-2 weeks will solve that problem.  They do not work quite as well as antihistamine medications on an as needed basis.  Many use them for a few weeks out of the year during a bad season.

Allergy shots are the most effective way of reducing long term symptoms.  They induce tolerance in the immune system by introducing a small dose of antigen on a regular basis.  Over time, the immune system becomes desensitized, similar to what happens with teenage boys when their mother speaks to them.  The trigger is still there but nothing registers.  There are some obvious drawbacks to injection immunotherapy (allergy shots).  First, they are given by injection.  Second, if the dose of antigen is too high, it can induce a more serious reaction in the whole body so they must be given at the doctor's office.  Third, they have to be administered weekly for the first few months and then monthly for many years.  The hassle factor can be a big impediment.  Lastly, if you move to a new area, you have to start all over.  The injections only work for the antigens in your current environment.

There are other possible ways to help your allergies as well.  The simplest, of course, is avoidance.  That may not always be the best course of action, however. There is some evidence that children born and raised in the city have more allergies than children born in the country.  There is likely a critical age in the developing immune system where exposure induces tolerance rather than activation.  The science behind this has not been completely worked out yet.  Some have suggested that ingesting unfiltered bee honey can help.  When bees return to the hive, they not only bring the nectar to form honey but also lots of pollen.  The rationale is similar to that of injections but instead of sensitizing to very specific antigens, this would in theory sensitize to a more broad range of them.  For this to work, it should be unfiltered honey from local bee keepers to make sure that the antigens are ones that exist in your own environment.  There are likely many antigens that would not be covered by the honey, such as animal dander or dust.

I hope you find this informative.  Thanks to Debbie for the requested topic.  If you have specific questions that I did not touch, on please let me know.

The Right of Vice?

The Bill of Rights

A patient comment recently had me thinking of the Bill of Rights.  It has been a little while since I took a government class so I decided to brush up on my history a bit.  As you may remember better than I, the Bill of Rights references the first ten amendments to the Constitution, specifically outlining the personal rights and freedoms that our government guarantees. It ranges from the right of free speech, to the right to bear arms, including  the right of a fair trial, to name a few.  

The comment that sent me on my historical inquiry was, "Everyone needs a vice, right Doc?"  It was in response to one of my encouragements to eat healthier.  It was said so authoritatively, I thought that it must be included in the bill of rights.  Now as I read through the list, the only one that might qualify is the eight amendment which reads, "Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishment." I suppose many may feel that taking away their chocolate, soda, ice cream, beer or cigarettes may constitute "cruel and unusual punishment," but I don't think that was what the Founding Father's had in mind.  

What is Your Vice?

According to one of my favorite sources of information (Wikipedia), vice is defined as follows:

"Vice is a practice or a behavior or habit considered immoral, depraved, or degrading in the associated society. In more minor usage, vice can refer to a fault, a negative character trait, a defect, an infirmity, or merely a bad habit."  

In this context, do we have the right to a vice?  My answer to the patient and to you is "No!"  What we do need are good habits.  We need to set up routines that edify our body and soul, not tear it down.  It has been shown that it takes on average twelve weeks to create a habit.  When embarking on a new diet or exercise regimen, the first three months are the most critical.  It is much easier to exercise when it is a foregone conclusion that has already been ingrained as opposed to a vigorous internal debate that has to be endured each and every morning.  

We all have habits. Look at the ones in your life. Fortify the ones that make you stronger and eliminate the ones that hold you down, the vices.  Rather than being constitutional guarantees; your vices guarantee declining health.  Get rid of them!

The Science and Art of Medicine

Terrified, on my mother's lap, gasping for each breath.  The doctor's office seemed a rather scary place to a seven or eight year old.  I can remember hearing frightening words such as "admit to the hospital" or "let's try this shot."  As poorly as I felt, I didn't even worry about getting the injection.  I just wanted to feel better.  I can't remember the pain of the shot but I can certainly remember my heart pounding nearly out of my chest.  I had been given an injection of epinephrine (adrenaline).  Even more terrified, I clung to my mother.  My breathing slowly improved and thankfully I was able to go home.  Though I am sure I had been in many before, this is the first time that I can remember being in a doctor's office.

A few years later I was in a different office.  It seemed similar, though less terrifying than the first.  I lay on the examining table on my back.  The doctor placed vials of serum on my chest and then held my ankles.  Somehow he could feel differences in my legs and would make notations in his chart.  From this he concocted serum that my father than injected into me once a week to treat my seasonal allergies (no, he is not a physician and yes, it was terrifying).  I was not a happy patient.  I had no trust in this homeopathic doctor's evaluation and resented each shot.  To this day, my mother is convinced that it helped us even in the face of the rude quacking noises coming from her sons' mouths.

These two experiences of mine illustrate a common occurrence in the practice of medicine.  As much as we have learned about the human body and how it functions, there is much we do not know.  Even in the face of accurate knowledge we often lack adequate treatments for some conditions.  That adrenaline injection I received is no longer considered to be an acceptable treatment for asthma.  Thankfully, the science has progressed, and the treatments have gotten better, less toxic and more efficacious.  The second treatment I received may still be offered in some corner of our society but has fallen out of favor.  Such treatments are not studied nor evaluated.  Therefore, there is no improvement.  They are discarded only to be replaced by some other theory.  I have little patience for proposed treatments that claim they offer something "your doctor doesn't want you to know about," claiming a conspiracy theory between scientific medicine and the pharmaceutical companies.  If someone comes up with a valid proposal, it will stand up to the rigors of scientific investigation.  Refusing to study such treatments is tantamount to snake oil in my eyes.

I am not suggesting that only FDA approved medications should be used in the treatment of health conditions.  If you have read my previous posts, you know that I am all for avoiding medications through healthy habits.  Regular cardiovascular exercise has been studied extensively and has found to be beneficial over and over again.  It is getting people to actually make such a habit that is difficult.  Being able to show patients the studies that support my claims helps me to make my point.  One of the favorite parts of my job is eliminating a medication due to a patient having changed his or her behavior.  Seeing people lose weight, stop smoking and drop their cholesterol or blood sugar values is very fulfilling.  Writing prescriptions to treat chronic conditions that could be otherwise controlled, if a patient would just change their life style, is frustrating.

I am grateful to be in a profession that forces me to keep learning.  We still have many inadequacies as a profession, offering "adrenaline" type treatments with the hope that better alternatives are on the way.  As much as we learn and as advanced as our treatments become, though, it is important not to lose sight of the basic tenets of good health.  Nothing will ever substitute for eating a healthy diet, getting plenty of regular exercise and keeping our stresses in check with balanced living.  Remember, keep it simple.

My Balancing Stick

I have hit a lag in my posting.  I appreciate all of you who have noticed.  Sometimes it is hard to know if it is being read.  Part of the reason for my lag is that I am running out of ideas.  I would love some feedback.  What would you like me to discuss?  I have had one request for migraines, so I will be thinking about that topic. Another reason for my lag is due to a consuming project that has been taking up almost all of my free time for the last six weeks.  In fact, it is the topic of this post.

The premise for "Simply Healthy" is just that, to keep health simple.  My four pillars are watching what goes in, to keep moving, maintaining balance and to ask your doctor about the rest.  I haven't touched too much on maintaining balance and will do so today.  As I talk to my patients and ask about their lives I have come to appreciate that we all have stress.  It comes in different forms.  It may be family related, work related, money related and often healthy related.  We all have times when it is worse than others.  How we manage it makes all of the difference.  Taking our mind off of the cause of our stress is essential.  Exercise is one of the best ways of doing that.  Another great way is to have a hobby or special interest.  Mine turns out to be wood carving.

As a young boy scout I was introduced to "whittling."  I loved using my pocket knife to make spears and arrows.  Making a chain out of a stick was more difficult but quite rewarding.  I never thought about doing more until about eight years ago when I decided to try and carve the nativity scene on a walking stick.  It was my first attempt to carve a human form.  I got hooked after that.  I started to find myself looking at arms and legs in a new way, paying extra attention to where the muscles came together and fit in with the body.  I would look at all the noses that came my way to try and decide which one I would use on my wise man.  At first, I used a simple exacto knife. I finally found a friend who also carved and he introduced my to "real" tools.  I started to collect not just knives but gouges, and bits to fit on my rotary tool and an electric chisel.  When I am working on a project my whole focus is centered on that piece of wood.  It is a great way to take my mind off of the stress of work.  I love the feel of the grain and get great satisfaction when a piece turns out well.

My recent project is for my wonderful parents.  They recently completed fifty years of marriage.  We have four children in our family.  Each of us are married and we all have four children. My oldest child married this April so that makes a total of 27 people in our family.  About a year ago I decided to carve something for my parents but couldn't come up with an idea.  One night I literally woke up with the idea for my project.  A verse in the fifteenth chapter of John came to mind where Jesus declares, "I am the vine and ye are the branches."  I envisioned creating a walking stick with vines wrapping up the stick, each leaf representing a member of our family.  I love working with cedar which has a red inner core.  I thought the stick would look great if I carved down to that red core and making the branches and leaves out of the outer white wood.  This symbolizes our family, tied together, centered on Jesus Christ.  With that in mind, I went out in the woods on my in-laws property and found a cedar tree that had been knocked over but was still alive.  I cut it down, sawed off the many branches and stripped the bark.  I let it sit in the basement for about six months prior to working on it.  I decided that I wanted each leaf to be centered on one of the knots in the wood, which would tie it to the red core.  I traced out my leaves and vines, counting over and over to make sure I had all twenty seven of them on the stick.  I would like to say the project then started in earnest but I didn't do much on it for many months after that.  I tend to work better when I have a deadline.  As the summer approached and the anniversary date started getting near I got more serious about the project.  At times in the beginning I nearly gave up on it, feeling it wasn't turning out as I had envisioned it but I kept at it, modifying the details as I went along.

I took it to every outside event that I went to, using the time at camp-outs, soccer games, and cross country meets to work on the project.  Several weekends ago, in its nearly completed stage, I took it to a scout retreat.  I was mostly sanding at this point.  Being around hundreds of scouts and leaders, many of whom had made walking sticks in the past, made me feel like a rock star.  I was pleased to see the response of those that wanted to see it and ask about how it was made.  The final task was the most rewarding of all.  After finally completing the many hours of sanding it down to a smooth sheen, I applied teak oil to the wood.  As I had hoped, it made the red core jump out of the wood, bringing out the grain and the knots.  I love how it turned out.

I know that this is not too "medical," but thought that many of you would enjoy seeing and hearing about my project.  It truly is a stress reliever.  We all need to have a stress relieving outlet besides the television set.  If you are feeling overwhelmed by life, pull out that old guitar, paint brushes, knitting sticks or whatever else it is that you love to do but may have put aside for awhile.  It is not just good for the mind, it is good for our health.