Online Follow up for Hospitalized Patients

I'm excited about a new program that we started today at the University of Arkansas, using the eDoc technology and team in partnership with the UAMS physicians.

We give every patient being discharged from the hospital a free subscription to our service, with the encouragement for them (or their family) to log on and ask a question or get a clarification about their recent hospitalization or other health questions that may be concerning them.

I don't know about your experience but, around here, when patients leave the hospital, it is not that easy for them to get in touch with one of the doctors associated with the hospitalization to get questions answered, etc.

So, anyway, they log on, ask our team questions and, if it is straightforward and we're comfortable answering, we do. If it needs to be passed on to one of the doctors who took care of the patient, we do that.

We're doing a three month pilot, then we'll reassess and see how we want to proceed.

What do you think of this idea? Let me hear from you.

Electronic Records and Confidentiality

At UAMS, we recently did a survey asking employees if they used the University for their health care and, if not, why not. A signficant percentage indicated that they elected to go elsewhere because of concerns about confidentiality of records.

Recently, at another local hospital, following a tragic homicide of a news anchorwoman at a local TV station, 7 employees were fired because they accessed her records without authorization.

At UAMS our compliance/HIPAA office indicated that, when they do audits of our EMR, they routinely discover MANY episodes of unauthorized access to our electronic medical records.

Electronic records have so many advantages, but this is one of the challenges that needs to be addressed. Communication, clear policies, and accountability measures are all critical to keeping folks' noses out of records where they don't belong.

One thing needs to be said in clarification, though. In the "old days" when paper records were the rule, I'm absolutely sure that confidentiality was just as big an issue, but we had no way of knowing if someone looked at records without authorization. Nowadays, if someone accesses a digital record, it leaves an electronic "footprint" that can be easily traced to the perpetrator. So, it could be that this is simply a problem that we now have more information about and can do something about, rather than actually being a new problem that is due to the EMR. On the other hand, it is likely that some occurrences of unauthorized access would not have occurred in the "paper era" because electronic lurking involves different settings, technology and skill than finding a paper chart and looking at it.

Can electronic records be constructed that assure that their confidentiality will be maintained? Probably not. Can more be done to safeguard patient online records? Without a doubt, yes.

This is an issue that the public needs to become educated about and weigh in on. What do you think? Do the advantages of an EMR outweigh confidentiality concerns? How concerned are you about this? Does it affect where you go and who you see for medical care?

Let us hear from you on this...

What to be Sure to Eat if You are on a Diet

Most Americans are overweight, so dieting is very common. We all know that losing weight means eating less and burning more calories. As we eat less, what should we be sure to eat?

A study published in the Journal of Nutrition in early 2008 followed 130 overweight people on two types of diets. The control group reduced calories based on the traditional food pyramid, so they ate the right types of food. The study group ate a diet rich in protein and calcium, emphasizing lean meats and low-fat dairy products. Both groups lost comparable weight over 12 months. The group on the protein and calcium rich diet had stable bone mass while the control group had some loss in bone mass. The protein rich diet also helps with maintaining muscle mass.

So, if you plan to lose weight by any method, be sure to get protein at every meal, and pay attention to getting enough calcium, either from dairy products or through a supplement. Also take a multi-vitamin daily if you are eating less calories than you burn, and be sure there is vitamin D that is necessary for calcium absorption by the body. Also, get regular weight bearing exercise such as daily walking to help protect your bone mass.

Source: University of California, Berkeley Wellness Letter, December 2008

How Important is Chewing?

Everyone seems to be in a hurry these days. Meal times, especially breakfast and lunch, are rushed. "Wolf it down" seems more common than taking our time with eating. We often swallow food with minimal if any chewing. Is this ok? No!

Chewing our food is an important first step in digestion. Skip it and you may miss getting some of the nutrients in some of the best foods, like our vegetables. Chewing has an important role in eating and should not be skipped. What does chewing our food do?

• Chewing transforms transforms food into a form that is safer for swallowing.
• Saliva contains the digestive enzyme amylase that begins the process of breaking down food for digestion into our bodies.
• Grinding food with our teeth is important in preparing the food for later digestion in the intestine.
• Taking our time with eating through chewing our food helps us eat less and not gain as much weight.

Chewing is not optional! It is part of good nutrition practice. Think about how much time you spend with chewing. Being conscious of our chewing is a first step in keeping this essential part of digestion in proper perspective.

On Line Interactions Can be Better than those in the Doctor's Office

It is sometimes said that contacting a physician online, especially one that doesn't provide your ongoing primary care, is an "iffy" proposition at best. And, truthfully, if you require lab tests, x rays, an exam or a procedure, that is certainly true.

However, for many problems, the most important need a patient has is to exchange meaningful information about the condition at hand and have a clear plan about how to address it. For example, whether a specialty referral or a particular procedure or medication is needed, just to name a few of the many examples.

But, consider the possibility that, for certain situations, on line interaction may actually be superior to in 0ffice care! I have been amazed at the number of times that clients using eDoc have said that our physicians have been even more helpful for their situation than their own doctor has been after several office visits. How could this be?

On line dialogue, both for the physician and the patient, provides a much more relaxed environment to think about a response to a question or problem. There is no embarassment and, consequently, often more comfort in sharing unpleasant or personal details about symptoms. If a physician is "pretty sure" how to answer a question, but is unclear on some of the details, he has plenty of time to consult a text or a web site and review a situation briefly before he responds. Patients then have an unlimited opportunity to clarify issues or respond back to physicians' questions.

Finally, physicians have an incredible treasure chest of web sites and resources called the internet that they can use to enhance their responses with patient education materials. So, in the end, many online episodes result in a patient who is more fully informed and more satisfied with their plan than they might be following one or more brief in office visits with their physician.

So, if you have not been sure that online health is for you, try logging on and asking one of the eDocs a question.

You'll be glad you did.

Next time, I'll discuss the debate about independent research v. consulting with a physician online to answer your questions...

Let me know if you have comments or questions.

Nutritional Quality Index - How Well Do You Know Your Foods?

In the supermarket, we have the greatest choices of foods in the history of mankind. Eating well can be an overwelming challenge. Most of us like variety in our foods, and we have that luxury. But making good food choices regularly is quite a challenge with so many factors to think about.

At Yale University's Griffin Prevention Research Center, an Overall Nutritional Quality Index has been developed with scores of 1 to 100 based on the nutrients, vitamins, sugar and salt, and the overall impact of foods on blood pressure and other health concerns like clogging blood vessels. The quality index will begin appearing on many food labels and at many stores. Look for it. The scores are available at: www.onqi.org. Here are some highlights.

Foods that rated a perfect 100 are: broccoli, blueberries, orange and green beans. Pinapple and radish get a 99. Summer squash (98), apple (96), green cabbage (96), and tomato (96) are among the others at the top of this food chain.

Near the bottom are: popsicle and soda both rating a 1, saltine crackers, bacon, and apple pie rating a 2, milk chocolate a 3 (very sorry), cheese puffs a 4, hot dog a 5, salami a 7 and white bread a 9. These are commonly eaten foods that can easily be eliminated from a diet. You will lose weight too.

Some interesting foods in the middle are: unbuttered, unsalted popcorn (69), 2% milk (55), pasta (50), New York strip steak (44), bagel (23) and salted dry roasted peanuts at 21.

Eating healthy is a big challenge but we know more about our foods than ever before. Nutritional knowledge is out there for us to make healthy choices. I hope this information helps you and your family live a healthier life.

I Have Diverticuli in my Colon, What Can I Eat?

Now that more adults are getting colonoscopies, more of us are finding out that we have diverticuli in our colon. A diverticulum is a pouch, like a small cave, coming out of the lining of our colon. It is common for adults over 40 to have them. If they become inflammed or infected, this is call diverticulitis. Stool may become trapped in the diverticulum and over time cause an infection, sometimes very serious if there is a ruture of the diverticulum causing the infection to spread in the abdomen (peritonitis).

It is generally felt that a lack of regular fiber in the diet causes these diverticuli to form. This has has never been clearly proven. It is clear that daily use of fiber, especially grain fiber like that in high fiber cereals, keeps the stool moving and helps avoid stool getting trapped in the diverticuli causing an infection.

There has been a belief, even a medical recommendation, that people with diverticuli should avoid certain foods such as nuts, corn, popcorn and berries, thinking that these foods might get trapped in the diverticuli and cause an infection. This is rational thinking but has never been proven. To the relief of us that have diverticuli, and I found out I do at my colonoscopy, a study has now shown that these foods to not present any risk to people with diverticuli. In a study of over 47,000 men, intake of these foods had no association with developing diverticulitis.

So, I will continue to eat my high fiber cereal, fruits and vegetables every day. I will continue to enjoy nuts, corn and berries since I love them, and will feel free to order popcorn at the movies. Isn't it nice when medical science helps us enjoy life a little more!

How to Get Your Anti-Oxidants - Food or Supplements?

There is a common debate among those wanting optimal nutrition. How best to get your anti-oxidants - food or supplements? Those against the food often cite things like with today's pesticides and fertilizers, you cannot trust or get enough nutrients from food. You need to take supplements to reliably get enough anti-oxidants. Unfortunately this argument is perpetuated by advertisements from the supplement industry, maybe mixed with some fear among the public.

Food sources are not only the best way to get our anti-oxidants, they are the only reliable way to get them in a way that actually helps prevent the ills of oxidation, cardiovascular disease and cancer. Why, because there are so many anti-oxidants and natural food is the only way to get them all, and in a blend designed so well by nature.

What anti-oxidants am I talking about? The main ones fall into the category of beta carotene and the carotenoids. These are the beneficial components of plants, our vegetables and fruits. There are at least 50-60 of them in healthy foods that benefit our bodies. One or several in a single expensive supplement does not come close to matching this. The other anti-oxidants, folic acid, vitamin C and vitamin E have all been shown to benefit us best when obtained naturally from foods rather than supplements. Pick your food from reliable sources and you do not need to worry about the pestacides and fertilizers.

You might say that some supplements are actually ground up food sources. Ok, but do you think you are really getting enough in that pill? I look at little capsules of grape seed extract and laugh, how much can be in there?

Save your money and develop healthy food habits and practice them every day. Get berries and other fruits every day. I eat a banana and have blueberries in my cereal every morning. Have good vegetables every day at lunch and dinner. This practice keeps me healthy and at the right weight, and I know that I do not need expensive supplements to complete my nutrition. We have access to the greatest variety of healthy food in the history of mankind. If we are smart about that, we can be the healthiest people ever.

A Special July 4th Celebration

Recently, our family has been spending July Fourth with my disabled son, who in a nursing home in Charleston, AR, about 30 minutes or so from the Oklahoma border. Charleston is one of those towns that are disappearing slowly from the American landscape--too bad! Most everyone knows each other and neighbors meet daily to talk.

Every July 4th, the City of Charleston (population 3500) and Greenhurst Nursing Home, where my son is cared for, collaborate on a 4th of July picnic. Everyone in surrounding towns come! The kids have a good time playing in the yard, fishing in the pond and relaxing on the porch til the party starts. The Nursing Home family council, to which my wife belongs, serves the hot dogs, popcorn, ice cold watermelon and drinks. The front lawn is filled with families on blankets and children playing frisbee and running around. A local rock band plays and, when darkness sets in a first class fireworks exhibit (accompanied by classical music emanating from the speakers) entertains the crowd.

My son is so disabled he can't do much, but he certainly can enjoy and wonder at the music and smile contentedly while he watches the fireworks display erupting around him. I daresay there aren't many American towns left that conduct a fourth of July celebration like this one--and that's too bad as it was one to remember. Jordan and the other folks in the nursing home, as well as the families and town people appreciate the effortand will look forward to next July!

Calorie Restriction and Fasting, Keys to Health and Longevity

A 2 day conference was held at UCLA recently on the lastest research on increasing health and longevity. Lots of things are being looked at, including understanding the very biology of how and why we age. Right now, the only proven way to increase health and longevity is through calorie restriction. Eat less, be lean and live longer, assuming you eat the right things, like vegetables and grains with the right protein, complex carboydrates and unsaturated fats.

Mini-fasts, or not eating for 12-24 hours, is also gaining attention. Many Mormans fast one day each month, only taking in water. In a study presented at the American Heart Association annual conference, those that do this have a 40 per cent reduction in cardiovascular disease (clogged arteries). Similar benefits have been found in those who practice the Islamic fasting of the Ramadan season (12 hour daylight fasting for about one month).

The bottom line here is that in our modern society, we eat too much. Food is abundant, even if it is getting more expensive. We eat out more than ever before and many studies show that when we eat out more, we consume more fat and total calories.

The evidence for calorie restriction and brief fasting is mounting and I think you will hear and read much more about this. Anyone can cut down on calories and eat the right things, we all know about that. It just takes discipline. If you want to fast more than skipping a few meals, talk with your physician if you have diabetes. Your medication may need to be adjusted.

I'm going to be 58 next month, and while I exercise a lot, I know that my 190 lbs are too much (I'm 5 ft, 11 in). My goal is to get to between 165 and 175 this year. How about you? This is not just about losing weight and looking better. This is about living longer and healthier.

Making the Most Out of Our Moments!

A few days ago, my sister sent me one of those e mails which, at the end, says: "send this to 8 people you care about". Although these types of messages are usually a nuisance, one line caught my attention: "Don't count the rest of your life in the number of breaths you have left, but in the number of moments that take your breath away". That same day, my wife, who has had a bone marrow transplant for treatment of lymphoma was overheard to say: "Maybe I'm celebrating too much, but I have made a decision to 'go for the gusto', so I'm not worried about it". Then, the very next day, some close friends of mine were in the Emergency Room because Mike had chest pain and nausea and his wife, Bonnie, wanted to make sure he hadn't had a heart attack. While we were waiting on the lab work to come back, they were talking about an expensive bass boat they had just bought and were recounting the headache they had deciding between two boats. The ended up getting the more expensive one that they really wanted. She said, if we hadn't gotten this one, I would have regretted it the rest of my life and I wonder how many other decisions I need to make so I won't look back with regret.

All this got me to thinking about how we live and how important it is to make the most out of the present. With all of our worries and cares, this can be really hard to do. But, yesterday, I started tweaking my thinking:

I didn't have a meeting scheduled at work until 10:30 a.m. So, instead of going in to the office early as I usually do, I went for a 20 mile bike ride. It was one of those mornings, clear, cool, low humidity, birds singing loudly. The Arkansas river was high and beautiful, everyone on the trail was in a good mood and saying good morning with a smile on their face. I stood up on my bike, picked up my pace and, smiling inside, remembered that this was one of those moments that I need to create more often by not allowing myself to be a slave to the schedule, to stop fretting about the mistakes of the past, worrying about the problems of the future, and enjoy this wonderful, but temporary moment.

Then, last night at dinner in our favorite Sushi bar, the manager was there with his wife and three delightful children. They didn't know me from Adam, but I grabbed the 1 year old little girl and lifted her up as she giggled and cooed, then picked up the 3 year old boy who, with a total stranger, rested his head on my chest in a short tribute to the precious value of human contact.

So, whether its being surprised by an unusually delightful morning bike ride, picking up a child to affirm them, or simply making sincere contact with a co worker, let us remember to stop living in the past and worrying about the future long enough to do a better job of enjoying our moments!

How about you? Do you have story to share about enjoying your moments?

How Would Patients Prefer to Interact with Doctor's Online?

I am interested in how the public feels about the best way to interact with medical providers online. Some companies prefer a structured response with a "fill in the blanks" form according to the initial symptom (e.g. back pain). Some simply facilitate communication with one's own physician, whereas others, such as eDoc, use a "free form" communication style and have a group of physicians, psychologists, and pharmacists to answer general questions about health, behavior and medications.

What do you think is the likely future of On Line Health Care and how would you prefer to use an on line service like ours? Would you prefer to limit your correspondence to your own physician, or are you comfortable relating to a team of professionals such as the ones that eDoc has assembled? Would you prefer a more structured format to provide input to the online doc, or do you prefer a "blank tablet" on which you can simply describe your symptoms? What other services besides the ones we provide would you like to see?

What do you think? I'd love to hear from you...

For Drug Questions, Check Out our new ePharm

This week, eDocAmerica launched a new service, ePharm, in which patients can ask any question related to medication. In the past, patients often directed medication questions to our eDocs, and they are certainly still free to do that. In fact, in some circumstances, a medication question is much more appropriately directed to a doctor than to a pharmacist. However, in others, you may actually get more specific or better information from the pharmacist than you would from the doctor. Examples which might be better answered by pharmacists include differences between generics and brand name drugs, drug side effects, and drug-drug interaction questions. Questions related to the clinical effects and effectiveness of drugs are mostly, probably, still best directed toward the physician, although clinical pharmacists, such as the one on our team, can often provide valuable input on these issues as well.

If you are comfortable making this decision to whom to direct your question, just log directly onto "ePharm", using the new icon on our menu or just use "eDoc" like you have in the past. If you aren't sure, go ahead and direct your medication question to the eDoc and, if he feels that the pharmacist is better positioned to answer it, he/she will forward it to him.

Our ePharm professional is Eric Schneider, PharmD. I had the pleasure of working with Eric several years ago when he served on the faculty of the Department of Family Medicine at UAMS. Since then, he has spent time in South Carolina and recently returned to Fayetteville, when he now serves on the Northwest AHEC faculty of UAMS in Fayetteville.

I believe that this will be a great new addition to the robust menu of services we are able to offer to our clients. Please feel free to log on to eDoc and send Eric a medication question.

Your comments and opinions are always welcome...

Go Nuts

I saw a news spot about how a vegetarian diet is not only healthy for you, but makes you "greener", that is reducing your "carbon footprint". Nuts become a mainstay of a healthy vegetarian diet since they are a great source of protein and essestial vitamins and minerals. Nuts are one of the best examples of a meat substitute.

The University of California Berkeley Wellness Letter, May 2008, reviewed the health benefits of eating nuts. Here are some of the highlights:

• Even though nuts have a lot of calories, 160-200 an ounce, numerous studies show that people who eat nuts tend to weigh less than those who don't. Obviously, such people use nuts as a healthy snack or part of a meal, and control how much they take.
• The fiber and protein in nuts make you feel full or satisfied longer, helping you to eat less during the day.
• The unsaturated fats in nuts are "heart healthy" and can reduce cholesterol levels. One reputable study showed that nuts led to a reduced risk of developing type 2 diabetes.
• Nuts have B vitamins, potassium, copper, magnesium, vitamin E, fiber and a range of other healthy chemicals.
• Watch out for the salt (sodium) in many packaged nuts. Eat unsalted nuts.
• All nuts share most health benefits, but there are some differences. Almonds are the richest in vitamin E and calcium. Brazil nuts are rich in selenium. Cashews are richest in copper and zinc. Peanuts are actually legumes, but are classified as nuts because of their nutritional qualities, and are high in resveratrol and arginine (both heart healthy). Walnuts are richest in the omega-3 fatty acids.

With all of this, make nuts a bigger part of your nutrition in place of meats. You will help your body and the planet.

Using a Heart Rate Monitor

In my recent post "Younger Next Year", Crowley and Lodge recommend, among other things, that we all need to exercise 6 days a week for the rest of our life and, for at least four of those six days, we need to serious aerobic exercise. But, how does one do "serious" aerobic exercise and how does one discern the difference between serious exercise and something less than that? The authors of this wonderful book suggest that "serious" aerobic exercise consists of exercise in the "aerobic" zone for 45 minutes or more for each of those days. They recommend the use of a heart rate monitor to make sure that you stay in the "aerobic zone" for all, or most, of that 45 minute period.

Having exercised for many years, and having recently taken up their advice (again) and started using a heart rate monitor, I have some comments on this approach that I think are important observations for anyone who is serious about this aspect of their life.

When I am exercising without a monitor, I tend to use the "perceived exertion" scale. This is outlined as follows:

Healthy Heart Zone 50%-60% 2-5 (perceived exertion)

Temperate Zone 60%-70% 4-5 (perceived exertion)

Aerobic Zone 70%-80% 5-7 (perceived exertion)

Threshold Zone 80%-90% 7-9 (perceived exertion)

Redline Zone 90%-100% 9-10 (perceived exertion)

Since the goal is to stay in the "aerobic zone", I seek the perceived exertion scale of 5 to 7, which is described as moderately difficult, but not painful, able to continue to carry on a conversation but you know that you are working.

What most people who don't wear a heart monitor don't realize is that there is a significant difference in what you think your heart rate may be and what it actually is when you have a heart rate monitor on. Generally, I find that I need to "pick it up" frequently during my workouts to maintain my target rate of 130 beats per minute (this puts me in the 80% of maximum heart rate range). If I don't have a heart rate monitor on, I tend to think I'm exerting myself at a higher rate than I actually am. This is human nature at its best, the tendency to fantasize, dream, imagine, or wish that you are stronger, better, faster, or more fit than you really are.

But, having a heart rate monitor on allows you to make almost constant, subtle adjustments, whatever your exercise type, in order to keep your workout at a high quality level.

Make no mistake, without a heart rate monitor, and just using the perceived exertion method, you can get and stay close to your target and will be healthier for doing it. But, if you want to get "younger next year", you must stay after it, maximize your efforts to get and stay fit and, for that, you need a heart rate monitor.

Your comments are always appreciated.

Six Nutrition Questions

Take a short quiz and test your nutrition knowledge. These are not trick questions, and they all have information important to your health. I have selected these from the UC Berkeley Wellness Letter, March 2008, as part of a larger Nutrition Quiz. I have modied the questions and answers with my own comments. There may be more than one correct answer. Here goes:

1. Fish is a good source of:
a. vitamin C
b. protein
c. beta carotene
d. omega-3 fatty acids

2. Nuts are high in:
a. calories
b. fat
c. cholesterol
d. all of the above

3. Rank the following foods for potassium, from the most to the least:
a. a cup of orange juice
b. a cup of yogurt
c. 3 ounces of halibut
d. a medium banana
e. a cup of broccoli

4. True or False:
Olive oil has more calories than butter

5. True or False:
Honey and brown sugar are healthier for you than white table sugar

6. To lower blood pressure, you should
a. eat more fruits and vegetables
b. eat low fat or nonfat dairy foods
c. use less salt
d. take a potassium supplement

Answers:

1. b and d. Fish has as much protein as meat, and is a good source of omega-3 fatty acids. Fish does not contain significant vitamin C or beta carotene, found in vegetables and fruits.

2. a and b. Nuts have 160-200 calories per ounce, with macademia nuts being the highest. Nuts are high in fat, but fortunately this is the healthy monounsaturated type of fat. Only animal foods have cholesterol.

3. b, a, c, e, d. While bananas are well known for their potassium (420 milligrams per medium sized banana), other foods are even higher. A cup of yogurt has 530 milligrams, and orange juice 500. The halibut has 490 milligrams and the broccoli 460.

4. True. Olive oil has 120 calories and 13.5 grams of fat per tablespoon, while butter has 100 calories and 11.5 grams of fat. However, the fat in butter is not the healthy type since it is saturated, while olive oil is rich in healthy monounsaturated fat. However, use it sparingly because of the calories and total fat content.

5. False. Sugar is sugar. Brown sugar is white sugar with a little molasses for coloring. The sugar in honey is similar to white sugar, and any other nutritional ingredients are insignificant. All sugars are ok in moderation and best if combined with other foods containing protein.

6. a, b, c. The DASH diet (see my Blog on this) for lowering blood pressure emphasizes fruits, vegetables and low fat or nonfat dairy products. Salt raises blood pressure in most people and should be avoided in any excess. No one should take potassium supplements unless prescribed by a physician. Potassium in foods, such as fruits and vegetables, are helpful, but not as supplements.

Doctor Patient e Mail: Stuck in First Gear

This article appeared recently describing the current state of doctor patient e mail. Although a few of us "committed souls" are modeling this as a great tool to improve access to health care, keep patients out of the office unless they really have to be there, and efficiently pass information back and forth, most US Health professionals are still unwilling to follow suit.

With few exceptions, most insurance companies don't reimburse for online office visits, so doctors are understandably reluctant to give their time away to e mail patients when they can bill for their time in the office. There are other barriers too, including lack of comfort or skill with internet/e mail, malpractice concerns, privacy concerns, and medical record documentation concerns.

These barriers need to be addressed and removed. Through widespread use of e mail, many office visits can be eliminated, greatly reducing the cost of care. Furthermore, one of the most frustrating aspects of the health care system is difficulty with physician access. With use of e mail, patients can get a timely response to many questions. They can also request prescription refills, appointments and review lab data. All of these are currently difficult to do, require playing phone tag and lead to tremendous frustration on the part of patients and physicians alike.

At eDocAmerica, we have seen, first hand, the enormous benefits of connecting patients with doctors via e mail. Connecting with your own doctor will be even more valuable. The eDoc staff developed a pilot project with a clinic in Portland, OR a few years ago and is now working on another one with the Family Medicine Clinic at the University of Arkansas in Little Rock, AR. We are hopeful that, as more and more of these pilot projects spring up, and more and more insurance companies begin to reimburse for e-visits, that e mailing your doctor will become routine before too long.

Your comments and opinions are always welcome...

DASH - A Diet for Preventing Heart Attacks and Strokes

The DASH (Dietary Approaches to Stop Hypertension) diet was developed as a lifestyle change to reduce blood pressure in people with high blood pressure (hypertension). It does work and is endorsed by the American Heart Association and the National Institutes of Health. This diet favors fruits, vegetables, whole grains, nuts and legumes, and low-fat dairy products; and avoids red and processed meats, sweetened beverages, and sodium.

Over 88,000 nurses between the ages of 39 and 54 are being followed in the national Nurses Health Study and nutrition researchers in Boston looked a the elements of the DASH diet and found that it had a significant impact in reducing the risk of heart attacks and strokes. The details of this study are available at: http://archinte.ama-assn.org/cgi/content/full/168/7/713

The DASH diet is one we should all eat whether we have high blood pressure or not! A comprehensive guide to this diet is available at the NIH website: http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

My New Knee

After suffering years of pain and increasingly limited activities, I made the decision to undergo a total knee arthroplasty in December.

The staff at the University of Arkansas decided to document this experience with a sequential video and I thought that some of you might enjoy it.

So, here is the link:

http://www.uams.edu/orthopaedic.asp

How Much Water Should I Drink Each Day?

It is often said that we should drink 8 glasses (I assume 8 cups) of water each day. That is a medical myth (a statement without any scientific basis). However, I think it is a good advice. Here's why.

8 cups is a half gallon. We should take in at least of half gallon of fluids each day. If we are physically active with exercise or just lots of movement at work or home, we need even more, up to twice that much. We lose water every day through our skin, with sweating whether we feel it or not. We breath out water vapor with each breath. We need water to help keep our stools soft and to keep our urine flowing. Our bodies are about 60% water, even more if we take away the bones. Almost every chemical reaction in our body uses water.

If we are not drinking water, what are we drinking? Sodas are not good for us, too much sugar and even the artificially sweetened ones have lots of phosphorus that leaches calcium out of our bones. Fruit juice also has lots of high glycemic sugar. Better to eat the natural fruit. Coffee is ok in moderation, but is a diuretic and makes us lose more water than we would naturally. Tea does the same thing, and is often sweetened. Water is clearly the best liquid to drink. I consider it the cleanser of the body. It washes out those waste products in the blood, especially the ones that come with losing weight.

So, make water the mainstay of your daily fluids. 8 cups is not too much to drink. Use other fluids sparingly and eat well. Even though the 8 cups recommendation is a medical myth, I think it is still good advice.

Should I Take Zetia or Vytorin?

Effectiveness of the cholesterol medications Zetia (ezetimibe) and Vytorin (simvastatin/ezitimibe) were called into question this week in well-publicized reports from the American College of Cardiology meetings, as published in the New England Journal of Medicine.

Specifically, the ENHANCE trial found that although adding ezetimibe to maximal statin doses over 24 months effectively lowered bad cholesterol (LDL) and inflammatory markers of heart disease risk, it did nothing to decrease the size of cholesterol plaques in the large neck arteries (carotid arteries). Such plaque size is a well-documented marker for heart attack risk.

Importantly, the ENHANCE trial does not raise safety concerns about ezetimibe, but rather questions its effectiveness in achieving one clinical outcome. Additionally, the study was conducted on a select population of patients with familial hypercholesterolemia and a very high mean LDL level of 317. The patients did not achieve the target cholesterol goals known to you loyal Bloggers. These facts make the study outcome difficult to interpret and somewhat controversial.

So, what should you do if you are taking these medicines or if you have non-goal cholesterol levels?
* Achive LDL levels at ATP III-recommended levels.
* Utilize lifestyle changes like diet and exercise in addition to optimal sugar and blood pressure control.
* Realize that statins are the first drugs of choice, and should be titrated to the highest tolerated dose to achieve the target.
* Know that if optimal statin dosing does not achieve the goal, additional therapy is needed. Options include niacin, bile acid resins (like Colestipol), psyllium (like Metamusil), and fibrates (like Tricor), in addition to cholesterol absorption inhibitors like ezitimibe (Zetia). Some authorities believe that the non-ezetimibe options should be tried first given results of prior studies.

Ongoing trials will help clarify these issues further. Stay tuned to the Blog, and, as always, if your levels are not at the goal, ask your doctor "why not?"

Hemoglobin A1C: How Low to Go?

Being a person with diabetes is hard work. Being a physician is hard work. I don't doubt that being a journalist is hard work too, especially with the focus on reporting what is particularly sensational. Good news, from a medical standpoint, is often just not very eyecatching.

What does seem to get a lot of press attention is reporting about research studies that are not completed. There have been efforts by the editors of medical journals requesting medical reporters and medical researchers to hold off until the research is complete and has at least undergone some initial analysis. Perhaps few people of any profession can resist the media spotlight.

As an example, interim findings reported in February from the ADVANCE diabetes trial did not show evidence of an increase in deaths of those persons in the "arm" of this study that worked to achieve a hemoglobin A1C of 6.5 or less (compared to those in the control arm who aimed for a HbA1C of 7.0 to 7.9). These findings were released in response to news from the ACCCORD diabetes trial which did show a higher mortality rate in those in that study's aggressive treatment group, who also aimed for a HbA1C of 6.5 or less.

The advice of the American Diabetes Association in response to both news stories is for persons with diabetes to NOT change their treatment regimens based on these preliminary findings as there is "insufficient evidence from what we've heard so far".

Very good advice. It is an admirable practice for persons with diabetes and the doctors who treat them to keep up with the latest information on diabetes treatment but very unwise to set one's course based on today's news stories or tomorrow's. Right now, aiming for a HbA1C between 6.5 and 7.0 is a sensible and solid course for which to aim.

Never Too Late to Get Healthy

My wife and I love to go walking at "Two Rivers", a beautiful, riverside nature reserve in Little
Rock. Typically, when we go early in the a.m., we see herds of deer numbering 50 or more, flocks of gulls, pairs of graceful cranes, groups of honking Canada geese, and others. You just never know what you might encounter on any given day.

Last time, we saw a wizened, bearded old man, hooked up to an odd bicycle contraption, loading concrete blocks into a basket/trailer. He noted our curious look and said "I used to weigh over 300 pounds, have lost 50 in the last 3 months, and have a goal of 160 pounds". He went on to say that he and his wife decided to start getting "healthy" this past year and that she walked while he pulled this weighted-down bicycle contraption to enhance his workout and increase his calories burned.

We had a delightful spontaneous dialogue and I suggested he get a copy of the book I have blogged about, "Younger Next Year", which he promised to read.

I wondered how he had come up with this approach, why he had waited so long to get healthy, and what his background was, but it reminded me that there are many ways to achieve our goals and most of them will work if we are committed to good nutrition and a consistent exercise program.

Your comments are always welcome...

It'll be Easier when they are Grown? Forget it!

This post is about being a parent of adult children. I have six of them. Although my youngest is only 20, I can now say that all of my children are, essentially, adults. Having six kids at any time can be a challenge, to say the least. But I well remember thoughts I had when we had three in diapers, couldn't stray 6 feet from them, and never got a full night's sleep. I thought to myself: "It'll be so much easier when they are all in school". Then, when they all got in school, I said: "It'll be so much easier when they all go away to college". Then, I remember thinking, "It'll be so much easier when they get married and have a life of their own".

Sadly, through all of these phases, I have learned a hard lesson: being a parent never gets any easier. The issues simply change. When children grow into adults, the issues become more worrisome and, occasionally, heartbreaking. I lose a lot more sleep now than I did when all I had to do was help change diapers, feed a child, or lend moral support in the middle of the night to my wife as she tended to a squalling baby.

Scraped knees and assuring a nutritious intake at mealtime gave way to conflicts with friends and threatened social isolation; painful tongue lashing/criticism from coaches; heartbreak over relationship breakups; worry about the impact of academic difficulties; problems finding (or holding) a job; relationships with in-laws; young family financial problems and on and on, ad infinitum.

I encounter a lot of young parents these days who, amusingly, also relate that "It's hard now, but it'll get a lot easier when they grow up some".

I no longer hesitate in saying: "Forget it!".

Nutrition News Today

Two nutrition items came out in the news today that should be of interest to eDocAmerica readers:

1. Foods rich in Vitamin C may reduce the risk of prostate cancer. A study of 1985 men published in the journal, Prostate Cancer and Prostate Disease, showed that intakes of vitamin C-rich foods, such as peppers, broccoli, and spinach, were associated with a lower risk of prostate cancer by about 50%. Interesting, vitamin supplement showed no benefit. Eat your vegetables!

2. Washing potatoes before frying them may reduce cancer risk. A suspected carcinogen acrylamide is created when starch-rich foods are cooked at high temperatures, such as frying, baking, grilling, or roasting. This chemical is reduced when the potatoes are soaked before frying, according to a study published in the current issue of the Journal of the Science of Food and Agriculture.

Hope this information may save a life.

Drop the Antidepressant?

Last week, many of the national television, print, and Web media had a story about antidepressants only helping persons who were severely depressed. So, should folks taking these medicines (118 million prescriptions in the US for this family of medicines in 2005 makes for a lot of folks) stop taking them?

There are good reasons not to drop antidepressants based on this one news item.

First, like all science, one report seldom makes for a definitive conclusion. It is sensible to discuss the report with one's physician before the next antidepressant refill prescription is made but wait and see how the medical researchers, pharmaceutical companies, and the Food and Drug Administration respond. And, don't expect that a report contradicting the bad press on antidepressants will necessarily get the same media attention.

Second, there are indications for antidepressants other than for treating depression. The report did not address using these medicines for assisting with pain control, treating anxiety disorders, and other uses. All that was questioned was the treatment of depression that is less than severe.

Third, going "cold turkey" off most antidepressants can make one feel bad for days to a few weeks. This drug withdrawal is not usually dangerous but can make one feel very anxious, irritable, out of sorts - all sorts of symptoms that might have been present before one started on the antidepressant but in this case, these symptoms are due to the body readjusting (too quickly) to the withdrawal of the antidepressant. One's physician should be willing to work out a slow tapering of the antidepressant over a period (ideally) of several months in order to avoid these withdrawal symptoms.

So, don't ditch the antidepressants due to one news story. Discuss any such decision with your doctor.

On Connecting and Committing

My recent blog post on the book "Younger Next Year" included Harry's 7 rules for more successful living and aging. The last one was "connect and commit". This rule deals with the question: "What is your passion", but it deals with a considerably more complex, slippery issue than that. I've thought a lot about myself and how I "connect and commit" and have to admit that I often come up short.

One of the essential ingredients of a full and happy life is the energy that we give to others as we make connections in our day to day lives. I see this so vividly in my office practice. On days when I feel good and have a patient that I succeed at making a connection with, I feel more alive, better physically and emotionally, and more certain that I am where I should be and doing what I should do. On the contrary, when I feel stressed and rushed, annoyed at a difficult patient, impatiently hold the door knob signalling that I need to move on to the next patient, I feel less alive and more easily discouraged by the inevitable challenges of the day.

On the the one hand, finding a favorite charity and giving of self and resources is extraordinarily rewarding but, on the other hand, simply connecting and committing in our everyday activities seems just as important, maybe even more so. It begins to reflect what we are really about, rather than allowing us to rise to that "platform" of our "passion", then leave it to return to our everyday world.

The idea is that we consciously aspire to "care" about our interactions with colleagues as well as casual acquaintances. Asking others simple questions to convey an interest in their lives is one example, compared to merely saying "hi" and walking on by. Making a conscious effort to call siblings, children, parents, and friends is another example, rather than just rushing home to read, workout, watch evening TV or fix dinner. Connecting and commiting can become a habit, part of one's way of life.

I tried this out the other day during my teaching day in the clinic. Normally, this is a challenge for me. I sit there for several hours and have to concentrate on the stories the residents relate to me about the patients, approve their treatment plans, ask the right questions to get to the meat of the matter, etc. It is tiring and easy to get annoyed if someone doesn't have the history well in hand or have a logical, correct, or appropriate treatment plan ready. But, on this day, I made a conscious effort to compliment good history telling, ask the residents something about themselves, and to listen more actively. To connect with them and commit to the job for that time slot.

I left this experiment with the conclusion that I could, by an act of will, do a better job of "connecting and committing" in the areas of my job that don't come naturally for me, or that I don't enjoy quite as much. I left that half day session a happier (and, I think, younger) person!

Now, I need to go home and connect and commit with the family!

Your comments are welcome...

The Upd and Downs of Vitamins

Should you take a daily multivitamin? This seems as obvious as motherhood and apple pie. Our understanding of the health benefits, and even health risks, of taking vitamins has advanced a lot in the past several years. The March, 2008 issue of the Harvard Men's Health Watch (HMHW) (www.health.harvard.edu) has an indepth review of the latest research on vitamin supplements.

There are 13 vitamins, chemicals that cannot be made by the body and are required for the body's metabolism. There are deficiency diseases for each one of them, like scurvy for a lack of Vitamin C. In order to function properly, our bodies need only small amounts of these vitamins, and a healthy balanced diet readily provides them. But, just in case, 35% of adults in the US take a multivitamin on a regular basis.

Vitamin intake rose dramatically in the 1980s and 1990s with evidence that anti-oxidants (Vitamin E, Vitamin C, Vitamin A and beta carotene which is converted to Vitamin A in the body) may help protect against heart disease and cancer. One report in 1999 showed that 39% of cardiologists were taking Vitamin E (not today, more on that later).

A second big boost to vitamin and other supplement intake came in 1994 when the Dietary Supplement and Health Education Act (DSHEA) was passed by Congress. Vitamins and other supplements were removed from the jurisdiction of the FDA and maufacturers could make great health claims without proof. After DSHEA, the sales of supplements in the US soared from $4 billion to over $21 billion dollars.

The early research on vitamins and supplements was observational, a crude type of research that does not prove cause and effect. Maybe vitamin takers were simply healthier people? Careful controlled research trials over the past 10 years have produced new light on taking vitamin supplements, light that shows very little benefit and even the risk of harm.

Careful research shows that taking anti-oxidant supplements do not protect against heart disease or cancer, and may increase the risk. For example, supplementation with Vitamin E may increase blood clotting and increase the risk of a heart attack or stroke. Almost all of those cardiologists have stopped taking Vitamin E. Beta carotene supplements increase the risk of lung cancer in male smokers, excess Vitamin A increases the risk of bone fractures and people who take anti-oxidant supplements may have a higher death rate per year than those who don't (HMHW, November 2007).

What about that great B vitamin, folic acid? We know that it prevents birth defects and lowers homocysteine, an amino acid associated with heart disease risk. Modest amounts of folic acid are helpful, but high amounts (1000 mcg or 1 mg or more) seem to make cancer tumors grow faster, raising the risk of more serious colon, prostate and breast cancer.

The HMHW states that there is one vitamin still standing that when taken as a supplement may provide more benefit than harm - Vitamin D. Vitamin D is important for bone health and taking supplements of 1000 IU or more may reduce cancer risk. Certainly more studies are needed.

Should you stop taking that one-a-day multiple vitamin? There is no evidence that the amounts in most once daily mutivitamins do any harm or good. However, if you take a heavy amount of vitamin supplements, you should take a careful look at current scientific evidence, and not the manufacturer's hype, and reconsider. A double tragedy is spending a lot of money and causing harm.

Younger Next Year

The book "Younger Next Year", by Chris Crowley and Henry S. (Harry) Lodge was recently recommended to me by a friend. He was a recently retired plastic surgeon, somewhat depressed and overweight. He said "this book is changing my life" which tends to get my attention! My wife bought the book and gave it to me that night and, over the next few days, I read it with great interest.

Harry's rules are:

1. Exercise six days a week for the rest of your life.
2. Do serious aerobic exercise four days a week for the rest of your life.
3. Do serious strength training, with weights, two days a week for the rest of your life.
4. Spend less than you make
5. Quit eating crap.
6. Care
7. Connect and commit

This book elaborates on these seven rules, which are a wonderfully simple approach to healthy aging. Although I am a fairly fit 58 year old, I can tell you I had some fine tuning to do after reading the book, and felt inspired to do it! Here is the tangible, near-term result of the book for me:

1. I am committing to trying some new things, such as a yoga class with my wife one or two days a week (I have been to three so far!)
2. Increasing my aerobic exercise duration to at least 45 minutes a day for at least 5 or 6 days a week.
3. Increasing the time and effort of my two times weekly weight workout.
4. Cutting out more fried foods from the diet.
5. Avoiding the temptation to have that third glass of wine at night.
6. Thinking concretely about connecting in my work and social interactions, rather than just going along for the ride.

I can enthusiastically recommend this approach to you if your life and your health is in a funk and needs a jump start. These guys are seasoned, realistic, optimistic and fun to relate to. They also have a web site http://www.youngernextyear.com.

Check it out. Comments always welcome.

Recent Heart Attack? - Take Your Clopidogrel!

Current guidelines recommend taking Plavix (clopidogrel) for 1 year following a heart attack. But what happens at the end of that period? A recent VA study suggests that there is a sort of "rebound period" at the end of clopidogrel therapy that might increase risk.

Specifically, among 3000 patients split between medical therapy and stenting, analysis showed a nearly twofold increase in risk for adverse events during the first 90 days after clopidogrel cessation. The theory is that platelets may become temporarily re-activated, leading to recurrent risk of thrombosis within the artery. The study has some limitations in that it involved a retrospective review of charts, but it does prompt certain steps to be taken by patient and physician:

First, be sure to complete your Plavix therapy for the full duration and then move seamlessly into aspirin therapy as directed. Second, if you have risks for recurrent arterial clogging, like multiple past stents, diabetes, or other uncontrolled risk factors, ask your doctor if extending Plavix therapy is reasonable. Better yet, control those risk factors as we discuss on the Blog!

What to Do When Valentine's Day Isn't So Sweet

Few Holidays seem to arouse as much emotion, as Valentine’s Day. For many, this very day can be downright depressing and dreadful. You have every right to send Cupid packing and find a way to actively cope. This does not mean that you have to ignore the Holiday, but rather not allow yourself to get caught-up in over-idealized romantic expectations that lead to disappointment and distress.

Here are Tips to Help:

Send the overvalued idea of Cupid packing.
Fire an arrow right through his cherub buttocks, if you have to. Consider how much this “loving” Holiday is based on little more than narcissistic commercialism and obligation that often leads even the most romantic toward disappointment. Go by any florist and you will see how much this Holiday costs. Notice too, that you will see mostly anxious men scampering in the shops. Isn’t that curious?


If you are single, whether you want to be or not, keep in mind that you are far from alone.
Don’t allow yourself to sit on a pity-pot and be caught off-guard this V-Day. Plan a social engagement (sorry) that involves people who simply care about you. Celebrate your whole life, not just because you have that one person to treasure, or who treasures you. Your life can be full, whether you are (or have) that “special” person or not.


Reach out to friends and family and avoid all of the V-Day hype.
For some, this means staying away from public areas, such as restaurants where there can be an over-abundance of partners lollygagging and portraying that perfect relationship. If you go out, take friends or family and celebrate life and independence. Avoid an indulgence that is guilt-prone, and be mindful to avoid excess of spirits or food. Sloth from overindulgence is Cupid’s breeding ground for guilt.

Don’t focus on thoughts of romantic loss, failures or idealism. Reframe, Refocus and Redeux this V-Day.
This is the holiday that can be loaded with self-punishment and guilt, so be cautious NOT to fuel the fire! Plan ahead; it’s OK to keep V-Day very low-key. Many feel an escalating obligation each year when it comes to V-Day. Break this dizzying cycle, and put Cupid in his rightful place. Don’t turn V-Day into Disaster-Day! Keep your expectations clear and avoid the merry-go-round of escalating expectations that creates nausea!


If you are partnered, do something out of the norm.
Haven’t we all seen enough of red roses and chocolate truffles? Do any of us really “need” any more chocolate candy? Hasn’t it all been said in a card before? This could be your year to do something novel, lively and even carefully daring. Real love is an action, not an obligatory habit at the end of flower stem, in a box of candy, or in a piece of jewelry.

If you, or someone you know has recently lost a partner for whatever reason, be sensitive to how this V-Day can impact them.
Do something helpful or meaningful for someone who might be feeling a recent loss. Your sensitivity and pro-action can be an experience that will not wilt, melt, add pounds or disappoint.

For the interestered, here are some Valentine's day statistics: http://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/003147.html


Comments Always Welcome!

Women: Age Gracefully -- Protect Yourself from Stroke

Studies show that one-third of strokes in women occur early -- that is, before the age of 65. Indeed, in the age group 45-54, women are twice as likely as men to suffer a stroke. A recent study of 17,000 patients attempts to define predictive risk factors among such women. The information is simple, straighforward, and quite practical. Importantly, it provides a quick checklist of features to review and correct.

Specifically, strokes were more prelelant in women with a large waist circumference, known heart disease, or recent migraine headache with aura. Other risks for stroke include cigarette smoking, high blood pressure, high cholesterol and diabetes.

Overall, these risks are similar to those we've discussed on the Blog many times in reference to prevention of heart disease. Younger women, however, may feel somewhat protected. Studies like this one should serve as a wake up call of sorts. We're prone to regard stroke as a disease of prevention. Accordingly, if you have more than one of the risks listed and you are a gracefully aging female, ask your doctor what you can do to stay that way.

More On Patient Internet Searches

Since my last post on potential dangers of searching the internet, I've learned of some potential problems and biases in the CMPI study that was quoted. Suffice it to say that the data from this study needs to be more thoroughly analyzed before it is taken seriously. While some patients certainly can be subjected to information that misleads or harms, it is equally clear that others are well informed, discriminating and intelligent. Moreover, many patients use other patients to review and validate data and benefit greatly from this.

I still believe that patients and physicians teaming up both in the office and in review of health data on the internet, as well as interacting on line about this data is a great, possibly optimal, model.

But, if you are a patient who has learned to use the internet successfully, by all means, don't be dissuaded or alarmed by the conclusions of my last post. However, if you are a patient who has difficulty knowing what to believe from web searches and you don't have a good support group to help you validate this information, interaction with a physician is a great way to get started sorting out what to do.

Your comments are always appreciated.

Searching the Internet on your own can Cause Serious Problems

The US Center for Medicine in the Public Interest (CMPI) recently released a report documenting that patients who search the internet on their own, looking for answers to health questions can make medical decisions that are potentially dangerous to their health. They note in their report that some patients have replaced their trusted physician with "google" or other search engines, but note that the medical information they find there always appears to be authoritative and accurate, but often isn't. They note examples of lawyers posing as medical experts, plaintiff firms searching for people willing to testify in lawsuits, and many groups or individuals selling alternative medical products of various sorts.

The authors further note that 65% of the first three pages of search results came from sites that were biased or contained unverified information. Nearly half of the first three pages of search results belonged to lawyers and attorney referral services seeking plaintiffs for class action law suits. Finally, they noted that no official regulatory pages or professional medical organizations appeared in the inventory of results.They note that persons who use the internet to obtain health information will find little that is reliable upon which they can depend and, worse, can get confusing, contradictory or dangerous advice or suggestions.

We have frequently noted on this site that we believe that the best model (other than working directly with your own personal physician) is to have a trusted physician who can either refer internet based information to you that relates to your particular issue, or send a site that you have found to a physician to review and verify its validity.At eDoc, the physicians almost always search the net and attach one or more relevant web sites to expand or illustrate our answers and comments. This provides patients with the best of both worlds: direct interaction with a trusted physician AND reliable, verified information from the vast resources of the internet.

Have you had frustrating experiences conducting your own searches? If so, I'd like to hear from you!

How to be Helpful to a Greiving Friend

Grieving has no season. Several folks have brought up the issue of how, now that the traditional Holiday Season is passed, they feel a surge of grief related to a recent loss. I wanted to share some tips modified from information on PsychCentral, on this important topic.

Often, I find that close friends who want to help just don’t know what to say or do. Indeed, sometimes we can say things that unintentionally make matters worse. Even if you are trying to help yourself through a difficult loss, I hope this helps. But, please don’t try to go through your grief alone; there are people who care and people helping you can really make a difference.
You can locate the entire PsychCentral article at <http://tinyurl.com/35xp7l>

Here are some Practical Tips to Consider

– Take action and do something specific that you think can help the grieving person. The well-intentioned offer, “Call if you need anything” usually is not enough.
– Encourage healthy expression of thoughts and feelings.
“Do you feel like talking?”
“I don’t know what to say, but I care, and I am here.”
“I can listen, and that might help you.”
“Please don’t worry if you cry in front of me.”
–If your friend uses email, keep close contact through short emails (this is not to replace other tips, but needs to be part of the overall action plan).
– Help create new traditions and memories.
– Help put regrets into perspective; no life is perfect.
– Help your friend look to their faith community for extra support.
– Urge discussing their grief with a behavioral health professional or even their primary care physician, if you feel this is more than you feel comfortable handling.
– Plan for difficult times/dates well-ahead of time (anniversaries, birthdays, holidays, mealtimes). The key here is to not be caught off guard with a surge of anniversary or nostalgic grief. Getting through the year of “firsts” can be particularly troublesome for many.
– Help clean out the loved one’s things.
–Encourage your friend to take care of their physical and behavioral health, and be a good role-model in the process.
–Be patient and be prepared for a roller-coaster of emotion. Grief is a process that takes time.
–Remain doing what a good friend would do: Put your good intentions into consistent, helpful, supportive and caring actions.

All comments welcome on this important topic

Antidepressants May Not be as Effective as we Think

A report recently published in the New England Journal of Medicine concluded that drug companies may have misrepresented the effectiveness of antidepressant medications by publishing those trials which showed better results and witholding other trials that were not as positive.

In the published reports, the drugs were about 60% more effective than placebo, but when the results of the unpublished reports were included, they were only slightly more effective than placebo in treating depression.

Over the past few years, it seems to me that patients and physicians alike have increasingly tended to rely on antidepressant medication to treat patients with depressed mood. It has even been suggested by some that we have been guilty of "medicalizing" sadness and treating relatively normal down times in life as a clinical illness, depression. But, clearly, depression is a common and serious malady in the practice of every primary care physician and we must always strive to maintain an effective approach to helping patients with this problem.

So, then, how do we take this recent finding and incorporate it into our practice? I think that antidepressants should be used, in most cases, as adjunctive, rather than primary treatment of depression. The medication clearly reduces anxiety, improves sleep, and in many cases, does elevate mood. But, we should all be cautious, especially in light of this insightful finding, about over-reliance on drug treatment. Use of psychotherapy and other forms of counselling, exercise, attention to sleep and nutrition, and addressing alcohol or other substance abuse issues are all examples of important aspects of treatment beyond just putting the patient on antidepressant medication.

If you have depression, are taking an antidepressant, but are not improving, you should strongly consider a return trip to your doctor to request a fresh approach!

Your comments are welcome...

Zetia, Premarin, and the safety of medicines

Part of our Federal tax money goes to support the Food and Drug Administration (FDA), charged with overseeing the safety of medicines sold in America. The pharmaceutical companies are quick to describe how very expensive it is to take a proposed new medicine through the FDA approval process. So, why is the effectiveness and even safety of Zetia, (ezetimibe; a component of Vytorin) a cholesterol reducing medicine, being questioned now quite some time after its FDA approval.

Everyone would like their risks of heart attacks and strokes to be reduced. This is the ultimate goal of preventing and treating cardiovascular diseases, the number 1 cause of deaths in the US. Heart attacks and strokes are thought to be caused by cholesterol plaque being deposited in the walls of blood vessels thus narrowing them or by clots lodging in the blood vessels of the heart and brain.

The ideal means of experimenting with a proposed medicine for reducing the risks of heart attacks and strokes would be to treat some people with the medicine and not treat others. Then, wait to see which group gets more and which group gets fewer heart attacks and strokes. And, ideally, everyone in both groups would have the same diet, stresses, living conditions, etc. Well, reality is far from the ideal and people tend to live for a long time so either the groups on the medicine and on a placebo need to be huge or the groups need to be followed for decades in order to get statistically valid results to answer the question - does the medicine prevent heart attacks and strokes.

We have thought that blood cholesterol levels served as indicators of what was going on in the blood vessel walls but this has not been shown to be the case for people on Zetia or for women taking Premarin (an estrogen hormone supplement). When the expensive studies were done, there was not a close correlation between the cholesterol levels and the diameter of the blood vessels (for Zetia) or the numbers of heart attacks and strokes (Premarin). We are just more complicated than was thought and these two surprises to medicine may end up having a great influence on how medical research is done and medicines approved in the future.

Are We "Overparenting" our Children?

Recently, I was driving down a rural Arkansas road and got "stuck" behind a school bus. That gave me an opportunity to observe the children that got off the bus. In one instance, there was this cute little redheaded kid that couldn't have been more than 5 years old, who got off the bus (at a busy road). His back pack weighed almost as much as he did. He proceeded to run happily down his rather long driveway to his farm house as his little dog made its way to meet him halfway. As small and young as he was, there were no parents or siblings there to meet him, escort him home, make sure he was safe, etc. But he looked fine, and very self assured for such a small fry.

For the next four or five stops, it was the same: The kids got off, happy, were not met by anyone, and proceeded towards their house to get started on the afternoon's activities. Where were their parents? Weren't they all being neglected? In my community of West Little Rock, these kids would all be met at the bus by at least one parent and, in most cases, would be whisked off to dance or music lessons, then on to a fast food restaurant or other venues, always closely supervised, accompanied by lots of questions, etc.

On the other hand, as I thought more about it, these kids were learning, at an early age, how to be more independent, how to solve problems and how to entertain themselves without the need for their parents to be in tow. In West Little Rock, parents tend to "helicopter" their kids and the result is often a child who goes off to college underprepared for independence, problem solving and good decision making.

Surely there is a balance in parental attention v. allowing the child to be away from a parent to learn the skills of becoming an independent person. But how does one achieve it? How do you know how much parenting is enough without smothering your kid with your attention? To what extent, I thought, have we parents crossed this line and have begun "overparenting" our kids. By washing, cooking, buying, transporting, thinking and, sometimes, even talking for them, we are likely robbing them of opportunities they need to experience.

What are your thoughts on this important issue?

Four Ways to Prolong Life

Greetings! I have been recovering from knee surgery for the last several weeks, so I haven't posted for a while. But, I'm happy to say that I'm doing well, and planning to return to work in a week.

How would you like to live an average of 14 years longer? A study reported today by Kay-Tee Khaw and colleagues at the University of Cambridge in the UK suggested that 4 behaviors would prolong life by an average of 14 years. These were:

1. Drinking only moderately (this is usually defined as no more than 2 alcoholic beverages per day)
2. Quitting smoking (or not starting if you don't)
3. Exercise (usually defined as 30 or minutes of aerobic exercise on 5 days of the week)
4. Eating five servings of fruits and vegetables per day.

The authors questioned 20,000 people between 1993 and 1999, assigning them one point for each of the above healthy behaviors. After controlling for age and other factors, they found that persons with a score of "0" were four times more likely to die.

The researchers tracked deaths among the participants until 2006 and found that a person with a health score of 0 had the same risk of dying as someone with a health score of 4 who was 14 years older, thus the presumption that the healthy habits were likely to proling life.

I have long advocated keeping simple goals such as these four behaviours for maintaining health. Therefore, I'm delighted to see quantifiable evidence of benefits. Since I haven't seen the original study or analyzed the data, I can't be certain that the study doesn't have some statistical flaws, but I am willing to accept that there is life-extending benefit to these behaviors and recommend them as the basis for good health.
In this season of resolutions, why not adopt these four simple, but profound, lifestyle changes and make a choice to lead a healthier and longer life!

Walk Further with a Pedometer

My wife and I recently installed a photovoltaic system at our house so that we can generate electricity from the sun. If we produce more than we use (which we do), we can sell it back to the power company. By producing an excess of electricity, I thought that we may become less careful about energy use, but the opposite reaction has occurred. We have actually become more conserving of electricity. Apparently, a similar mentality occurs when people use pedometers to keep up with the amount of walking they do on a daily basis.
The Journal of the American Medical Association recently summarized the results of 26 studies involving 2767 healthy adults that evaluated the association of pedometer use with physical activity and health outcomes. This review found that by simply wearing a pedometer, participants were motivated to increase the number of steps that they took each day. Overall, pedometer users increased their physical activity by an astonishing 26.9% over their baseline. But better yet, these same subjects also significantly decreased their body mass index as well as their systolic blood pressures.

The health benefits from use of a pedometer were clear in this study population. For those who require some extra motivation, this may be an easy way to increase their amount of daily exercise. The authors of this study weren’t sure if the level of physical activity and improved physical parameter would persist, but I can tell you that after 6 months of our photovoltaic system being on-line, we are still enjoying watching our electric meter “run backwards”.

Successful Dieting for Weight Loss

Losing weight is probably the most common New Year's resolution. Losing weight and keeping it off is hard work. If you are reading this, you may be among the many who are working at it.

My local San Diego Union Tribune had a very nice article in the Jan. 1, 08 issue called "Dieting Detours" by R.J. Ignelzi. I'd like to give you some of the highlights I thought were great practical suggestions. The bold topics are his, the comments are mine. A dieting detour is something which knocks you off course in your quest for weight loss.

Eating in a Restaurant: People who eat out, eat more than at home. Restaurants sell large portions to please you (they think) and keep you coming back. Don't eat it all! You may have grown up like I did with the "always clean your plate" culture. Only eat what you need to satisfy your hunger and send the rest back! You will feel good about that. Tell them what you want: You do not have to get the food like they want, make it the way you want. Hold the butter and put the salad dressing on the side are good starters, and save many calories and fat intake. Beware of buffets: This is where you eat multiple plates just because you can. Have a plan and make sure you only eat the meal you really need.

Family Gatherings: Be sure what you bring is healthy. Be conscious to only eat what you need. If you cannot help but eat more, burn some of that before and after the event through exercise. Burn what you eat is a great rule for maintaining weight.

Vacations: On vacation you will usually eat out more, so the first category above is important. Avoid alcohol in larger amounts. Alcohol is very high in calories and makes you store as fat much of what you eat. Stay active: Plan exercise into your daily routine, much like at home. My wife hates cruises because of all the food and the weight gain. I love them, and jog the deck and use the fitness center every day. I get off the ship stronger with no weight gain.

I hope these ideas will help you with successful weight loss for 2008.
Healthy New Year!