Thursday, April 17, 2008

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:

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:

Friday, April 11, 2008

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:

Tuesday, April 8, 2008

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.

Friday, April 4, 2008

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?"

Wednesday, April 2, 2008

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.