Defining Diabetes

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

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

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

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

Sleeping Soundly

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

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

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

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

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

How Hard to Push

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

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

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

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

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

What is Health?

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

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

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

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


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

Primary Care for the 20 Something Generation

I was asked this week to comment on the status of primary care for those in their twenties.  I am using my answer for this weeks' post.  For more information and discussion on this topic click here.

Should 20-Somethings Have and See a Primary Care Doctor?
I am obviously biased in regards to this question, but yes, absolutely.  Do they need to go for frequent check ups if they are otherwise healthy?  No, they do not.  Early on in the twenties is a great time to establish a relationship with a doctor who can help guide them through their health for the decades to come.  For young women who are otherwise healthy, this may be their gynecologist.  An Internal Medicine physician is certainly appropriate.  That first visit is important to first establish a relationship.  That way, when illness or injury comes along, there is someone ready to help.  Secondly, it is a chance to evaluate one's health habits.  This decade is a critical time for establishing healthy habits which will endure a life time.  The human body goes through a big change in those years.  The ever active metabolism characteristic of adolescence simmers down to a slowly declining  state.  If anticipated and accounted for with dietary changes, the not so unusual 15-20 pound weight gain can be avoided.  It is much easier to maintain body weight than it is to spend the rest of your life trying to lose it.

Are Young People a Drain on the Health Care System?
Not at all.  In fact, young healthy people are viewed as one of the keys to controlling health care costs and being able to provide health care for our entire population.  If we did not have young, healthy people carry insurance, all of us will pay a larger price.  That said, if young people do not have a primary care physician established, they will present to emergency rooms with conditions which could easily be evaluated in a physician's office.  The cost of emergency care is exponentially higher than it is in the primary care setting.

What Tests Do Young People Need to Get?
In the absence of any concerning symptoms or physical findings the most important "test" to be done is that initial history and physical examination.  More than any battery of tests, that first visit will help guide the physician to tailor any testing to the needs of the individual.  If it has not been done previously, I recommend at least a total cholesterol level as a baseline.  A family history of diabetes may prompt testing for blood sugar.  Symptoms of fatigue in a woman with heavy menstrual cycles would prompt a test looking for anemia.  However, from a purely routine standpoint, that initial visit carries the most weight.

Do Doctors See a Difference in the Way in which 20-somethings Approach Health Compared to Older Generations?
I don't think a broad generalization is possible here.  I know many young adults who take exceptionally good care of themselves and are extremely health conscious.  I also just met a young woman who basically eats junk food for all three of her meals a day.  She starts with a pop tart.  Chips and soda often pass for lunch and she may finish at Taco Bell that night.  I do think that elderly patients think of their health a lot more but this is because they are now suffering from many more conditions than before.  Some ailments come as a natural result of aging but many could have been prevented had they cared for their health better when they were younger.

Staying Sharp

Mental health is something most of us take for granted until we start to lose it.  When I refer to mental in this instance, I am specifically referring to our ability to think, reason and remember.  Just as we need our muscles to move our bodies, we rely on the brain to direct all of our activities.  Our ability to do so profoundly affects our physical health.  I have a patient who is 106 years old.  She has experienced many years of good health but she is now blind and can hear very little.  She mostly mumbles to herself and her mind is no longer functioning well.  Though she has been healthy enough to reach such an advanced age most would agree that we would not want to be in such a condition.  I have another patient in her nineties who stays active and continues to teach a dance class.  Her mind is active and quick.  One would even say, "sharp as a tack."  If we are going to live a long life, we want to maximize our chances of staying "sharp."  Though there are no guaranties that we will not experience dementia or other problems, let me share some ideas on how we can maintain our mental acuity.

First, keep your mind free from mind altering substances.  Drugs such as alcohol and marijuana will dull our senses.  One of the biggest brain depressants are sedative sleeping pills.  One would think that getting a "good night sleep" will help you be more alert and less tired the next day.  However, studies have consistently shown that patients given sleeping pills function more poorly.  They perform less well while driving and doing tasks requiring concentration.  Antidepressants need to be used with caution as well.  Although depression itself can cause symptoms identical to dementia, the medications used to treat it can cause one to be less than sharp.  It is appropriate once an initial response is achieved to then decrease the dose if maintenance is required.

Stimulants trade short term mental activation for longer term lethargy.  Most who grab something with caffeine to "wake up" don't think of the longer term consequences.  Habitual caffeine use can result in more persistent, longer term fatigue and "brain fog."  Methamphetamine abuse is soaring.  Anyone who has known an addict will not confuse their mental sharpness with that of a sharp instrument.  I have the same concern for prescription stimulants used to treat ADD.  When they are absolutely necessary, the lowest possible dose should be used for the shortest period of time.  We really don't know the long term ramifications of regular use for more than just a few years.

One of the biggest determinants of brain health in later years is maintaining blood flow to the brain.  Just as decreased blood flow to the heart or the kidneys can cause disease, the same is true for the brain.  This goes right back to our physical health.  You want to be exercising, eating right and maintaining normal blood pressure and cholesterol values.  This has been discussed in more detail in my previous posts.

Just as regular exercise keeps our muscles strong and active, regular brain activity keeps the brain connections working as well.  It has been shown that those who do so have a seven fold decreased risk of developing Alzheimer's.  This beneficial effect is for greater than any medication or supplement.  Too many of us let others do our thinking for us.  We spend too much time in front of television screens and not enough time reading, writing, speaking a foreign language, playing a musical instrument or doing puzzles and games.

Someone with a sharp, active brain is more likely to take an active interest in their health.  They will study and learn about any conditions they have and may actually read this blog!  Let us all do what we can to hone our brain.  Let's keep our brains clear, let's stay active, let's stay sharp.

The Indomitable Human Spirit

One of the aspects that I love about my job is reading about scientific advancements.  The human body is a remarkable organism and the more we learn about it, the more amazed I am.  Each new scientific advancement is like peeling away the layers of an onion.  That said, there are times when I cannot explain by scientific means what I observe with my own eyes.  This often occurs at the end of life.  Time and time again I'll see a patient at the end of life in the hospital whose organs are failing and may not even be conscious any more.  I know as a physician that death could come at any time but what happens more often than not is that as soon as the last family arrives from far away, the patient will then slip away peacefully.  I am convinced that amid the millions of cells in the body resides the spirit of man that cannot be quantified or studied in the usual way.  Some how, some way, the patient senses the presence of his loved one.  The spirit then is free to leave this life and the body is left lifeless.

Though the details may vary, the belief in a higher power and of man's spiritual nature are pervasive through almost all cultures.  Assuming that we indeed have a spirit and that there is a higher power, how does that affect our health?  Researchers have even tried to study the effects of prayer on health.  The results have been controversial.  It is difficult to quantify the "dose" of prayer and faith and the effect it may have on an individual.  A more consistent finding has been that church attending individuals are generally healthier than their counterparts.  It is hard to know if this is due to increased spiritual power, to the beneficial effects of quiet meditation and prayer on stress, to healthier life styles or to a combination of all of the above.

I have my own beliefs, of course, and feel strongly that our spiritual lives most certainly affect our physical health.  It is not something I actively ask my patients to pursue but I do ask about it.  I certainly encourage patients to both reach out to others in their congregations when they are in need as well as avail themselves of such support themselves during times of illness.  I may not ask someone to pray but I will inform someone that I will pray for them.  I certainly pray myself that I may make good choices for my patients and do what is best for them.  I have felt a quiet power in my life as I deal with the stress of having someone's health depend upon my ability to both diagnose and manage thier conditions correctly.


If you have inclinations to seek for spiritual enlightenment, I encourage you to pursue them.  A strong spirit will lead to a strong body, as we strive to keep all things in balance.