Wednesday, December 23, 2009

Reflections on the State of Online Health

As 2009 draws to a close, the US health care system is ailing and quasi-reform proposals are frantically being debated and voted on. Although some type of reform is likely in 2010, we will have only scratched the surface of what still needs to be changed. One particular aspect relates to the ease with which patients can use the internet to improve their health care. At eDoc, we've been using the internet to improve the health of our users for over a decade. Ten years ago, I predicted that patients would routinely use internet messaging to interact with the health care industry by now, but I was wrong. Although, increasingly, web 2.0 approaches are providing innovative communication and health management tools for patients, the growth of interaction between patients and doctors has been much slower than I predicted it would be. And the future still remains cloudy. The issues are nothing new and include:

1. Many patients still lack ready, reliable internet access. This is especially true for those who need it most: sick, elderly, and financially disabled persons.
2. Most insurance companies do not recognize e visits as reimbursible under health insurance plans. This provides a powerful disincentive for physicians to spend significant amounts of time answering e mail questions from their patients, since they are reluctant to bill patients directly for this type of service.
3. Professional liability issues have not been well worked out, leaving physicians and malpractice insurers feeling squeamish about supporting this approach.
4. Licensure issues remain the domain of individual states, are not consistent from state to state, and maintain unachievable standards in their definition of "doctor patient relationships". This requires a physician who wants to provide "on line care" to have a license in every state for which they provide this care (edoc provides medical information, not on line practice). Moreover, they define the minimum requirements for establishing a doctor patient relationship as an "in office" history and physical examination performed by that individual.
5. Physicians and health care providers who are interested in providing online care are dissuaded from getting involved lest they be tarred by the brush of thousands of online health care supplement companies, bogus care recommendations from quacks, and illegal drug distributions sites.

So, how will we deal with this, and in what direction will we go in the future? Hopefully, my predictions for the next few years will be more accurate than my last ones:

1. Online care will continue to grow, in spite of the obstacles mentioned above, because the internet an incredibly powerful and efficient resource for patients. The growing demand will eventually overwhelm the remaining barriers.
2. Patient and peer groups will become increasingly sophisticated, with or without the cooperation of health care providers, and will increasingly rely on each other, rather than sole reliance on trained professionals.
3. Grudgingly, more payers will begin to support online care as the patients/employee groups realize the benefit and demand it of their employers and insurers.
4. Access to online services will continue to grow, including adaptation on cell phone applications, which will lower the bar for patient groups that are currently left out of the action.

The ability to communicate with a physician via secure e mail has tremendous benefits, including saving unnecessary office visits, allowing patients to optimize the timing of their visits to physicians, and increasing patients' confidence to act on issues and questions. Moreover, it allows physicians and patients to emphasize and more efficiently monitor preventive practices such as healthy diet, exercise programs, weight loss programs, smoking cessation and others.

Health care reform may increase the number of patients who have some type of insurance, but thus far, has not included proposals to reform the online environment to encourage or stimulate more communication between doctors and patients.

As always, your comments or dissenting opinions are welcome.

Merry Christmas and Happy New Year to all, and thanks for being a part of eDocAmerica!

Thursday, December 17, 2009

Do Diet Sodas Make You Fat?

You would expect that diet sodas would help you lose weight since they have no or minimal calories. Drinking a diet soda rather than a regular soda saves you all that sugar, right? Many people develop diet soda drinking habits due to several factors, the caffeine, the sweetness or just wanting to drink something without the calories.

The link between diet sodas and weight is not what you might expect. Reviewed recently in the medical journal JAMA (Dec. 9, 2009), a major heart study showed that people who drank more than 21 diet sodas per week had twice the risk of becoming overweight or obese compared with people who don't drink diet soda. In another major study, daily consumption of diet soda was associated with a 67% increased risk of developing type 2 diabetes (cause by excess weight). Drinking diet sodas gives you the same "sweet tooth" behavior as other sweets and actually results in people eating more calories than if they stayed away from sweets in general.

Other research is even more disturbing about the addictive nature of diet sodas. When rodents are fed artificial sweeteners, not only do they consume more calories and become obese, but they become very addicted to the sweeteners. When given the option of repeated use of cocaine or diet soda, they preferred the diet sodas!

There are so many options for healthy drinking than diet sodas. Water is the healthiest beverage to complement natural foods. If you want some caffeine, coffee or tea would be healthier than diet sodas. Be mindful of what you put in your body and I'm sure most of you have thought that diet sodas are not very good for you.

Wednesday, November 18, 2009

Is a Low Carb Diet a Bad Mood Diet?

An interesting study out of Australia suggests that long term use of a low carbohydrate diet may result in more common bad moods and hostility. 106 overweight and obese people were followed over a year with either a low carb diet without fat restriction (the Atkin's Diet) or a low fat diet. Both resulted in the same amount of weight loss, but those on very low carb diets were cranky more often. This makes sense since carbohydrates increase serotonin in the brain, an important neurotransmitter that affects mood. Common anti-depressant medications such as Prozac work by increasing serotonin. Fats and proteins reduce serotonin.

How you put these findings in perspective? It all leads back to a balanced diet. Whole grains, a natural source of carbohydrates, are good for you! The bottom line is that we all should eat a healthy diet and avoid excess calories that put on excess weight. Simple carbohydrates, such as sugars, cause more hunger and induce us to eat more. Complex carbohydrates, especially when mixed with protein, do not do this. Saturated fats also are not optimal foods in any large amounts.

Eating right means eating healthy foods most of the time, and not too much food. Grains, vegetables and fruits are the foundation of any healthy diet. Protein sources should be healthy, such as nuts, vegetables, fish, dairy and lean meats. Healthy fats such as vegetable oils should be eaten regularly and in moderation. Beware of any diet that seriously restricts any natural food type. You might lose weight, but having frequent bad moods is certainly not worth it!

Monday, October 26, 2009

New Journal for Health Professionals and Patients Launches with Ambitious Ideas

Last week at the Connected Health Symposium in Boston, a new journal was launched, The Journal of Participatory Medicine ( This journal's mission is to transform the culture of medicine to be more participatory. This special introductory issue is a collection of essays that will serve as the 'launch pad' from which the journal will grow. I would like to ask you to log on and read these essays and help us as we connect patients, caregivers, and health professionals.

I am one of the Journal's Co Editors. The other is Jessie Gruman, PhD, founder and president of the Center for Advancing Health, a Washington-based nonprofit organization funded by the Annenberg, Macarthur, Kellogg Foundations and others. The Center works to increase patient engagement. She holds BA from Vassar College and a PhD from Columbia University teaches at The George Washington University. Jessie authored The Experience of the American Patient: Risk, Trust and Choice (2009); Behavior Matters (2008) and AfterShock: What to Do When the Doctor Gives You -- or Someone You Love -- a Devastating Diagnosis (2007).

Please take a look and send us your ideas.

Sunday, October 18, 2009

What is Your Daily Glycemic Load?

I've written before here about the glycemic index, that measure of how fast a food causes your blood sugar to rise. High glycemic foods, like simple sugars, cause our blood sugars to rise quickly resulting in a pouring out of insulin, a rapid fall in our blood sugar, and we become hungry again soon. Protein in our diet blunts this glycemic index effect, as does eating more complex carbohydrates such as in vegetables.

An new concept has emerged that complements the glycemic index, called the glycemic load. The glycemic load reflects how much total carbohydrate is released in your body from various foods. While carbohydrates, sugars and starches, are a core part of our nutrition, we know that eating a lot of them results in more hunger and we end up eating more calories and gaining weight. Low carbohydrate diet plans have shown some advantage over low fat diet plans for losing weight, although both work if the total calories eaten are reduced.

Dr. Mabel Blades has written a simple book that can be used as a guide to the glycemic load of common foods. I have used it to reduce my glycemic load, for example how much Cheerios I put into my morning cereal. I have increased the ratio of protein from yogurt to the amount of grains, keeping enough grains to give me the desired amount of fiber. I have also cut down on how much bread I eat, one of the first dietary interventions of low carbohydrate diet plans like the South Beach Diet. If you would like to order this simple handbook, you can find it from any online book source:

The Glycemic Load Counter. Mabel Blades. Ulysses Press, Berkeley, CA 2008. My doctor actually gave me a copy as part of my physical exam and health assessment. I'm five pounds lighter after just a couple of weeks.

Sunday, September 20, 2009

More on Participatory Medicine: Patient Research

This post is adapted from one I wrote last week on Blog:

Matthew Herper’s post about thalidomide treatment of Myeloma is a good example of how patients will contribute to medical knowledge in the future, and may form a cautionary tale for patients who get involved to this degree in formulating new treatment approaches.
I work with Bart Barlogie, MD, (quoted in the article as the physician who ran the first clinical trial of the use of thalidomide in treatment of Myeloma) who is an innovative clinician researcher who has extended the life of many patients with Myeloma with his treatment approaches. He is also treating my wife who was diagnosed three years ago with Waldenstrom's Macroglulinemia, a form of lymphoma that resembles Multiple Myeloma (she has responded very well to his treatment).

I was a good friend of Tom Ferguson, MD, who came to UAMS and was treated with thalidomide in 1999. Tom was also the founder of the “e-patient scholars” who started this web site and still meet annually. What he began has morphed to the budding Participatory Medicine movement, evidenced by the formation of the Society of Participatory Medicine and the soon-to-be-launched Journal of Participatory Medicine, which I will Co Edit along with Jessie Gruman. And that takes us back full circle to this story of a patient doing research about their condition as an example of Particpatory Medicine, which Tom strongly encouraged, facilitated and exemplified with his actions.

Whether Beth Jacobsen’s accusations about Celgene stealing her husband’s idea has merit or not is not something I am prepared to comment on. I’ll let the courts sort that out. But the fact that her husband pushed her physician to try a novel approach to try to save his life, and that it was tried (even though it didn’t work for him), is an example of what will happen increasingly in the “new world of Participatory Medicine”.

The article notes that, although Mr. Jacobsen didn’t respond to Thalidomide, the next patient had a dramatic response. Again, ironically, Tom Ferguson was one of the early patients who was treated at UAMS by Dr. Barlogie with Thalidomide. His Myeloma was rather advanced at the time, in 1999. Whether the Thalidomide was the reason or not, he did well for years after that. I didn’t meet Tom until much later, in 2005 and he died of complications of his disease in 2008.

So, he would undoubtedly be cheering with the knowledge that the treatment that helped him beat back his disease for over a decade was probably “discovered” by a patient who was practicing Participatory Medicine!

How many other clinical trials are out there waiting to be started by ideas engineered by patients who have the utmost to gain and the ultimate motivation–saving their own life.

Participatory Medicine: Patients doing research, usually online, and taking the ideas into the medical arena. Get ready, it’s going to be a brand new world!

Tuesday, September 8, 2009

When Dreams are NOT So Sweet

Have you ever been startled out of a deep sleep by a crying child? The first few times this happens, we parents levitate out of bed with our heart pumping and adrenaline surging, ready to do battle to protect our offspring. Parents are ever diligent during the day to make their children’s world as safe as possible. We hold their hands while crossing the street, we child proof our homes, we make sure their daytime care facilities – be it daycare, babysitter or school – are a safe environment. And at night, we tuck them in their warm and cozy beds with a full tummy and a gentle kiss on the forehead. Then we allow ourselves to relax, enjoy adult company and finally sleep before we have to do it all over again the next day.

Then the nightmares begin. For most children, nightmares are occasional incidents that can often be attributed to a specific event, or to an overtiring and difficult day. Sometimes we never know what triggered them. We are just glad they don’t happen very often.

Are nightmares normal? It certainly looks that way. Most children will have some experience with them. Nightmares may be the brain doing some extra work, below the level of full consciousness, to work through a stressful situation from their day. We all need time to process difficult issues and sometimes nightmares are a side effect of that healthy process. When the nightmares happen more often, this could be a sign that the child is not coping well with something stressful. The nightmares continue, increasing in frequency, as the child tries and fails to resolve the stressful issue.

How can we help our crying child in the middle of the night? Alan Siegel, Ph.D. from Cappella University suggests the four R’s for nightmare relief.

Reassurance that they are not alone, that they are safe and that it is OK to talk about their dream is the most important first step. Give your child a hug and let them know that you understand about nightmares and that everyone has them. Then discuss the dream.

Rescripting how the dream ends after you’ve gotten the details of the actual dream is like assertiveness training for the imagination, (according to Gordon Halliday, see reference below). Encourage your child to use their imagination in changing the scary parts and rewriting the ending where they are in control of the situation. Put that dinosaur in time out, tell that tiger, “bad kitty!” and make him turn into a kitten, or shout, “Boo!” to the ghost and scare him away. But be cautious about using so much imagination here that the nightmare’s message or warning of a possible coping problem goes unanswered. And certainly, don’t be so creative that you end up creating your own nightmare scenario!

Rehearsal goes a step beyond the new endings we imagined in rescripting. We go over the dream again with our new solution, and then we apply that tool to a similar situation.

Resolution involves getting to the root of the matter. Or what caused the nightmare in the first place. If the child had difficulty with a similar situation the previous day, ask them how they would now change that outcome? And remember that children will only talk about the scary stuff when they feel safe enough to relive it in the retelling. Writing, art work, or creating a play or story are good alternate ways your children can express their fears.

So what do we do when nightmares occur too frequently? When the nightmares are consistently violent or disturbing, when they just won’t go away no matter what you try, it may be time to turn to an expert. Your pediatrician can rule out any side effects from prescription drugs or any physical condition that may be triggering the nightmares. After the physical aspect has been ruled out, a behavioral health specialist should be consulted.

Now, as a practicing psychologist, I can tell you that I have also used some of these same procedures, very slightly amended, to help older children and adults as well. So, keep that in mind if you have your own issues with troubling dreams. Hopefully, this little ditty on nightmares will help you and help our little ones sleep like the proverbial baby.

Pleasant dreams.

Thanks for reading and please leave a comment on your own experience with childhood nightmares.

References for this blog:

Dreamcatching: Every Parent's Guide to Exploring and Understanding Children's Dreams and Nightmares by Alan Siegel and Kelly Bulkeley. Published by Random House's Three Rivers Press. Copyright © 1998.

"Treating Nightmares in Children" by Gordon Halliday in Charles Schaeffer, (editor) Clinical Handbook of Sleep Disorders in Children (New York, Jason Aronson, 1995)

Monday, September 7, 2009

The Four Pillars of a Healthy Lifestyle

I recently moved my work to the Palm Springs area of California. I am the Vice President for Primary Care at Eisenhower Medical Center in Rancho Mirage, California. My duties include starting a new primary care practice where I also work as a family physician. This week I developed a preventive medicine presentation I will be giving to groups of people, mostly seniors, in our area. I would like to share my key messages here.

Balance is the key to health in many ways. Our lifestyle choices play the major role in whether we are healthy or sick, outweighing our genetics and the bad luck of getting a disease for no apparent reason. There are four areas where lifestyle play a major role in our health. Do these four things and you are likely to be healthy:

Eat Right: We are what we eat, so what goes in our body is vital to our health. The mainstay of our nutrition should be vegetables and grains. We should avoid the saturated fats found in many animal meats and dairy, and the trans fats found in many fried foods and pastries. Eat healthy fats like those found in nuts and quality vegetable oils, such as canola and olive oil. We should avoid simple sugars that make us hungry and have protein at every meal (Nuts, low fat dairy, lean meats and fish). We should avoid excess salt. Do not eat many more than your body needs to maintain a healthy weight. See my other blogs since I write here about nutrition every month.

Be Active: Use it or lose it is a good rule for keeping our bodies healthy. Look for opportunities in your daily life to walk more, climb stairs and be active. Then, devote 5 of the of the 168 hours in a week to one or more physical activities of your choice. Being physically active is the best long term predictor of living a long and healthy life.

Sleep Well: We trained our children in how to sleep, but many of us forgot the lessons. Prepare for a good night's sleep by winding down our daily activities, turn down the lights, and leave the problems of our day behind. Imagination is ok for adults to use to enter the world of sleep. As adults, 6 to 8 hours of refreshing sleep is usually enough to replenish our bodies.

Manage Stress: Stress can wear down even the healthiest body. Be aware of our stress levels at home and at work, and seek ways to reduce the stressors. Some of us thrive on a certain amount of stress, that is fine. We know when we are distressed because we are not at ease and not smiling as much. I like these three rules for handling stress: 1. Don't sweat the small stuff, 2. Everything (just about) is small stuff, and 3. If you cannot fight, and you cannot flee, then flow.

Take a moment to reflect on these four "pillars" in your life and see what adjustments you can make to preserve your health.

Saturday, August 8, 2009

Food, Inc. The Movie

I have never been one to shy away from the truths about our world. An Inconvenient Truth was a movie that affected many of us profoundly. Most of my family does not like Al Gore because they are in deniel about what is happening to our planet, and our role in that. A new movie does the same about our food sources in America. It is called Food, Inc. It may upset you, but I highly recommend it. The authors explore just where our food comes from, the chicken, the beef, the grains and how our big corporate food industries operate.

I am not an anti-corporate person. I agree with Calvin Coolidge that the business of America is business. In our modern life, we have accomplished many things through industry. Our supermarkets contain a richer variety of food than ever available before in the history of mankind. But, there are important issues for us to address. What are the implications of feeding our cattle corn meal when that is not their best food source? What danger do we have of serious bacterial contamination? How do the big food corporations treat our farmers? These are all questions explored in this film. Like Anderson Cooper on CNN, this film "keeps them honest".

Two of the main characters in the movie are authors I admire a lot: Eric Schlosser, who wrote Fast Food Nation, and Michael Pollen, author of The Omnivore's Dilemma. These men are dedicated to keeping our food supply safe and healthy and for us to avoid the traps that make us unhealthy and obese.

Should you become a "locavore"? That is a new word to describe someone that only eats locally grown food. That may be an option for some but not for others depending on where you live. Locally grown food, like what is found in a Farmer's Market, is more likely to be fresh and have fewer questions than other commerically developed foods. I saw an interesting bumper sticker today, "Supermarkets have branches, Farmer's Markets have roots".

The tagline for Food, Inc. is "You'll never look at dinner the same way again". I must say that is true. I continue to shop in supermarkets and eat in restaurants, but I am much more mindful about what I put in my body. We all should be.

Monday, August 3, 2009

Participatory Medicine: Now is the Time to Make Your Move!

Participatory Medicine is a cooperative model of health care that encourages and expects active involvement by all connected parties (health care professionals, patients, caregivers, etc.)

When patients are aware of such things as their weight, BMI, blood pressure, recent key laboratory results, and so on, and when they come to the office motivated and prepared, outcomes are likely to be much better. The patient who passively waits for advice and direction from the physician is more likely to forget instructions, make excuses for failures, lack the discipline to lose the needed weight or stay on the required diet, and so forth.

Patients themselves, not their doctors, must be the ones to make the essential decisions about their health. They must be able to obtain the necessary information to make key decisions, then act on them.

How does this process happen? A patient may agree with this statement and want to begin to operate in this mode, but not know how to do it. Here is a short list of the essential steps necessary to begin the practice of participatory medicine:

1. If possible, find a physician who understands, and supports, this concept, including one who is willing to communicate with you by e mail and directly answer your phone calls.

2. Consider the option of using a service like edocamerica, that is dedicated to providing you with the information necessary to make decisions about your own health care. They can supplement your physician and are available to you 24/7 and always welcome your questions. Moreover, they are dedicated the concept of PM and are oriented towards health and wellness, not just managing your diseases.

3. Start following blog and twitter posts by persons who are now actively discussing how Participatory Medicine is going to change the way health care is practiced.

4. Keep a current list of your medications, including the Brand name, generic name, dose and frequency of each one.

5. Look up the most common side effects of each of your medications.

6. Check your medications for any drug-drug interactions. You can use a web site such as for this.

7. Keep a list of all of your current medical conditions and review the basic information about each of them. A site such as Mayo Clinic or Medicine Net are good, trustworthy sources for this review.

8. Start making a list of questions that you want your doctor to answer for you. If he doesn't have time to answer all of them at the next visit, ask him if you can e mail them to him. If not, ask one or two at each visit until you get them all answered. If you can't get him to address all of your questions in a satisfactory and timely fashion, consider getting another doctor who will.

Participatory medicine, working on an equal footing with your provider, in a partnership for your optimal health, is the only way you can get the most out of the health care system. So, get on the train before it leaves the station!

Your comments and dissenting opinions are always welcome.

Wednesday, July 22, 2009

The Pain of Rejection

Two very interesting articles were published recently on the health effects of job loss and on-the-job rejection.

The first article looks at the health of people who have been fired. They limited their study to previously healthy adults who got sick after they lost their jobs. It didn’t seem to matter why they were let go or how quickly they found a new job. Kate Stully, an assistant professor in sociology at the State University of New York at Albany and author of “Job Loss Can Make You Sick” found that losing a job is linked to a higher risk for high blood pressure, heart disease, heart attack, diabetes or depression. I would also add an increased risk of suicide to this list.

The second article looks at what happens when you’ve been left out (or just think you’ve been left out) of the loop at work. Purdue University’s professor of psychological sciences, Kipling D. Williams, reported that hurt feelings for a perceived slight can affect morale, hurt job performance and productivity, and can even hurt the company financially in his article, “Avoid the Dark About Effects of Leaving Others Out of the Loop”.

The first article looks at how we define ourselves and our place in society by our jobs. The second looks at how damaging a perceived slight can be to productivity. Now these two articles on the surface seem to be talking about two different things. But if we take a closer look, aren’t both of these articles talking about the effects of rejection?

No matter how much we would like to say we don’t care what other people think, we really do care much more so than we might think. And it hurts when we feel left out or feel unwanted. According to the first article, it can even make us physically sick. It matters that we feel needed and accepted by those who play a large part in our lives. And let’s face it; we spend a lot of time with our coworkers so it would naturally follow that these people would have some influence over how we feel about ourselves.

The second article explains how just a small amount of the cold shoulder can have a significant impact on how we feel about ourselves and how we perceive others feel about us.
So how do we cope with feelings of rejection in the workplace? Most of us spend more time with coworkers than we do our families, so they often become our second family. In some cases, our work family may be the only one we’ve got. And family rejection is often the most devastating to our self-worth.

The first step in dealing with any rejection is a critical look at the rejecter as well as the rejected. Is she really rejecting me by talking with another coworker? Sure, we were a team in the meeting, but after the meeting she talked to someone else in the hall. Does this mean rejection, or does this mean she had a follow-up comment to something that person said in the meeting? Is my being fired from my job a reflection on my job performance or downsizing of the company? If it is my performance, was the job really a good fit to begin with? How could I have changed the outcome to better serve me? Could I have stepped up my performance, or changed jobs to one that I liked better? How will I deal with this in the future? Do I really want to be a part of this group in the first place? Is my desire for alliance with this group solely based on popularity? Does this group fit with my own morals and ideals? We all want to fit in, but not at the expense of losing ourselves in the process.

The second step is to realize that in order to feel rejection we must first give someone else the power to do so. Am I setting myself up for rejection? According to psychiatrist, Karen Horney, we tend to move toward, away from, or against others. Am I open and meeting others half way? Am I waiting for others to come to me or making others work harder to approach me? Or am I mistakenly pushing others away from me by rubbing them the wrong way or coming on too strong when all I really want to do is connect? Am I trying to alienate others before they get the chance to alienate or reject me?

The third step is to understand that rejection is a negative experience just like any other and that the hurt lessens when shared with others. Sometimes we can “feel” rejection when we are not being rejected at all. If I was cheated on by a loved one, or a family member raked me over the coals for showing up late for dinner, I would find a sympathetic ear to talk it out with. By discussing rejection, we find that we are not alone. We may even find that our story is not so bad when others share their horror stories of rejection. And don’t worry about fearing that we’ve blown the situation out of proportion. Maybe we have not been rejected at all. Our true friends will be the first to tell us when we are full of hot air. Our fake friends will be the last to tell us when we are wearing our underwear on our heads!

I’ll leave you with a couple of quotes on fitting in:

“I refuse to join any club that would have me as a member” Groucho Marx

“I want my individuality, so why can’t I get a tattoo? Everyone else is.” My neighbor’s teenager

The floor is now open for your comments. Please join in.

Sunday, July 19, 2009

Which Fish Have the Most Omega 3 Fatty Acids?

Most of us know that fish are a good source of omega 3 fatty acids, and that these are the "healthy" fats that help prevent heart disease. Is there much difference in omega 3 fatty acid content among various fish? I found out the importance of this question when it showed up on my board examination this past week.

In general, fresh water fish have LESS omega 3 fatty acid content than fish from salt water, although trout is a pretty good source. The correct answer on my board question was most probably salmon, although herring has a higher content (was not listed as a choice). Not all salmon have the same amount of omega 3s, with Atlantic, Coho, and Sockeye salmon leading the list. Besides salmon, tuna, mackerel, herring, trout, sardines and halibut are good sources of omega 3 fatty acids.

Some fish and vegetable oils have more omega 6 fatty acids, not considered a "healthy" fat for reducing heart disease. Some evidence suggests that the ratio of omega 3 to omega 6 is important for reducing heart disease risk. I found out recently that tilapia, a fish I order sometimes, has a much higher content of omega 6 than omega 3 fatty acids. No more tilapia for me!

Like most areas of nutrition, drilling down to the next level of information is important. Eating healthy is one of the most important things we do. With these blogs, I strive to give you the best nutrition information possible so you may make wise food choices, one of the pillars of good health.


Friday, July 17, 2009

eDoc Begins a New Era with Statewide Medicaid Coverage

Beginning July 1st, eDocAmerica began offering eDoc services to Medicaid recipients and their families in Arkansas. Since there are about 800,000 Arkansas Medicaid recipients, when added to our previously covered clients, this program takes us a long way towards offering the benefit to the majority of Arkansans.

It is especially exciting to begin offering a cost effective health care benefit to this large, underserved population. eDoc services can help with so many of this patient population's needs, including whether a child needs to be taken to see a doctor for acute care needs, to provide information that can help a patient determine if a second opinion needs to be sought for a given care situation, to provide information about medications that patients are on, to provide information to families of nursing home patients that they can use to ask intelligent questions about their family member's care, and many others. For nursing home patients, we encourage family members to log on and ask our professionals questions about their family members anytime, for any reason.

It is a daunting task to effectively communicate the availability of this benefit to this group of patients. We'll be working diligently over the coming weeks and months with the Arkansas Minority Affairs Commission, the Arkansas State Health Department, the Community Health Centers of Arkansas, Area Health Education Centers and Arkansas State government agents to increase awareness of this program and encourage its use.

One of the barriers to this program's success is that many patients either won't have a computer, or won't have access to the internet. We have addressed this with a toll free number (877-581-3362) that Medicaid recipients can call to ask their question. Our call center is staffed by trained nursing personnel who will relay the message to the professional staff and then call the patient back after the answer has been posted.

In addition, we are finalizing an iPhone application that should be ready to go within a short time. We hope to use this new initiative to begin to address some of the health care disparities that exist in the state.

I hope that we will soon see the day that every single resident in our State, insured or not, will be able to log on ask one of our professionals a question that will, in some small way, improve their health!

Monday, July 6, 2009

Positive Thinking, Negative Thinking, and why it’s better to be on the Fence

Since the publication of Norman Vincent Peale’s 1952 book called The Power of Positive Thinking, the world has been bombarded with a plethora of self-help books guaranteed to show us the way to happiness. But is there a down-side to these suggestions?

If we do as instructed, by a multitude of sources, to push away the negative, or bad thoughts and focus only on the positive, or good thoughts, how do we prepare for the bad times of reality?

Come with me, if you will, on a journey through the cluttered half-baked theories of my mind, but watch your step, there’s no liability insurance in here. If you trip into the corpus callosum, you’re on your own.

Part one of the half-baked journey begins with the extreme outcome of pure positive thinking. If I am truly thinking positively, then nothing at all could possibly go wrong, I have nothing to worry about, I am perfect just the way I am, and the world exists just so that I might gain pleasure from it.

If nothing could go wrong, why should I plan for a rainy day? My job will last forever, the roof will never leak, and my kids will remain perfectly healthy. There is only sunshine in my world.

If there is nothing to worry about, then I can count my life savings while walking down a dark alley without fear, my car will last forever- that banging under the hood means nothing and adds an interesting beat to the music playing on the radio, and I will never grow old. Throw away the botox; there are no wrinkles here.

If I am perfect just the way I am, why should I exercise to take off that extra ten pounds, why should I try to improve my mind with literature, the theater, or a higher degree. Why should I get off the couch?

If I buy into this extreme sport of pure positive thinking, why would I work like a dog to get ahead? Wouldn’t I be perfect enough for everything to be given to me?

Now for part two of the half-baked journey; are you still with me? We are getting really deep in the frontal lobes now.

If I remain in a positive thinking mode until I gain a serene, carefree state, does that mean my brain is unstimulated? And in turn, does that mean that the firing of neurons has diminished so much that if danger were to occur, I would not be able to act quickly enough for self-preservation? Would I react at all if I were a true positive thinker? What could happen if I stayed on the couch?

Let’s go back to the unstimulated idea. If I continue to not stimulate my brain, will my brain begin to deteriorate? After all, the old adage “Use it or Lose it” has been around longer than “Think Positively”. Let’s throw in another adage: Necessity is the Mother of Invention. That being said, if we have no necessity because we are positively thinking about everything and therefore need nothing new, why would we trouble ourselves to invent new things?

If I remain unstimulated for an extended period of time, what will happen to my mood? If there are no highs or lows, no release of adrenaline to handle excitement or danger, no need for the release of serotonin or dopamine to stimulate my brain, will these receptors be decommissioned as no longer needed? Will my mood sink into depression?

Now for the flip side of this saga.

What if I experienced continual negative thoughts? Would my life mirror the same lack of moving forward I found while hanging out on the couch with positive thinking? I may have more supplies stored in the basement with negative thinking and the door would be locked, but would my life be any more interesting? Would it be just as flat, but in a negative way?

If danger startled me off of the couch, would I be too paralyzed by negativity to react in time? If I think nothing good will ever happen, have I made this come true simply by closing the door to the possibility?

This leaves us with the good old fence straddlers.

Ordinarily, sitting on the fence is thought of as a bad thing. We are urged to choose a side, be decisive and stick with our convictions. What if I had a mixture of positive and negative thinking tempered with a good dose of reality thinking? Would my life attain a better balance necessary to survival? Would I have happy little neurons firing quickly and efficiently because they were getting a healthy dose of exercise and rest? If I use reality thinking with a mixture of both positive and negative thinking, will I be better prepared to weather hard times?

If I have a huge project due at work, would I be more effective if I used a dose of negative thinking that I don’t have enough time to complete this project, mixed in a little anxiety that if I don’t finish then my job may be finished, added some positive thinking that all I can do is my best, and stirred it around with reality thinking that I’ve proven myself by meeting hard deadlines in the past and have the ability to do so again. My project will most likely be completed on time because I have made this mixture of positive, negative, anxiety and reality work for me instead of against me. Too much positive thinking and I won’t push myself hard enough to make the deadline. Too much negative and I will give up before really trying.

The fence straddlers can enjoy a healthy mixture of both positive and negative thoughts, knowing each has its own value if kept in balance. And the view from the fence is not bad either.

Thank you for coming along on this trip through the half-baked theory region of my mind.

Now that I've shared some of my thoughts, feel free to share some of your own.

Tuesday, June 23, 2009

Our Health Data Rights

My colleague, Alan Greene, has been in the lead with a group of professionals putting forth a declaration of health data rights and, as founder of eDoc, I am completely in support of it. He points out that more than 7 percent of abnormal tests results fall through the cracks, according to a study released today in the Archives of Internal Medicine. According to Alan, as quoted today in his blog: "Whether we use this power to track our family’s medications, BMIs, lead levels, vaccines, or allergies, by being more actively engaged I believe we can make better health choices, reduce costs, reduce errors, and enjoy better health. Too often, bureaucracy, old thinking, or paternalistic concerns keep people from having their own health data or from
having the courage to act on it. I believe this is about to change. On June 22, 2009, we released a Declaration of Health Data Rights a profound, simple statement that, among other things, we all have the right – the license – to take possession of a complete copy of our health data without delay and at minimal cost, in a computable form if our lab data or pharmacy records or growth charts or other health data exist in that form....This doesn’t mean that we won’t value physicians and others who have devoted their lives to a study of health, but it does mean that we will engage with them in a new and more effective way...I hear concerns from some doctors that patients shouldn’t have a set of keys: they won’t make safe drivers. And it would be dangerous, for instance, for patients to be able to get worrisome lab results or biopsy results without someone present to reassure them. As I’ve heard more than once, what if this led to suicidal behavior? Yes, I think it’s valuable to have support when getting bad news, but I also think the choice of whether to have support, when, and what kind belongs to the person getting the news. Our routine of keeping people in the dark until we are ready for them to get information is too a high price to pay. What if people misinterpret or misuse their own health data in less extreme situations? No one has a greater interest in an individual’s health than that individual and their loved ones. Armed with up-to-date data, they are free to consult experts and other resources as they wish. Our health is our responsibility, and having our own data is essential to taking charge.

The Declaration of Health Rights is simple, clear, and self-evident – but I expect the implications of this Declaration will continue to unfold over the years to come What if people misinterpret or misuse their own health data in less extreme situations? No one has a greater interest in an individual’s health than that individual and their loved ones. Armed with up-to-date data, they are free to consult experts and other resources as they wish. Our health is our responsibility, and having our own data is essential to taking charge...One natural extension of this will be people’s ability to order lab tests for themselves. Of course, insurance will only pay for the tests if the situation warrants, but if your child has a sore throat and a fever, why shouldn’t you be able to order a strep test? Or if you’re a parent in your thirties or forties and have high cholesterol, why shouldn’t you be able to have your child’s cholesterol levels checked? We live in a country that allows people to smoke cigarettes and carry guns. Having our health data is far less dangerous and carries with it the possibility of great good. Let’s shake hands; let’s pick up our keys.

To learn more about the Declaration of Health Data Rights, click here.

To become a signer of the Declaration, click here."

Thanks, Alan, for stating this so well. I couldn't do it better than you, so thanks for allowing me to quote you!

Friday, June 19, 2009

Recent Heart Attack? Consider Cardiac Rehab!

Cardiac rehabilitation, or guided exercise under direction of a physical therapist, is a valuable yet underutilzed therapy for patients suffering a heart attack. Importantly, in those patients with ongoing risk factors related to obesity and insulin resistance/diabetes, aggressive cardiac rehab was recently shown to be especially effective.

Specifically, two groups of patients were enrolled in high intesity (5-7 days weekly of 45-60 minutes exercise) versus standard (3 days weekly of 25-40 minutes exercise).

High intensity patients lost more than twice as much weight over 5 months as standard patients (18 pounds vs. 8 pounds and had significantly greater reductions in 2 major cardiac risk factors -- waist circumference and insulin resistance. At 1 year, both groups had gained a couple of pounds over 5-month weights, but total body-fat percentages in the aggressive group remained significantly lower than initial readings. Other cardiac risk factors changed too - including decreased insulin resistance, increased HDL (good) cholesterol, and decreased measures of insulin, triglycerides, blood pressure, plasminogen activator inhibitor-1, and the ratio of total to HDL (good) cholesterol.

Overall then, patients who took advantage of their motivation after heart attack to aggressively address exercise goals reduced potential risk factors and set the tone for a healthier life. If you have been a heart attack sufferer, ask your doctor about cardiac rehab. If you are not a heart attack sufferer but have risks, ask your doctor about trying a program like this on your own.

Questions and comments welcome as always!

Thursday, June 18, 2009

Problems with your “Z’s”: New research on treatment of persistent insomnia – help is more than just medication.

The May 20th issue of JAMA (Journal of the American Medical Association) includes an article on treatments for persistent insomnia. Insomnia is the most common of all the sleep disorders and is described as having problems with the ability to gain sufficient sleep or to feel rested and characterized by difficulty getting to sleep or staying asleep. Insomnia may be situational, recurrent, or chronic. Most people know if they have problems with sleep, and most of us have had personal experience with occasional bouts of insomnia.

Lack of adequate sleep over time, or persistent insomnia, can have a very big impact on daily functioning; it will lower your quality of life and can contribute to various health and emotional problems. When untreated, insomnia can also contribute to major depression and other physical problems. When you get behind the wheel with not enough quality sleep, you not only put your life at risk, but those around you as well. A large number of auto accidents are attributed to driving while drowsy. Although it may be tempting to use alcohol as a sleep aid, it will work in the opposite way and create insomnia and other health-related issues as well. And…of course this will not help your driving either!

Here are some sleep-promoting tips that can work well to help you get into a healthy sleep routine:

1. Maintain a regular bedtime and awakening time schedule including weekends. Get up about the same time every day, regardless of what time you fell asleep.
2. Establish a regular, relaxing bedtime routine. Relaxing rituals prior to bedtime many include a warm bath or shower, aroma therapy, reading, or listening to soothing music.
3. Sleep in a room that is dark, quiet, comfortable, and cool; sleep on comfortable mattress and pillows.
4. Use your bedroom only for sleep and sex. Have work materials, computers, and TVs in another room.
5. Finish eating at least 2-3 hours prior to your regular bedtime.
6. Avoid caffeine within 6 hours; alcohol & smoking within 2 hours of bedtime.
7. Exercise regularly; finish a few hours before bedtime.
8. Avoid naps.
9. Go to bed only when sleepy. Lay in bed only for sleeping, not for work or watching TV.
10. Designate another time to write down problems & possible solutions in the late afternoon or early evening, not close to bedtime.
11. After 10-15 minutes of not being able to get to sleep, go to another room to read or watch TV until sleepy.

This latest research in JAMA shows that CBT (Cognitive Behavioral Therapy), a structured form of psychological treatment that focuses on modifying thoughts and behavioral patterns, was effective for treating persistent insomnia. The addition of a sleep medication to CBT treatment like zolpidem (generic name for a prescription sleep medication) produced some benefits, although such benefits were modest to treatment outcomes. Such findings suggest CBT may provide an added benefit in treatment of insomnia.

Since you are awake anyway, sign on and leave a comment about how your sleep is going. All comments from those who are sleep-deprived and others are always welcome. Sweet Dreams!

Sunday, June 14, 2009

Tips for Vegetarians

Some people decide to become vegetarians. There may be a personal philosophy against killing animals for food, religious convictions or a desire to eat a very healthy diet. There are different types of vegetarians. All avoid animal products, but some will eat dairy foods (Lacto-vegetarian), eggs (Ovo-vegetarian) and others will eat none of these (Vegan). Some vegetarians will eat fish (Pesco-vegetarian). Being a healthy vegetarian and getting all essential nutrients in the diet takes knowledge and effort. If done right, studies show that vegetarians are leaner, have a lower blood pressure, lower cholesterol and lower blood sugar.

Vitamin B12 is naturally only present in animal foods. Since it is added to fortified grains and cereal, vegetarians can still get B12 from food. Adequate iron is hard to come by for menstuating female vegetarians. Spinach and other greens do have some iron but it is not well absorbed. B vitamin and iron supplements may be taken to ensure good nutrition. Protein is the building block of most tissue, and getting all of the essential amino acids (what constitutes protein) from vegetables takes knowledge and a willingness to eat a variety of foods, especially beans, brown rice, nuts and greens.

As our global population continues to grow and our "carbon footprint" is measured, it is likely that more people will become vegetarians. This will be a good thing as long as a rich and diverse vegetarian diet is followed.

Sunday, May 31, 2009

Participatory Medicine will Change the Health Care World as we Know it!

One of the reasons eDocAmerica exists is to empower patients to take more control of their own health care. A wonderful group of people, patient advocates, physicians and other professionals alike have created a broad platform for this "e patient" movement, called Participatory Medicine. This group was originally assembled by Tom Ferguson, MD, an esteemed colleague who died after a courageous battele with Multiple Myeloma, and has since continued to meet. They created an excellent blog site, that anyone who is interested in this subject should visit regularly.

Participatory medicine is a cooperative model of health care that encourages and expects active involvement by all connected parties (healthcare professionals, patients, caregivers, etc.) as integral to the full continuum of care. The ‘participatory’ concept may also be applied to fitness, nutrition, mental health, end-of-life care, and all issues broadly related to an individual’s health. This group is forming a society, the Society of Participatory Medicine and, soon, there will be a web site where interested parties can join and "participate" in the discussion. The society's first president is Alan Greene, MD, author of popular Pediatric website In addition, the Society is founding a new journal, the Journal of Participatory Medicine. The Journal will bring together the best available evidence and examples of participatory medicine to:
a) Make a robust case for its value to people – sick or well –, advocates, and health professionals
b) Serve as a meeting place and rallying point for those at the leading edge of participatory medicine
c) Engage, inform and include those who have been involved in, or practicing, participatory medicine. We aim to advance both the science and practice.

The mission of the Journal is to transform the culture of medicine to be more participatory; and we believe that doing so, as the saying goes, will take a village – perhaps even a large metropolitan area! JPM constitutes a major investment of time and talent in community development. The journal will be entirely electronic, using the Open Journal System platform of online publishing. Yours truly, along with Jessie Gruman, the founder and president of the Center for Advancing Health (CFAH), an independent, nonpartisan Washington-based policy institute funded by the Annenberg Foundation, the W.K. Kellogg Foundation and other foundations, will serve as Co-Editors in Chief of this new journal. We expect to publish our first issue of the Journal sometime in the fall of this year.

This is an exciting group of talented, engaged people who have the capacity to create something that will make a major difference in our health care system. eDocAmerica has a powerful collaborative opportunity here to participate with other key individuals and groups to help change health care!

Your comments and opinions are always welcome...

Friday, May 29, 2009

Is it Time to Rethink Aspirin?

Aspirin? - Yes, I should take that to prevent heart attack and stroke, right??
Well......perhaps. A new study (called a meta-analysis), the largest comparative trial of its kind, shows that being overzealous about aspirin use for prevention of initial heart attack and stroke may be unsubstantiated.

Specifically 95,000 subjects were evaluated in this series, producing 1671 strokes and heart attacks in the aspirin group and 1883 in the control group. Aspirin was associated with an absolute reduction of 0.06% heart-related events per year. Correspondingly, aspirin did not significantly reduce ischemic (non-bleeding) stroke risk, but researchers noted a borderline-significant increase in hemorrhagic (bleeding) stroke. Aspirin also increased the incidence of bleeding outside the brain. Overall, aspirin was not associated with a significant reduction in vaascular death.

What does it mean? The advantages of aspirin in low risk patients are scant. As cardiovascular risk factors (like smoking, high cholesterol, high blood pressure, diabetes, family history of early stroke/heart attack) pile up, aspirin gains a bit more support, though there is a modest associated bleeding risk.

We will be following this data and it's analysis further. In the meantime, it may be reasonable to discuss things with your doctor, or perhaps cut aspirin dosing to the appropriate lowest dose (81mg in most patients).

Want the original? See Collins R et al. for the Antithrombotic Trialists’ (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: Collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009 May 30; 373:1849. We will post the appropriate link after publication to make it easier.