eDocAmerica

Phone service expands eDoc's Reach

2011-08-07T03:18:00.000-07:00

One of the limitations to eDoc's information services is that one has to have a computer linked to the internet. This, of course, is not always possible. So, if you're away from your computer, don't have a link to the internet, or may simply not have internet access at all or may not even own a computer, you can communicate with us by telephone.

Since our service is "asynchronous", meaning provider and client are not connected in real time, we do this by using a unique telephone interface that records your message and transmits it to the eDoc providers in a voice file that we can open and listen to at our computers. We then can type an answer to your question and our system calls you back and "reads" our answer over the phone. It has a little bit of a "robot" sound, since the text to voice technology is not actually a human talking.

I encourage you to put the phone number in your directory and, the next time you need to ask us a question, but aren't close to your computer, give this new technology and try. Then, let us know how you like it or how well it worked for you.

By using technology the folks at eDoc are trying to improve your health, and the health care system, by making it easy and convenient to get the answers you need, from reliable professionals, at the time you them them.

Thanks for using eDocAmerica.

eDoc Launches New Site for Individuals

2011-01-26T04:07:00.000-08:00

If you are an individual, not associated with a corporation or group that already has eDoc benefits, log on to our new site http://www.edocamerica.com/individual and check us out. This new plan allows you to access to eDoc services free for the first month, then for the low price of $11.99 a month after that.

Give us a try. I believe you will find our services to be second to none in the category of reliable, on line health information.

On Patient Autonomy

2010-12-28T12:48:00.000-08:00

Recently, I was involved in a discussion on an e mail list serve and decided to takes some of my comments on patient autonomy and blog about them. This arose following a debate about whether the term "patient" engendered a sense of passivity and, therefore, whether the term should be dropped in favor of something else, like "client" or something similar.

Having participated in the preparation and dissemination of the white paper on e patients, I don't see the need for 'factions' or disagreements in the service of advancing Participatory Medicine. As Alan Greene aptly stated, "This is a big tent, with room for all". I want all of my patients to be as autonomous as possible. In my view, their autonomy is independent of the doctor/patient relationship that I have with them. They make the choice to enter into, or to activate or deactivate the relationship with me. They may ignore my input, seek a second opinion, or fire me and seek the care of another physician at any time. They truly are in control, in that sense. The only thing I have control over and am responsible for is trying to provide the best advice or consultation that I can.

They use the internet for education about their health issues and, increasingly, to join patient communities for problem solving, support, information and research. Some even seek the input or advice of professionals they have never met through online services like eDocAmerica. Sometimes, they may find that information they get on the internet or from other patients demonstrates that what they received from me was in error. So much the better, if they can use networking to improve the quality of the information at their disposal, we will have a healthier, more efficient health system.

The less they "need me" the better I like it but I continue to hope, in their best interest, that they are exerting their autonomy by making good choices and achieving optimum outcomes. Just like I don't expect to achieve an optimum outcome with a complicated home repair without a consultant such as an electrician, or to be able to fix my car without a mechanic, or achieve a legal victory without a lawyer, most patients won't achieve optimum medical or health outcomes without a medical consultant. And, has also been pointed out, some outcomes absolutely require a physician (e.g. surgery, intensive care, chemotherapy, radiation, etc).

And, do these consultants ever make errors, be they of commission or omission, you bet! That is why the partnership is important. As good or as meticulous as a doctor might be, he is inevitably going to miss things that the patient and their caregivers are in the best position to recognize and correct. They may also be, by virtue of networking and patient communities such as ACOR and others, privy to information that is more current or more relevant than what they may receive by their own physicians. We, as physicians should not worry about, or be threatened by this, but should embrace it as the best chance for the patient to achieve optimum outcomes.

Fitness, Part 2

2010-10-15T12:47:00.001-07:00

This is another "eDoc Academy" video on non aerobic fitness. I hope you enjoy it.

More on Fibromyalgia

2010-10-14T14:57:00.000-07:00

I'm calling these Youtube videos "edoc Academy". This is the third in an ongoing series of topics from my practice. This one on Fibromyalgia.

Fitness

2010-10-14T13:48:00.001-07:00

Take a look at this cam recording video that I did on getting started with a fitness program:

Introduction to Participatory Medicine

2010-09-02T14:15:00.000-07:00

This is a video called "Introduction to Participatory Medicine" which I recorded today on You Tube. Take a look if you get a chance and feel free to share your ideas and reactions.

Thanks.

Sugar May Be Raising Your Blood Pressure

2010-07-04T08:41:00.000-07:00

Most of us know that salt raises blood pressure in many people. When I learned that in medical school almost 40 years ago, I have not touched a salt shaker since. I enjoy having a low normal blood pressure. A new study published in the Journal of the American Society of Nephrology (July, 2010) suggests that sugar, especially the fructose that comes from corn syrup, may also raise blood pressure.

A study team from the University of Colorado in Denver looked at sugar intake among thousands of Americans in a major national nutrition survey between 2003 and 2006. Those who consumed more added sugars such as the fructose in soft drinks had significantly higher blood pressures than those who did not and ate more natural foods such as fresh fruit.

Fructose from corn syrup is a major cause of the obesity epidemic and may also be contributing to the most common chronic disease of adults, high blood pressure.

I have a bold suggestion to make that if followed will improve your health and that of our nation:

Eliminate all soft drinks and fruit drinks from your diet and the rest of your family. Whether with sugar or "sugar free", they adversely affect your health. Drink water instead. If you want caffeine or some other flavor, drink tea (not sweet tea) or a modest amount of coffee, both natural substances. Use a slice of lemon in your water or tea if you prefer to alter the flavor. Get your fruit natually from an orange, apple, bannana or berries, not from juice.

The elimination of soft drinks and fruit drinks would transform the American diet and help us be healthy again. And don't worry about the soda companies. A growing part of their business is bottled water today. We need to move them in the right direction too.

Food Rules to Live By

2010-05-22T19:56:00.000-07:00

Michael Pollan has become one our most important writers about human nutrition. His book, The Omnivore's Dilemma (2006), spelled out why the almost 8 billion humans on this planet had better balance what we eat, for our own health and the health of the planet.

He published a small book in 2009 (Penguin Books) called Food Rules: An Eater's Manual. His rules are around 7 words in 3 brief statements: Eat Food, Not Too Much, Mostly Plants. How simple and wise is that!

These three statements make up the three parts of this small book, with lots of practical "rules". Here are some of the best:

Don't eat anything your great-grandmother would not recognize as food
Avoid food products containing ingredients that no ordinary human would keep in the pantry
Avoid foods that are pretending to be something they are not (like imitation butter)
Shop the peripheries of the supermarket and stay out of the middle
Treat meat as a flavoring or special occasion food
Eat animals that have themselves eaten well
Don't overlook the oily little fishes
The whiter the bread, the sooner you'll be dead
Be the kind of person who takes supplements - then skip the supplements
Eat more like the French, or the Japanese, or the Italians, or the Greeks
Have a glass of wine with dinner
Stop eating before you are full
Eat when you are hungry, not when you are bored
Eat slowly
Spend as much time enjoying the meal as it took to prepare it
Buy smaller plates and glasses
Serve a proper portion and don't go back for seconds
Breakfast like a king, lunch like a prince, dinner like a pauper

and the last one:
Break the rules once in awhile

So, enjoy a healthy diet and eat right!

Getting and Staying Healthy: Getting Enough Sleep

2010-05-19T14:26:00.000-07:00

Our busy lifestyles often aren't conducive to getting the recommended amount of sleep at night. According to the National Sleep Foundation, adults need between seven and nine hours of sleep every night. Dr. Kenneth Berg from the Mayo clinic states that persons who get less than seven hours of sleep per night have a higher mortality than those who have adequate sleeping habits. Inadequate sleep has been linked to increased risk of motor vehicle accidents; an increase in body mass index – a greater likelihood of obesity due to an increased appetite caused by sleep deprivation; increased risk of diabetes and heart problems; increased risk for psychiatric conditions including depression and substance abuse; and decreased ability to pay attention, react to signals or remember new information.

So, if you are currently getting less than 7 good hours of sleep at night, consider making a change to try to increase that to a minimum of 7 or 8 hours. Here are some other suggestions for you to consider to improve your quality or quantity of sleep:

1. Establish regular sleep and wake schedules.
2. Have regular, relaxing bedtime routines such as taking a hot bath or playing quiet music.
3. Create a dark, quiet, comfortable and cool environment.
4. Make sure you have a comfortable mattress and pillow.
5. Avoid watching TV, using a computer or reading in bed.
6. Avoid eating 2-3 hours before your regular bedtime.
7. Exercise regularly during the day, but avoid exercise at least a few hours before bedtime.
8. Avoid caffeine and alcohol products close to bedtime.

Let me know if you have comments or additional suggestions...

Exercise Part V: Exercise and Weight Loss

2010-05-09T07:20:00.000-07:00

I am often consulted about diets and weight loss. I witness a blinding array of dietary approaches to weight loss and, alas, have discovered that most simply don't work! Yes, that's right, diets if they work at all, tend to be short term solutions at best. People can usually rally their will to restrict their intake and lose for awhile but, inevitably, without a more basice lifestyle change, the pounds slowly creep back over weeks or months.

So, if you are overweight (over 63% of American's are obese or overweight), and want to shed pounds what is the answer? It's actually very simple. The basic concept is "calories in-- calories out". One merely needs to slightly reduce the number of calories consumed per day and burn additional calories over what has been your past pattern, such that a "deficit" is created between the number of calories consumed and the number of calories burned.

If this idea seems rediculously simple, it is but, apart from bariatric surgery, or the rare case of a life-changing epiphany, a simple commitment to combining exercise with moderate caloric restriction is the secret to losing and maintaining weight.

Let me provide an example of how this might work in practice: Let's say, you are 10 to 15 pounds heavier than you want to be and have been having trouble losing it. How should you approach it? First, decide a couple of items typically consumed in a day that you can manage to leave aside that would amount to between 250 and 500 calories. Let's say you decide to give up one soft drink, or one Starbucks flavored coffee or Latte plus the bag of chips that you usually have for lunch; or that you give up the piece of pie or cake that you have with dinner. That's it. It's just that simple. Otherwise, just continue with the diet that you are accustomed to.

Then, with your exercise program that you have committed to (30 to 45 minutes five days a week in the "aerobic zone"), you are burning an extra 300 to 500 calories. At the high end of this scheme, you would have a "1000 calorie deficit" (the 500 fewer calories you take in and the 500 extra calories that you are burning). This would take you towards a faster weight loss and at the low end (250 fewer in and 300 burned) to a 550 calorie deficit. The latter plan would likely result in a one or two pound per week loss and the former a 2 to 4 pound loss.

This is not an exact science and, since everyone is different, daily flexibility and adjustment is required. Therefore a daily or every other day weigh in is essential. If the weight is not trending in the right direction, an adjustment is made, either in cutting out a few more calories from somewhere or increasing the duration or effort level of your exercise. This is the fine tuning that is the ultimate secret to the success of this approach. And this regular adjustment process should continue indefinitely. This daily/every other day weigh in serves to reinforce your program and remind you of your commitment to maintaining fitness and weight control.

So, there you have it. The exotic Smith plan for exercise and weight loss, otherwise known as the "Anti Diet Plan".

Your comments and dissenting opinions are always welcome...

Exercise, Part IV: Injury Prevention, Stretching, Warm Up and Cool Down

2010-05-02T17:59:00.001-07:00

Preventing injury is an often-neglected component of an exercise program but, when the basics are incorporated into your daily routine, you will be much less likely to spend time on the sidelines because of pulled muscles and other overuse injuries.

Warming up can be confusing to many who are starting out with an exercise program. But, there is nothing complicated about it. The basic tenets are simply to start slow and stay slow until your body is ready for the stress of the workout. This will allow your cardiovascular system to infuse all of your key muscles, and will get your heart and lungs functioning on "high alert" to endure the stress of the workout. For most people, this process involves exercising at appoximately half speed for about the first five minutes; then, if all seems well, you can move to full speed and complete your exercise session. Failure to properly warm up may result in a high degree of muscular stress on muscles and tendons that are still tight and not adequately vascularized, and render them much more susceptible to injury.

Cooling down is a good idea and is almost as important as warming up. What cool down accomplishes is allowing the body to reduce the heart rate and blood flow while, at the same time, reducing the amount of stress and work that the muscles are doing. During this time, the blood courses through the muscles and begins the work of cleansing toxic breakdown products such as lactic acid that can cause soreness and stiffness. It also provides a few relatively stress free minutes to concentrate on form and technique, which are also important, over the long haul, to staying in balance and avoiding injury.

What about stretching? How often should you do it? How should you do it? And, should you stretch before or after a workout? Stretching is important in maintaining optimum flexibility and preventing injury. Failure to stretch results in progressive shortening of the muscles and tendons to the point that, after years of exercising and not stretching, some people literally cannot completely straighten their legs. For walking, running and biking, the most important stretches are the legs. For tennis, weight lifting, handball and other upper body skills, arms and shoulders are most important. It's not that you shouldn't stretch all of these areas regardless, it's just that, if push comes to shove, it is much more critical for a biker to stretch his hamstrings and quads that it is for him to stretch his shoulders and arms.

Stretching should be done a minimum of 5 or 10 minutes three to four times a week. The preferred technique is "proprioceptive neuromuscular facilitation", which involves alternating contraction and stretching of the muscle in question. I prefer to stretch hamstrings for 30 seconds, then the other side, returning the first one for a total of two stretches on each side. I do this by placing my heel about waist high and leaning over til I feel the stretch, alternating contraction and stretching to increase the amount of muscle lenthening that can be accomplished. I stretch the quads by holding on to my foot behind me, same way, 30 seconds on each side, repeat times one. Most people tend not to like to stretch and, so, they often avoid doing it, resulting in a very tight body that cannot perform optimally and is more prone to injury.

Next time, we'll talk about exercise and weight loss...

Your comments are always welcome.

Exercise, Part III: Motivation and Recommitment

2010-04-30T12:32:00.000-07:00

Everyone who has exericised regularly has experienced problems and challenges of remaining motivated and committed to keeping up with your exercise schedule and level of intensity in order to stay at the peak of fitness. Some days, if you exercise in the morning, you just feel too tired to get out the door to do your workout. Other days, you feel emotionally lethargic because you have something on your mind that you just can't get over long enough to get started on your daily workout. Other days, you have a cold, headache or other illness that makes it all but impossible for you to workout.

Sometimes, when two or three of these days pile one on top of another, you find yourself falling off the wagon and, suddenly, you realize you've missed a week or 10 days and panic starts to set in. What if I lose everything I've worked so hard to gain? Why does it seem like getting back in shape is so much harder and takes so much longer than it takes to lose it?

Here are my "10 commandments" for dealing with this problem:

1. Realize that every fitness enthusiast has this problem and it doesn't mean that you are lazy or that there is something wrong with you.

2. Don't entertain the illusion that daily workouts are "fun" or a "piece of cake" and, therefore, it should never seem easy to just bounce out of bed and do your daily workout. Regard daily workouts as part of your work, not part of your play. That is why it is called WORKING out!

3. Remember that becoming fit requires weeks of work, not days and don't allow yourself to become discouraged when you don't feel fitter or slimmer after a few days, or even a few weeks, of working out.

4. Give yourself permission to take two days "off" per week and position those days strategically (such as days you have early meetings or days when you stay up late the night before, etc).

5. Remember to advance your efforts no more than 10% per week, so that you don't overtrain. Overtraining is one of the best ways to injure yourself or just plain burn yourself out.

6. If possible, band together with one or two others who will help motivate you and hold you accountable to your fitness program.

7. If you're having a bad day or feel rushed, give yourself permission to shorten your exercise session for that day. It is better to work out for 20 minutes than to miss the day altogether.

8. In a similar vein, if you don't feel great or are just having a low energy day, give yourself permission to lower your target heart rate by 10 or even 20%. It is better to get in a light day of exercise than to miss the day entirely.

9. If you start to feel burned out with your exercise because you are doing the same thing every day, change your course or use a different modality. For example, if you are a biker, get on the elliptical or treadmill on occasion for a change of pace. If you are a runner, get on your bike. Cross training is a great antidote to boredom and burnout.

10. If you have trouble getting up and jumping into your exercise clothes, get up early enough to enjoy a cup of coffee and read the paper before you venture out.

Everyone struggles with motivation to do their daily workout. The fitter you are and the longer you've been in the habit of doing it, the lower your risk of becoming discouraged and quitting, but motivation issues never go away completely. Just accept their inevitability and apply one or more of the 10 commandments noted here to help you get back in the game.

Next, we'll talk about injury prevention, including warm up and stretching. Your comments are always welcome.

Exercise, Part II: Getting Started

2010-04-25T06:30:00.000-07:00

Perhaps you, like many patients I talk to, would like to begin an exercise program, but the idea seems overwhelming. It can be if you decide to start a program without a sound plan, because it will almost certainly not be something you can sustain for the long run. Patients often have no idea how long to exercise, how much to stress or strain their system, or how long it takes to "get in shape". All of this tends to lead to early errors, injury, or discouragement and giving up on the idea of becoming fit. It is important, and possible, to avoid this trap with the proper approach.

If you haven't been exercising regularly, it is important that you first consult with your doctor about whether it is safe. If you are 45 years of age or older, it is probably a good idea for you to obtain a treadmill exercise stress test. It is also important to have a good idea of your risk factors for cardiac disease, including your cholesterol and blood pressure level. You should also get a reading of your body mass index and set a target for your weight (more on weight loss later).

Assuming you get the green light, I recommend starting with about 15 or 20 minute sessions, three days a week. You should choose an aerobic activity, such as walking, jogging, biking, swimming, or an exercise machine like a treadmill or an elliptical machine. Aerobic activities are important to form the basis of your program because they are sustainable and lead to better cardiovascular fitness. We'll talk about the value of anaerobic activities, especially weight workouts, later.

If possible, either work out on a machine that has a heart rate monitor or else purchase a wireless continuous heart rate monitor. It is very difficult to exercise for fitness efficiently without one and they have become very affordable in recent years. As I noted earlier, it is important to exercise in the "aerobic" zone, which is about 60 to 80% of your maximum heart rate. You can obtain an estimate of your maximum heart rate by subracting your age from 220. For example, if you are 30, your estimated maximum heart rate is 220-30=190. So your exercise target is between 114 and 152. I usually recommend a midrange target of 70% or about 130 for this example.

It is important to be patient and persistent, remembering that each day builds on the last and that rest and exercise work together to stregthen the muscles and the cardiovascular system. By starting at 20 to 30 minutes three days a week, you minimize the risk of becoming too sore or fatigued to continue your program. A good rule of thumb is to increase your workouts by about 10% per week. So, if you start with 30 minutes, three times a week the first week, then you should increase one of your workouts by 10 minutes the second week. Then, the next week, increase one of your other workouts by 10 minutes. The next week, increase one of your workouts to 45 minutes and repeat the cycle. When you are up to 45 minutes three times a week, then add a 15 or 20 minute session on another day a week; then increase that session to 45 minutes, until you get to 5 days a week, 45 minutes a session. By the time you have reached this schedule, you will have completed at least 12 or 14 weeks and should have achieved a pretty good level of cardiovascular fitness. Congratulations!

Then, when you have achieved this schedule, which is reasonable to maintain, you can continue to pursue your fitness by maintaining your heart rate targets as you become more fit. As you do this, you will actually work harder and the the "10% rule" will continue more or less automatically by allowing you to "do more work" at the same heart rate as you become more fit. This is called the "training effect".

Next time, we'll talk about issues with motivation and what to do when you "fall off the wagon".

A Series on Getting and Staying Healthy: Exercise, Part I

2010-04-11T04:59:00.000-07:00

I was reflecting on an earlier post I wrote after reading the book "Younger Next Year" and decided I'd write a series of blog posts on some of the basic principles of getting and staying healthy. These include eating a good, well balanced diet, avoiding smoking, avoiding excessive alcohol intake, managing your stress levels and exercise.

I'll start with the last item, exercise. I'm going to start by telling you what I do now, then backtrack and talk about aspects of an exercise program in more detail in subsequent posts. I'll include motivation, getting started, how much and what kinds of exercise are needed, staying on track, avoiding injury, hydration, warm up and cool down, stretching, rest days, exercise for weight loss, and exercise and staving off depression.

So, let me start by telling you what I do now. I was doing about 30 minutes a day of aerobics about 4 or 5 days a week, but after reading the book, committed to increasing that to at least 45 minutes a day for 5 days or more a week. Most weeks, I work out six or even seven days. I used to be a runner but, since I had my knee replaced a little over two years ago, I've completely given this up. My favorite exercise is on my road bike, a custom-built titanium beauty that is really fun to ride. I often use a pulse monitor to assure that I stay in the aerobic zone (I'll say more about this later). This is, for me, between 70 and 80 percent of my maximum heart rate which is about 130 beats/minute. At that level of work, I am "working" not just playing or having fun. So, one of the key things I tell people is to consider exercise as enjoyable work, not just play or fun. In order to get the benefits of exercise and stay physically fit, you need to do this "work". So many people stroll along on their walks or bike in an upright, comfortable mode and their heart rates are likely not above 100 beats/min. They will get some benefit from this, but nowhere near the maximum result.

On most days, I go on a ride that combines hills and flat terrain about 10 to 12 miles and that takes me about 50 or 55 minutes. On weekends and on some days when I don't have an early meeting, I enjoy going longer about 1 1/2 to 3 hours. One of my favorite rides takes in the Arkansas river, over the Dam Bridge and along the river trail walking/biking trail. In the mornings, with mist coming off of the river, with gulls flying, deer in the pastures, and energetic fitness enthusiasists around me I learn to rejoice in the moment and recognize for those brief swatches of time that "it doesn't get much better than this!".

When weather doesn't permit outdoor biking, I often hop on my reserve bike that is tethered to an indoor magnetic trainer (called a Kurt Kinetic) that does a great job of simulating the road and allows me to get a very good workout indoors. Again I typically use a pulse monitor and will say more about that in subsequent posts. Indoor bike workouts are typically for 45 minutes in front of ESPN SportsCenter or, sometimes, with a workout video to guide me.

For a change of pace, I get on an indoor elliptical machine. It is a good idea to have at least one or two alternative aerobic activities that allow resting of some of the muscles that get maxed out in the other training modes. I either do a programmed workout that does a good job of pushing me through some fitness improving intervals or I just put the machine on manual mode at about a 10 or 12 level that keeps my pulse at the target rate.

I save the sports section of the paper for cool downs and breakfast with cereal and fruit before showering and going to work. This program has served me well for years and allows me to go to work energized and ready for the day.

Next time I'll talk about how to get started on an exercise program for those who may not be doing it on a regular basis.

Could My Body Fat Lead to Dementia?

2010-03-02T08:57:00.000-08:00

One of the great fears we all have is to lose our mental ability as we grow old. No one wants to end their life with dementia (such as Alzheimer's Disease). We all should be highly motivated to do things to avoid this tragic outcome. We already know that regular exercise is good for the mind and may reduce the risk of dementia. Recent evidence shows that the use of statin medications to lower cholesterol may help reduce dementia risk. Now we have evidence that the roll of fat around your waist may be a marker for increased dementia risk.

The University of California, Berkeley Wellness Letter (February, 2010) reports on a study published in the journal Neurology that followed 1500 Swedish women for 30 years. Those with more fat around the waist were twice as likely to have dementia by age 70 compared with thinner women. A 2008 study from Kaiser Permanente that included men and women showed similar results.

The fat around the waist is a better marker for internal fat than the fat around the hips. If a woman has a waist of 35 inches or greater, and a man a waist of 40 inches or greater, that is evidence of increased cardiovascular risk and dementia risk. The leaner the better as we get older.

Losing this fat is hard work. It requires an excellent diet and regular physical activity. Medications should be used if needed. A healthy body and mind in the senior years cannot be taken for granted. We may be lucky with good genes, but we all must live a healthy lifestyle in order to earn our good health later in life.

Fibromyalgia--Is it Real?

2010-02-03T07:14:00.001-08:00

Every Tuesday, I conduct a diagnostic clinic at the University of Arkansas. This clinic sees patients referred throughout the state with complex or hard to manage medical problems, or patients that the referring physician is not sure who to turn to for advice or answers.

One of the most common problems I see is a patient with diffuse, hard to categorize soft tissue pain. Most of the patients have a diagnosis of "fibromyalgia". The patient that I saw this week told me her physician sent her to our clinic because "he doesn't believe fibromyalgia is real". Physicians often become frustrated with these patients because the pathophysiology of this condition is not well understood, and because effective treatment takes time and patience. The physician cannot rely on brief office visits and prescription refills to adequately address the issues of most fibromyalgia patients.

Fibromyalgia is very real and is a common problem in practice. Any busy primary care physician will attest to the fact that a significant number of patients with this condition visit our office every week. Fibromyalgia is a rheumatic condition whose characteristics include widespread muscle and joint pain and fatigue as well as other symptoms. Fibromyalgia can, and often does, lead to depression and social isolation because patients are so uncomfortable and fatigued. Patients with chronic fibromyalgia are often really miserable and need the help of a competant, sympathetic physician. Patients with fibromyalgia often complain of "total body pain". They almost universally have great difficulty sleeping. Most have tenderness when you press on the muscles of the upper back and shoulders. Females are 10 times more likely to complain of these symptoms than men.

How well do patients respond to treatment? I have yet to find a single patient who responds quickly or dramatically to any treatment. Rather, they tend to gradually improve with effective treatment of sleep and depression and tend to improve with stretching and exercise and, occasionally, with certain medications.

There are no blood tests, biopsy findings or imaging studies that confirm the diagnosis of fibromyalgia. This lack of clarity and specificity has led many to assert that this diagnosis is "not real". But many patients, mostly middle aged women, have chronic, diffuse, muscle and soft tissue pain and they all need help managing this condition.

The best treatment approach for those who suffer from this problem includes drugs, as well as alternative remedies and lifestyle habits that may help decrease pain and improve sleep. Medications include antidepressants to help alleviate the pain, fatigue, depression, and anxiety that comes with the disease. In addition, your doctor may recommend physical therapy, moist heat, regular aerobic exercise, relaxation, and stress reduction to help you self-manage your symptoms. There is no one "pill" that treats or cures fibromyalgia. A multidisciplinary approach that uses both medication and alternative or lifestyle strategies seems to work best. Medications that help in certain patients include Cymbalta, Savella, and Lyrica.

Patients with fibromyalgia badly need a compassionate, patient primary care provider who can see the patient at regular intervals and who will take a multidisciplinary, long-term approach to managing this condition.

Ideal Cardiovascular Health

2010-01-24T18:07:00.000-08:00

You too can have ideal cardiovascular health. What is that you may ask? The American Heart Association has come out with a new report that defines it.

Ideal cardiovascular health means you do all of the following:

1. You do not smoke
2. You are not overweight (normal body mass index, or BME less than 25)
3. You get regular physical activity, about 5 hours a week
4. You eat a healthy diet low in saturated fats and simple sugars

You also have the following:

1. Your total cholesterol is normal (generally below 200 or a healthy ratio of total cholesterol and HDL (good) cholesterol)
2. Your blood pressure is aroung 120/80
3. Your fasting blood sugar is less than 100 (better yet 90 or less)

All of these are within reach of most everyone, with or without treatment. Ideal health is a choice and requires a commitment to action. Go for it. There are no justifiable excuses.

Reference: Circulation: January 20, 2010

Reflections on the State of Online Health

2009-12-23T10:59:00.000-08:00

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!

Do Diet Sodas Make You Fat?

2009-12-17T12:04:00.001-08:00

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.

Is a Low Carb Diet a Bad Mood Diet?

2009-11-18T06:17:00.000-08:00

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!

New Journal for Health Professionals and Patients Launches with Ambitious Ideas

2009-10-26T08:39:00.000-07:00

Last week at the Connected Health Symposium in Boston, a new journal was launched, The Journal of Participatory Medicine (http://www.jopm.org/). 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.

What is Your Daily Glycemic Load?

2009-10-18T08:25:00.000-07:00

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.

More on Participatory Medicine: Patient Research

2009-09-20T07:08:00.000-07:00

This post is adapted from one I wrote last week on e-Patients.net Blog: http://e-patients.net/archives/2009/09/participatory-medicine-and-patient-research-its-gonna-be-a-new-world-indeed.html.

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!

When Dreams are NOT So Sweet

2009-09-08T10:13:00.000-07:00

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)

The Four Pillars of a Healthy Lifestyle

2009-09-07T15:15:00.001-07:00

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.

Food, Inc. The Movie

2009-08-08T12:26:00.000-07:00

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.

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

2009-08-03T06:43:00.000-07:00

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 drugstore.com 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.

The Pain of Rejection

2009-07-22T13:31:00.000-07:00

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.

Which Fish Have the Most Omega 3 Fatty Acids?

2009-07-19T07:07:00.000-07:00

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.

Source: http://www.omega3oils.info/omega3sources/fishoil.php

eDoc Begins a New Era with Statewide Medicaid Coverage

2009-07-17T10:25:00.000-07:00

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!

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

2009-07-06T09:38:00.000-07:00

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.

Our Health Data Rights

2009-06-23T06:58:00.000-07:00

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!

Recent Heart Attack? Consider Cardiac Rehab!

2009-06-19T20:42:00.000-07:00

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!

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

2009-06-18T14:47:00.000-07:00

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!

Tips for Vegetarians

2009-06-14T20:54:00.000-07:00

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.

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

2009-05-31T05:07:00.001-07:00

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, e-Patients.net 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 Dr.Greene.com. 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...

Is it Time to Rethink Aspirin?

2009-05-29T20:38:00.000-07:00

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.

Overcoming your Headaches

2009-05-18T15:21:00.000-07:00

One of our most revered faculty members, Lee Archer, MD, a neurologist, provided a copy of the handout he gives to his headache patients. With his permission, I adapted it for use with my own patients. I thought it was so good that I asked him if I could publish it on my blog so that others could benefit from his advice.

Headaches are incredibly common and usually frustrating for providers. It has become increasingly evident that chronic or frequently occurring headaches are often virtually impossible to identify as either "migraine" or "tension" headaches and often simply are called "chronic headaches". Treatment often becomes a revolving door of trying new medications that sometimes work, but more commonly don't. And, even worse, many headache patients gradually simply become dependent on addictive pain medications just to try to cope with their often daily discomfort.

But, there are some really basic things about dealing with chronic headaches that we should never forget to try. So, without further ado, here is his advice:

Ten Steps to Overcoming Your Headaches

There are some things that everyone can do to help their headaches. There are a number of things you can besides just take medication to help their headaches. If someone follows all of these directions, the need for prescription medication is often dramatically reduced if not eliminated.

1. First and foremost, taking pain medication everyday is definitely not a good idea. Daily pain medication tends to perpetuate headaches. This is true for over-the-counter medications like Excedrin and BC powders, as well as prescription medications like Fiorinal, Midrin, and “triptans” like Imitrex, Zomig, Relpax, Frova, etc. Exactly why this occurs is unclear, but it is a well established clinical finding. Anyone who takes pain medications more than twice a week is in danger of perpetuating their headaches. Occasional usage of pain medications several times in one week is permissible, as long as it is not a regular pattern. For instance, using pain medication several days in a row during the perimenstrual period is certainly permissible.

2. Regular exercise helps reduce headaches. Exercise stimulates the release of endorphins in the brain. These are chemicals that actually suppress pain. I encourage people to aim for at least 20 minutes of aerobic exercise (like walking or swimming) five days a week if not daily. In addition to helping reduce headaches, this also will prolong your life because of the beneficial effects on your heart.

3. Stress reduction is a definite benefit in reducing headache frequency and severity. Headaches are not caused by stress alone, but can make most headaches worse. There are no easy answers for how to reduce stress. If it is severe, we can consider referral to a therapist for help.

4. Too much or too little sleep can trigger headaches. Pay attention to this, and note whether or not you are tending to trigger headaches from sleeping too little or too much. People differ as to how much sleep is “right” for them.

5. Caffeine can precipitate headaches. I encourage patients to try stopping caffeine altogether for a few weeks, and we can decide together whether or not caffeine might be contributing. Abruptly stopping all caffeine can trigger headaches, too, so try to taper off over a week.

6. NutraSweet (aspartame) can cause headaches in some people. If you are drinking multiple servings/day of beverages containing NutraSweet you might consider trying to stop that, and see if your headaches respond.

7. There are some other foods they may trigger headaches in some people. Usually people learn this very quickly. For instance, red wine will precipitate migraines in many people, and chocolate, nuts, hot dogs and Chinese food triggers headaches in certain cases. I generally don’t advise omitting all of these foods, unless you notice a pattern where these foods are causing headaches.

8. If I give you a prophylactic medication for headaches, you should take it daily, as prescribed. If you have trouble tolerating it, please let me know and we can consider using something else. No prophylactic medication works in every patient with headaches. Generally, each of the medications works in only about 60% of people. Therefore, it is not uncommon to need to try more than one medication in any given patient. We must give any of these medications at least four to six weeks to work before giving up on them. It generally takes that long to be sure whether or not a medication is going to work.

9. Keep a calendar of your headaches. Use a standard calendar and mark the days
that you have a headache, how severe it is on a scale of one to ten, what you took
for it and how long it lasted. Also note anything that you think could have
precipitated it. By keeping this over time we can tell if our efforts
are helping.

10. Riboflavin (vitamin B2) 400mg daily helps prevent migraines in many people. It
comes in 100mg size tablets, so you will need to take four of them each day. You
can add it to anything else we try. You do not need a prescription for it.

Do you have chronic headaches? If so, I challenge you to apply these ten principles, then come back and provide a comment on this blog post!

Thanks and good luck!

The Measure of a Life Well Lived

2009-05-18T06:15:00.000-07:00

When it’s all said and done, when the piper has played his last note, the farm is well and truly purchased, the bucket come to rest, and the fat lady’s final lyrical note but a fond memory, what is the yardstick we use to measure the worth of our lives? Do we tally up bank accounts to see who won? There will always be someone whose net worth is greater than the next guy’s. Mine, unfortunately will not even be a contender for that particular prize. Maybe we could compare the grandeur of our cars. Mine is a clunker well past its warranty, but it holds a lot of good memories. My car’s value is not in its blue book value, but in the memories it holds. So if memories are more important as a measure of a life well lived than monetary possessions, how do we measure memories?

We should measure the worth of our memories by those who will carry them on after we are long gone. How many people have you positively touched in your life? How many of those were a lasting, memorable touch? How many of those went on to touch others because of your actions? This is your measurement. This is your legacy.

Randy Pausch touched millions while he lived, and continues to have a positive impact on people’s lives today. I’ve included a video clip of his address to the graduates of Carnegie Mellon University. I think everyone should watch this clip at least once in their lives. And stay tuned through the end when he carries his wife off stage and gives her a beautiful kiss behind the stage. Your relationships with the special people in your life are what really matter when it’s all said and done. This is what people will remember. Not the degree you earned, not the handy little nest egg you managed to build, not even the size of your office - although it seems very important now.

And when it is your time and they record the important stuff on your tombstone, what will it say? Your name that your parents chose, you didn’t have anything to do with that. Your birth date, again, more your parent’s business than yours. And your death date. You shouldn’t decide that either. No, the only thing you have to show for an entire life is the dash between the dates. And how many of us make it a hard, fast dash to the finish line? So this entire life that is summed up by a mere dash etched in granite is where we insert the memories of the relationships, the love, the life, the passion, the person.

“Even though our culture puts a strong emphasis on attaining wealth and fame, pursuing these goals does not contribute to having a satisfying life. The things that make your life happy are growing as an individual, having loving relationships, and contributing to your community," says co-author Edward Deci in a news release about his article, Achieving Fame, Wealth, and Beauty are Psychological Dead Ends.

So when it’s all said and done, let’s have no regrets on our way to the top of the ivory tower of our choice. Let us be remembered as a person who had a positive impact on others, who loved and lived life to the fullest, and made the most of the time we had. Play on piper. Ours will be a mighty dash. We’ll measure up just fine.

Missing Someone Special on Mother’s Day: Coping Strategies in Action

2009-05-08T21:35:00.000-07:00

Mother’s Day is just around the corner and web pages and blogs are full of gift idea do’s and don’ts for your mother. I won’t go there. I think the topic has been covered quite nicely by better shoppers than I could ever hope to be.

You’ve also, no doubt, been bombarded with the plethora of tear jerker emails cautioning you to spend time with your mother while you can. She’s older than you, you know, and may not last until next year for you to make it up to her if you miss this Mother’s Day. That topic’s been covered too.

I’d like to talk with you a little bit about how to get through Mother’s Day after you’ve lost your mother. And I especially don’t want to forget the reverse situation; how to cope with Mother’s Day if you have lost a child, the hardest pain of all to overcome.

So how do you survive this Sunday if half of the equation is missing? You could hide under the covers until Monday. The protective property of the blanket works for monsters under the bed, why not against monsters of the heart as well? You could ignore that the day has any other meaning and treat it like any other Sunday, but that tends to backfire with a nasty trap of emotions smacking you back into reality the hard way at the worst possible time. Don’t let it catch you off guard; the day is coming whether you are ready for it or not. Or you could cry in your beer (over 21, please), but that just makes your eyes red and dilutes the beer.

Here are some coping strategies for bereavement:

Talk about it with a friend or family member you trust to handle the sensitive and powerful emotions you feel towards Mother’s Day

Realize that Mother’s Day is only one day out of the year and it has been commercially blown out of proportion and this too shall quickly pass

Be around friends who understand and can help you cope with the day

Acknowledge it can be a hard day and distract yourself with a movie or something that has a positive and endearing memory of what this day was initially designed to represent

And remember that your mother will always be your mother no matter where she is. And the same goes for mothers who have lost children. Once a mother, you will always be a mother even if you can no longer hold them in your arms.

If you are an eDocAmerica participant, you can send a message to the ePsych Psychologist for individualized coping strategies. Many people use this helpful option with good results whether it’s Mother’s Day or not.

All comments welcome.

When Pigs Fly: Dealing with the Swine Flu Jitters

2009-05-04T14:40:00.000-07:00

Remember the old adage, "that'll happen when pigs fly"? Well, the swine flu is floating around.... Does that count?

If so, we have nothing to worry about with the swine flu; it's merely a symptom. The real things you need to worry about are all of the "that''ll never happen" things that are about to come true. Like Carrot Top winning a Nobel Prize or the Rams winning the Superbowl, or a black man being elected president. Oh wait, that's already happened and I voted for him. See? It's already started. What will happen next? Will Angelina stop adopting kids?

I think it's time to put the swine flu epidemic in perspective. According to a recent WebMD article: In a typical U.S. flu season, an average of 36,000 people die of flu or flu complications, and about 200,000 people are hospitalized.

Swine flu hasn't come anywhere close to that. Swine flu has sickened at least 141 people in the U.S. and 365 people worldwide, according to the CDC and World Health Organization's tally of lab-confirmed swine flu cases as of Friday, May 1.

Here in Arkansas at UAMS there has been such a run on Tamiflu prescriptions, an anti-viral medication, that all physicians have been requested to think very carefully before giving in to patient hysteria when prescribing this medication. Predictions are that much of the Tamiflu prescribed will never be taken, but it is removing significant numbers from pharmacy shelves which may be detrimental in the future should we need it. So far, there are no reported cases in Arkansas.

So how do you stay informed without letting the hysteria take over your life?

Adopt Rational Measures

· Hand washing. Mom always said, “Wash your hands” because she knew it prevents more illness than any other single proactive thing you can do to keep yourself healthy. But we don’t want to tip the scales into obsessive compulsive behavior. Wash your hands as needed relative to your situation and exposure. If you have minimal contact with others at work, you are not at as great a risk as someone in the health, school, nursing home or daycare industry.

· Cover your mouth. Another gem from Mom. It is common courtesy to cover your mouth when coughing or sneezing, then go back to the first example given here and wash your hands.

· Avoid sick people when you can. You can’t avoid your sick husband or two year old, but if someone is hacking up a lung in isle three, use isle seven to get to the milk.

· Go home if you’re sick. Don’t expose everyone else in the office just because you have to update your spreadsheet. It is much more cost effective for you to miss a day than the entire office.

Restrict Media Exposure

· A little bit can go a long way. The best way to scare yourself about anything is to become an expert on the subject. Too much information can generate its own anxiety. Only read what you need and leave the technical stuff to the experts who get paid to worry.

· Be a good role model for your children and grandchildren. Your role is to take care of them and make their world a safe and secure place. So if they see you watching CNN all day long willing to drop everything when they announce an update, children will take that fear you are demonstrating and multiply it out of orbit. Do not transfer your fear into your child’s anxiety. Unless you like staying up with a four year old too afraid to go to sleep because the swine flu might get them.

The bottom line is stay informed, but stay sane in how you go about it. Keep your update watching in moderation and take normal precautions with the health of yourself and your family. Yes, moderation works for swine flu fear too.

And since we are in Arkansas and our favorite football team is the Razorbacks, I’d like to add that the only swine you should fear is on the football field, “GO HOGS!”

Vitamin D May Be Our Most Important Vitamin Supplement

2009-05-03T07:29:00.000-07:00

Vitamins are those special chemicals that help our bodies function properly. Most studies support getting our vitamins in food rather than in supplements. Food products naturally balance the content of nutrients including vitamins, and it is possible to take too much of some vitamins if we take supplements. Besides Vitamin D, discussed here, the other most important vitamin supplement is folic acid (a B vitamin) if you are a woman and might get pregnant, and during pregnancy.

Recent studies show that Vitamin D is beneficial for many things, from preventing diabetes and heart disease to preventing cancer and having healthy bones. Vitamin D is not really a vitamin but a hormone substance that is vital to the body. Hormones are chemicals produced in one part of the body and travel to other parts to help the body function. The thyroid gland, the ovary and the testicle are examples of organs that make vital hormones. Turns out, Vitamin D is made in the skin from sun exposure and travels throughout the body doing good work.

To avoid skin cancer, and because of living indoors much of the time, we are not getting as much Vitamin D as our ancestors. Sunscreen blocks the sun absorption that produces Vitamin D. There is a lot of discussion today about getting enough "healthy" sun exposure to both produce Vitamin D and yet not raise the risk of skin cancer. About 20-30 minutes a day of direct sunlight to our skin seems to be more beneficial than harmful. Natural sun is preferred rather than "tanning booths" that only give certain UV radiation.

Vitamin D can be taken as oral supplements. In the past, 200 - 400 IU was considered an adequate daily dose, and many calcium supplements have this amount of Vitamin D. The Institute of Medicine Food and Nutrition Board now feels that we should be getting 1000 - 2000 IU daily. Stay tuned to this as the discussions are ongoing. The good news is that Vitamin D is readily available and inexpensive to take. It may be the most important of all vitamin supplements for children and adults of all ages. People with limited sun exposure, dark skin, over age 50 and overweight or obese have an increased need for the supplement. It is safe in doses up to 2000 mg for adults. Supplement doses for children are still being worked out.

So, put Vitamin D down on your list of important health habits and consider both your regular "healthy" sun exposure and taking a supplement.

Do You Live Your Life in Bullets?

2009-04-23T15:50:00.000-07:00

You’ve seen bullet formatting - they show up everywhere; those little abbreviated lines creating a quick and easily skimmed list of the most important highlights of information. But are we living our lives in this abbreviated form as well? Are we losing the ability to stop and smell the roses?

We tend to live our lives in the fast lane, squeezing as much in a day as we can. We power walk, power lunch, have power meetings, and power our way through the day until we collapse and have to power nap before moving on to the next item on our busy agenda.

My blogs recently have revolved around the recession and how it has affected our general mental health. With these added stressors of layoffs, rising prices, and dwindling opportunities it is more important than ever to protect the mental health of ourselves and our loved ones.
This is often hard to do when we feel the need to push ourselves even harder to beat out the next round of layoffs or take on that second job to keep the house out of foreclosure. Patience flies out the window. When we speed up our own personal production, we tend to get frustrated by those who are still running at normal speed.

Here are a few warning signs of living life in bullet format:

You find yourself getting short with coworkers who take their time in getting to the point

You grumble as you speed around people in the “slow lane” of hallways just as you do on the roadways as you calculate which would be faster, the elevator or the stairs

Everyone but you is working in slow motion

You are moving at such a fast pace that quality work takes a back seat to just getting the job done so that you can move on to the next four or five jobs on your list

You begin to lose the ability to successfully multitask and prioritize, and feel the need to speed up even more to compensate

You take this sped-up version of yourself home to your family and expect them to bullet their time with you as well

You find it hard to unwind and let go of the hyper speed you have achieved

You forget to smile

Your caffeine consumption skyrockets; at the end of the day you always feel you need one more drink

What can you do if too many of these examples describe you? A friend or loved one shouting, “slow down” seems too simple a fix, but it may be just that simple. Slowing down won’t fix the amount of work you have to do and it won’t pay the mortgage. But it could save your life.
We all know behavioral and physical health are linked. Unhappy, over-stressed people tend to live shorter lives than their counterparts. So in the midst of the hyper-fast, bulleted life you lead, don’t forget to schedule time for you.

Ways to rewrite the bullets of your life:

Take time to notice those around you. Are you wearing that same pinched look of stress you see in others? Relax your face and try on a smile. Compliment that person and watch as they startle out of hyper speed.

Schedule time for meditation. You don’t need a special place or special equipment to get started. Just close your eyes and breathe deeply and evenly for 2 minutes. Concentrate on how far you can expand your lungs, and how slowly you can inhale and exhale. Steal a few of these moments for yourself throughout the day. If you prefer guided instructions, check out Soft Belly Meditation, a free four minute guided breathing relaxation meditation exercise available over the internet.

Pause for a moment to appreciate the little things in your life: You may find the little things are really what’s important to you! BE in the moment. Stop and just do one thing at a time!

After work, take the time to reconnect with the special people in your life. Say “Hi” to your neighbor across the backyard fence. Reconnect with the lost art of the long-winded yarn Grandpa’s across the country made famous. And above all, take time to smell the roses while they are still in bloom.

Finding Quality Mental Health Treatment: Voodoo Science

2009-04-16T13:47:00.000-07:00

The Wall Street Journal posted an article reporting that primary care physicians have difficulty getting mental health services for patients. One blogger rightly mentioned that mental health treatment is still considered a ‘voodoo science’ even in the medical community. Great Point! Let’s face some other hard facts.

Overburdened PCP’s have been asked to handle mental health issues for too long

Mental health treatment has the stigma of a second class citizen in the medical community

Many educated persons can’t tell you the difference between a psychologist, psychiatrist, and a social worker

Mental health treatment is shunned by insurance companies

Few patients can pay for mental health services

It is no wonder that services are under-funded and quality mental health providers are hard to find. Based on these facts, anyone going into the mental health field should have their head examined.

We need to face the fact that relationship problems, community violence, job loss, financial stress and depression are increasing along with mortgage foreclosures. There is a lot more to do in dealing with these problems than reaching for Prozac! Most mental health patients get very little in the way of targeted treatment, and often receive a treat ‘em and street ‘em approach characterized by promiscuous prescribing practices and embarrassing treatment outcomes if not outright fraud.

The Mental Health Parity Act promises better days ahead, but it is no bail-out. In fact, it will be a while yet before anyone can receive help. The parity act has been delayed until 2010.

I am proud to be affiliated with a helpful resource that is affordable, effective, and readily available here with eDocAmerica.

Check out the website, ask a question of one of our experts and post a comment on our blog.

A Patient with a Uterine Mass: The Case for becoming an E patient

2009-04-15T07:10:00.000-07:00

This article was co-authored by Elyse Chapman, who became an e-patient through the following process:

I recently became acquainted with a woman in Iowa, Elyse Chapman, who was concerned about her “fibroids”. I heard about her from a colleague whose online moniker is “e-Patient Dave”. Dave deBronkart used information from the internet to successfully steer the course of his own therapy for kidney cancer . Elyse is a friend of Dave’s who was scheduled for a hysterectomy because of a very large, mass, probably a uterine fibroid, a benign but often problematic tumor of the smooth muscle fibers of the uterus. She had problems with excessive painful cramping, bladder pressure and a sensation of swelling and bloating in her abdomen. A CT scan was ordered and showed a mass either on the ovary or uterus. The mass was so large that her doctors wanted to make sure that this was not a malignant tumor of the uterus or ovary. They had scheduled a total hysterectomy via exploratory laparotomy in 3 weeks and Dave was “consulting” with his online friends to see if anyone knew of a patient group with whom she could collaborate to see if there was an alternative to major surgery.

I volunteered to help. Shortly thereafter, I received an e-mail from Elyse and then gave her a call. I heard more details about her history, learned that she had lost her husband recently, and as a single parent, felt very shaky about the prospects of recovering from major surgery without help at home. She wondered why her doctors were so focused on performing a total hysterectomy and why she wouldn’t be a candidate for a laparoscopic approach. She also wondered if she really even needed to undergo surgery now, or could she safely wait and watch for a time.

Unable to determine for certain that an alternative approach was feasible in her case, I encouraged her, at the very least, to become more assertive about getting answers to her questions: If she wasn’t a candidate for laparoscopy, why not? I told her I’d do some further research about this and get back in touch with her. I looked this up on the internet and then sent her this e-mail:

I looked at some sites on laparoscopic hysterectomy. Here is one I thought was good:http://www.ohanlan.com/laparoscop.htmFrom what I can tell, it should be possible to remove even a large uterine mass via laparoscopy.Good luck getting an answer on this that makes sense to you. Let me know if I can help any further.

Elyse actually communicated directly with a nurse at the above site and it bolstered her belief that it may not be necessary to undergo a total abdominal hysterectomy. She communicated this to her doctors in Iowa who were still uncomfortable exploring alternative options. So, she sent me the following e-mail:

http://www.google.com/search?hl=en&q=fibroids+ultrasound&btnG=Google+Search&aq=0&oq=fibroids+ul

Charlie, have you heard of this — nuking the fibroid with ultrasound while using MRI to view and target the waves? Just learned of it today.Seems to me that U of I is wanting to just yank everything out even though there's no proof that this growth is malignant. Sounds to my laywoman’s brain like at very worst there’s a 50-50 chance of malignancy, yet they do not want to do a biopsy for fear of rupturing something that might be ovarian and malignant, causing easy spread of malignant cells. What I don’t understand is how anyone can determine if its malignant without a biopsy, but obviously someone knows how to do that, because links in the above results say the ultrasound procedure works well for non malignant fibroids, which means that somehow there’s a way to determine malignancy or no without too much fuss.U of I insists that there is no better imaging method than the CT scan I had, but at least some of the above links state that MRI is better. Huh?? Who is right? Is this a case of “we only know how to use a hammer, so everything we see must be a nail” or maybe “we’re financially invested in [name your imaging method of choice], so we’re going to use and promote that”?Thoughts, please?

Elyse

Well, truthfully, I had not heard of this technique, so I did some additional research and found that the number of sites offering the procedure were limited, but sent these to her, with some additional links from the internet. In addition, this e-mail string reminded me that an increasing number of doctors and patients are opting for uterine artery embolization. I mentioned this, and she e-mailed me back that she was unable to find links for this procedure that I mentioned.

Here is my reply to her:

Elyse,

I should have used the “correct” term: uterine artery embolization.
Here: http://www.fibroidworld.com/UAE.htm
This is another very reasonable alternative for you to consider, maybe even more realistic than the ultrasound approach.

Charlie

After several more fax and phone exchanges between Elyse and the physician in California who published the web site noted above, and after phone exchanges with the physicians in Iowa, Elyse underwent an ultrasound examination that confirmed a large, single uterine fibroid about 6 or 7 cm in diameter. The Gynecologist/Oncologist in California felt that surgery was entirely optional at this point, noting that Elyse would likely experience shrinkage of the mass following menopause within a few years.

She is still in the process of finalizing her decision whether to proceed with a laparoscopic hysterectomy or take the “watch and wait” approach but is certain of one thing: she is NOT going to proceed with the scheduled total abdominal hysterectomy.

So, that is where we stand. But, what is the point? Well, the HUGE point is, Elyse is no longer content to blindly follow her doctor’s suggestions. Whereas they suggested she undergo a major surgical procedure, they didn’t even mention two significant new, less invasive procedures that might well be appropriate for her to consider, and did not give her clear information to consider the option of just watching and waiting.

The other point of the story is that a wealth of information is available on the web, but patients often need encouragement to seek it, and help interpreting it and applying it to their own situations. Peer support groups on line are one way to accomplish this and finding an interested, available physician to serve as an “e-patient advisor” is another way.

Either way, it is a good example of how patients are moving into the e-patient revolution and, through this process, the health care system is changing. In the meantime, join me in hoping Elyse soon finds the perfect solution for herself and has a great outcome.

Want To Prevent Stroke? Take 4 Steps

2009-04-09T19:21:00.000-07:00

Stroke is a major cause of disability and death in the U.S. and worldwide. Modern medicines like statins (and old ones like aspirin) are helpful in preventing both initial and secondary stroke in patients at risk. But, are there simple things you can do to lower risk?

Yes, you say! Well, indeed, you are correct. Twenty thousand men and women (age range, 40–79) without histories of stroke or heart attack were recently analysed in the U.K. for the effect of 4 simple behaviors: not smoking, regular physical activity, moderate alcohol intake (1–14 drinks weekly), and high fruit and vegetable intake .

Patients engaging in 3 or 4 of the activities were significantly less likely (2 times!) to suffer a stroke over the next decade. Patients who slipped up a bit and only did 1 or 2 of the activities did have significant stroke risk, though not quite as much as those who sat on the sideline and engaged none of the behaviors.

So, grab the baton and step up to prevent stroke. As always, questions and comments are welcome.

Can e-social Networks be the Latest New Health Hazard?

2009-04-09T08:43:00.000-07:00

We are all looking for ways to handle today’s difficult economic realities. As unemployment heads toward record levels many people are turning to the comfort of e-social networking instead of seeking opportunities for actual face-to-face social interaction.

In a recent blog, I mentioned how unemployment is hitting the male machismo right where it hurts. More and more unemployed people are conducting their job searches entirely online with little or no face-to-face reinforcement to the actual employer. Now, new research indicates that there may be long term health risks and higher rates of premature death among those who heavily rely on e-social networking rather than physical social interaction. Preliminary research suggests that e-social networking may not have very much social benefit after all, especially when it takes the place of meaningful literal social activity. Dr Sigman spells out his warning in the spring issue of Biologist, the journal of the Institute of Biology, and maintains that social networking sites have played a significant role in people becoming more isolated.

For many of us, the bombardment of email, FaceBook, MySpace , Twitter and the like can leave us too mentally weary to seek out face-to-face social activities. Perhaps using e-social networks to augment social interaction, rather than replace, would be a better way to go. In everything, there must be balance.

What we must guard against is the tendency to use e-social networking as a security blanket to avoid sharpening our social skills in the flesh. It can be all too easy to hide behind the keyboard to escape sometimes awkward social realities. However awkward face-to-face interaction may initially be, we learn from each encounter. By using our computers as a distancing object in our interaction with others, we reinforce this unhealthy comfort zone, become more sedentary and more socially isolated.

Are we using social networks as a substitution for social interaction? If so, we may be doing so at the expense of our health. Maybe we all need to get off the keyboard and find a healthy balance of social interaction the old fashion way.

Start monitoring your e-social time tomorrow, because we would really like to hear from you today! Comments, criticisms, manifestos and questions are always welcome.

What Is Insulin Resistance?

2009-04-09T07:42:00.000-07:00

You may have heard the term "insulin resistance" and wonder what it means. It does not sound like a good thing, and it isn't. You probably know that insulin has something to do with diabetes, and wonder if it means you have diabetes. Let me shed some light on this and help you avoid insulin resistance, an important risk factor for heart disease.

The official definition of insulin resistance from the NIH is "a condition in which the body produces insulin but does not use it properly. Insulin, a hormone made by the pancreas, helps the body use glucose for energy. Glucose is a form of sugar that is the body’s main source of energy." In other words, you have plenty of insulin being produced but there is "resistance" at the cell level from it doing its job, and your blood sugar stays high. This is the underlying cause of most type 2 diabetes, the most common form of diabetes.

Besides a high blood sugar, people with insulin resistance usually have an abnormal cholesterol pattern. They have a lower level of "good" cholesterol (HDL cholesterol) and a higher level of the "bad" cholesterol (LDL and VLDL cholesterol). This combination causes plaque to form faster in our blood vessels leading to the blockages that cause heart attacks and stroke.

While there is an important family history (genetic) component to insulin resistance, there is something that you can do to reduce or even eliminate it. The degree of insulin resistance you have is directly related to our fat cells. The more body fat, the more insulin resistance. The less body fat, that is becoming lean, the less insulin resistance. That alone is a strong motivator to lose body fat. Also, a healthy diet of less saturated fat and more vegetables, and exercise, all help to lower insulin resistance.

Hopefully you are now able to understand and explain this important concept. There is no blood test that measures insulin resistance specifically. Your doctor can estimate it presence based on your blood sugar and your cholesterol pattern. Ask about that at your next check-up.

Good source for more information: http://diabetes.niddk.nih.gov/DM/pubs/insulinresistance/

Men Less Powerful in the Boardroom and Bedroom?

2009-03-28T00:30:00.000-07:00

Tune up your violins and bring on the ratchet rhapsody. Recessions not only hit the bank account; they affect martial and domestic relationships too!

I recently read an article in the New York Times that reported more men are losing their jobs than women; over 80% of job losses due to economic recession are affecting men.

For the first time in American history, women may soon surpass men when it comes to payroll. That is big news! Reasons for this may be that the jobs being lost are in the hardest hit areas like construction, held primarily by men. Women tend to hold jobs in more recession secure areas such as health care. One drawback is that women’s salaries have traditionally been seen as supplemental income. Women still only make 80 cents on the dollar compared to men, and often hold less financially rewarded jobs with little or no benefits.

Traditional gender roles are in for some fast moving and turbulent changes! We’ve come a long way from the era when homemaker Mom made dinner in the kitchen every night while breadwinner Dad relaxed over a martini, but there are more changes on the horizon. The division of domestic labor will swing more toward men picking up the slack as disposable income used for take-out and housekeeping services dry up. It stands to reason that marital relationships are bound for significant changes as well.

How we go about embracing these changes will play a major part in our long-term happiness. This shift will translate into the household and even into the bedroom. Men may struggle with feeling displaced or inadequate and may have a hard time coping. Women may struggle with the fear and pressure of survival on only one income. How do you support each other through these trying times?

Men, who are traditionally less likely to seek behavioral health services, will be in need of new forms of support to help deal with these changes. See how some brave men are tackling this head on in a brief CNN Video.

How is the recession and changing roles affecting you and your relationship? Comments and discussion are always welcome.

What Will it Take for "Online Health" to Work?

2009-03-25T07:58:00.000-07:00

"Internet 2.0" emphasizes social networking over simply downloading and reading "content". The world of Twitter, blogging, facebook, e mail, and text messaging is revolutioning our society and rapidly becoming a major force in the way we work and play. It remains to be seen, however, how it will impact health care. There are many, many issues that are no where near resolution.

Although, at eDoc, we have been involved in online health for over a decade, we still run up against innumerable barriers and resistance factors that prevent this modality from truly becoming mainstream.

In order for this to occur, I believe the following needs to happen:

1. The team providing the service must be of high quality. This is difficult to determine in the best of circumstances and almost impossible in the often murky, even sleazy, world of internet
2.0. Until there is a better system for this, the user must be careful to scrutinize the credentials of the professionals involved and understand the business model behind the product. Check to make sure that the physicians are board certified. Beware of industry supported sites that are, essentially, using their web site to sell another product and "giving away" medical content or advice. If possible, find someone else who has used the service and ask whether the service is reputable. If you decide to try the service, dip your foot in the water and assess the quality of what you get back. If you like what you get, try again. If not, run in the other direction!

2. There has to be a widely available method for professional reimbursement. At eDoc, we developed a business model in which sponsoring corporations purchase the service on behalf of their employees or members. Most insurance companies do not cover on line visits with a physician but this is likely to be the case in the future; and, until that occurs, most docs won't or can't afford to, get on line to provide feedback or information to their patients.

3. Better tools are needeed. Although there are a lot of good web sites with good medical content, web tools are just starting to be designed to take advantage of the Web 2.0 world. Good, user-friendly, secure patient and provider portals will need to be connected to eprescribing hubs, will need to readily switch to search for internet sites to attach, will need to accept and view video footage, will need capability to connect through digital cameras for real time viewing and communication, and need easy to use, menu driven drop downs that guide the patient and provider through an online encounter.

For now, eDoc has a high quality team that uses a free form communication model and offers medical, dental, pharmaceutical and mental health professional advice. We are watching with eager anticipation to see what the future brings and, hopefully, we can stay ahead of the curve and continue to offer the highest quality online heath professional experience.

Your comments and dissenting opinions are welcome...

Helping Patients Partner with Docs for Better Health

2009-03-10T10:50:00.000-07:00

Don't get me wrong, I'm 100% for patients taking responsibility for their own health care and helping them do it. There is a lot being written nowadays about patient empowerment, patient's using the internet to do their own health care research, and promotions for systems like ours which encourage on line communication with medical professionals.

I've recently been talking with patient advocates who rightly articulate the failiings of the medical system in helping patients better manage their own health. And, to be sure, there are forces at work that make it difficult for the patient who wants to be more active, ask questions, and "be in charge" of their own health care.

But there is another side to the story. As a physician in practice for many years, there just simply aren't many patients yet who know what this picture looks like, and many others who simply don't want to, or are unable to, do it.

Realistically, in order to "take charge" of one's own health, one needs to be educated, internet savvy, have good communication skills and a high level of focus and determination. That defines about 5% or less of my patient population. The others seem either to desire or require a more paternalistic caregiving approach. But, maybe its just a blind spot in me!

Clearly, we can continue to advocate for this, and can work to make it easier for more patients to do it. But, in the meantime, patient empowerment and self management will continue to be a movement that tiptoes around the fringes of medicine.

Among other things, we need a national network of physicians who are able to communicate online with their patients and be reimbursed for that so that the patient can do some of their own research and check back for guidance and direction from time to time without having to wade through the morass of office visits each time they need to discuss or verify a medical issue with their doctor.

Your comments and dissenting opinions are always welcome.

Choice of Diet Does Matter

2009-03-06T06:58:00.001-08:00

A recent article in the Journal of the American Medical Association (JAMA) reported that all diets that reduce calories work equally well. Of course that is true. Reduce calories, lose weight. The article suggested that it does not really matter whether you choose to lower your carbohydrates, your fat or whatever, just so you reduce your calories consistently over time. Like most large studies of weight loss, the overall results are disappointing in that most people do not stay with weight loss diets and the average weight loss is modest. That is because the people not staying with their diets dilute out those who lose a lot of weight.

What these studies miss is what your experience is with different diet approaches. How do thay affect your overall health? In my previous Blogs here, I have emphasized the importance of reducing simple carbohydrates, like sodas and sweets, since they drive hunger. It is very hard, probably impossible, to stay on a diet program if you are always hungry. Good protein sources, whether from dairy, lean meats, fish, nuts and vegetables, suppress hunger by causing your blood sugar to rise more slowly and remain more steady throughout the day. The rise and fall in blood sugar impacts your hunger. Finally, saturated fats are not good for your health and should be avoided in any healthy diet.

So, what you eat does matter. Your choice of foods will impact your hunger and affect how many calories you are likely to eat in a day. Your food choices affect more than your weight, but also your cholesterol and other risk factors for heart disease. When choosing a diet program for weight loss, make a healthy choice and choose a program that you can stay on for life. Afterall, weight control is a lifelong pursuit. You can vary your protein sources depending on your food preferences, and focus on healthy fats like vegetable oils and avoid the unhealthy satureated fats from things like hamburgers and french fries. Choose a diet program that works for you throughout the day and results in your not eating any more calories than you want to either to lose weight or maintain a healthy weight.

And remember, be physically active to burn those calories so you are more likely to lose unwanted weight.

Where will Twitter fit in the New World of Online Medicine

2009-02-21T09:38:00.000-08:00

As a recent new user of Twitter (a social networking site that is based on short, up to 140 word, messages called "tweets"), I have been intrigued with the role that products like this may have in the new online world of the future, especially online health information.

The environment is fast and allows groups to find and communicate with each other in an "instant message" atmosphere.

For example, today, I signed on and began exchanging views with a couple of experts in the field of patient advocacy. Before I knew it two other people had picked up on this conversation and began "following" me (the word for having someone's "tweets" automatically show up in your inbox area. As a result, I quickly made and solidified new relationships in the area of using online health for patient advocacy. Another cool feature is that you can put a "hashtag" (# sign) beside a term in your message and, by clicking that term later, can go directly to all the messages from all of the users that also put that term in their message. In that way, it is easy to sort and keep up with the areas of your interest.

So, whatever your interest area, it is easy to find others on Twitter who share it and, soon, develop a network of "tweeps" (people who are twitter users) to communicate with about your favorite topic.

One word of caution: it is addictive and, due to a lot of "junk" on there, it is easy to waste time if you're not disciplined about the way you use it.

So, give it a whirl. I think you'll be intrigued as well.

Would you Like to Have a Doctor's Office you could Communicate with via E Mail?

2009-02-17T13:00:00.000-08:00

Today, we started a program at UAMS Family Medicine Clinic that allows patients to e mail, using a secure web site. Using this system, all of our patients can contact their physicians via e mail and:
1. Request an appointment
2. Get their medications renewed or refilled.
3. Send a clinical question to the doctor.
4. Receive the results of recent lab tests and x ray tests.

We are excited about the system and believe it will be the way most medicine is practiced in the future. The patient must complete a written authorization, including their e mail address and signature. Then the office staff sends them an e mail message with a link to the website where they simply create a user name and password and they are ready to go.

These messages are initially read and screened by the office phone nurse and routed to the appropriate physician for a reply. When the encounter is completed, the phone nurse copies and pastes the transaction into the electronic medical record.

Would you like to participate in a practice that offers these services?

I'll let you know how it goes, but I am excited to get this off the ground here.

Eat Less, Remember More

2009-02-01T14:11:00.000-08:00

Calorie restriction has been associated with health benefits, such as increased longevity. It is no secret that most of us eat too much. A new study published January 26, 2009 in the prestigious Proceedings of the National Academy of Sciences suggests that calorie restriction may improve our memory.

50 men and women age 50-72, normal weight and overweight, were studied on three nutrition schedules: a 30% reduction in calories, same calories but an increase in "healthy fat", and no change in diet. The group that reduced their calories were able to do better on tests that involved memorizing words. The other two groups showed no change.

How could this happen? Eating less calories causes us to be more sensitive to the blood sugar regulating hormone insulin and have a drop in the inflammation-associated molecule C-reactive protein. Past evidence has linked these factors to an improvement in brain function. Experts suggest that increased inflammation and a drop in insulin sensitivity (which is known as insulin resistance) may help explain why obesity and type 2 diabetes have been linked to worse mental performance and a greater risk of Alzheimer's disease.

Lean and healthy go together. Staying lean is a big challenge today with the abundance of inexpensive and "fast" food. Being lean requires a special commitment to healthy eating every day and regular physical activity. Clear mental performance can now be added to the potential benefits of living this healthy lifestyle.

Using IT to change the Health Care System

2009-01-24T09:46:00.000-08:00

The possibility of revolutionizing the Health Care System using information Technology is exciting, and I hope I live long enough to see it reach its full potential. I've blogged a lot about the concept of patients using the internet to help them take more control over their own health care. But, there are also provider-based technologies that will increasingly become available and also will improve the care system.

At eDoc, we've recently undertaken several project that, I hope, will be emulated or duplicated widely to improve the efficiency and quality and reduce the cost of health care. Briefly, these projects are:

1. Providing eDoc services to all Medicaid patients in the state of Arkansas (this project is slated to start in July of this year).
2. Providing a secure, online, web-based consultation portal for physicians in Arkansas to consult with a physician at the University of Arkansas about a problem patient.
3. Providing patients being discharged from the hospital with a card that gives them the URL to connect with physicians to ask questions about their hospitalization.
4. Providing a secure, web based portal for patients in the outpatient clinics at the university to contact the office and renew prescriptions, request appointments, receive lab results or ask clinical questions.

Broad use of these technologies thoughout the US will undoubtedly greatly reduce health care costs and improve patients' access to the health care system. By using online services like this, patients should never have to go into the office to see their doctor unless they have to have blood work, a physical exam, an imaging procedure, or some other procedure.

Viva the e patient revolution!!

Patient Advocacy During Hospitalization

2009-01-14T15:01:00.000-08:00

I have had three recent family situations which have gotten me heated up on the issue of the need for patient advocacy. Its not that care without advocacy is necessarily bad. Its just that, as I reflect on it, I'm not sure it CAN be adequate without someone sitting by the patient who cares at a deep level--whether this person is a friend, spouse, family member, whatever--who is able and willing to constantly advocate for the patient.

Briefly, my "three situations" are: 1) a wife who has Waldenstrom's, post bone marrow transplant, who is returning for chemotherapy after three years treatment free; 2) a daughter who is pregnant (separated from husband), living with us, who is receiving obstetric care; and 3) a disabled son who is currently hospitalized in a small community hospital 2 hours away.

So, here's the dilemma: Each of these patients has varying needs and abilities to "fend for themselves" in the health care system. One of them is totally disabled and, thus, without someone present is totally at the mercy of the "nurse of the day". One day, he had a nurse who was caring and attentive and, the next day, he had someone who seemed to be totally over her head and, although she thought she was doing a good job, was doing a terrible job of taking care of the basics, monitoring output, attending to basic hygeine, etc.

So, I have been involved in a varied and fairly active advocacy role in each of these three situations and it is not an exagerration to say that none of them would have received optimal care without it.

What do advocates do and how does that impact the patients' care? Here is a brief list:
1. Assess the patient's physical comfort level and provide little necessities, body position adjustments, etc.
2. Double check all medications administered to make sure they are what has been ordered, in the right doses, and given at the right time.
3. Ask about key lab results and, if possible, keep copies and, if necessary, ask for interpretation from nurse or doctor.
4. Ask questions, questions, questions: is it time for the catheter to be taken out? If not, when? Is the IV leaking? When is discharge planned? What are the plans for discharge medications? When is the follow up appointment? And so on...

But, in spite of the importance of physical presence and asking questions, I am convinced that the mere presence of a "caregiver and advocate" changes the fundamental dynamics of a hospital care situation. It not so subtly gives a message that "we are watching what you are doing and will ask you if we have any questions or concerns about what is happening"?

It is not even fair to say that hospital caregivers intentionally neglect patients who don't have bedside advocates. I believe it is just that they are spread thin and stressed and, in many instances, need our help to meet the needs and priorities of the patient...

So, don't hesitate to serve as strong advocates for your hospitalized relatives!

Your comments and opinions are always welcome.

Are We Getting What we Pay For?

2009-01-09T12:28:00.000-08:00

In today's Wall Street Journal, Deepak Chopra, MD and his colleagues wrote a very interesting opinion piece on the mainstreaming of alternative medicine. But I really thought the core message of the article was that, in the US, we are spending billions on health care, procedures, medication, and technology when much of what we are buying could be reversed with simple lifestyle change.

Instead of needing coronary stents or expensive cholesterol, diabetes or blood pressure medicine, patients really need to embrace smoking cessation, exercise, stress reduction, better nutrition, and having a more active and more supportive social life.

Physicians should be as excited about advocating healthy lifestyles (and providing guidance on how to do it) as they are in making complex diagnoses and prescribing procedures and medications.

Let me know what you think about this issue.

Are You Eating Your Way To Diabetes?

2009-01-05T07:01:00.000-08:00

We all hear about the rapid increase in people with Type 2 Diabetes. The number of people with this disease in the U.S. has doubled in the last 20 years. If you do not have this type of diabetes, mostly caused by obesity, do not think you won't, especially if you are overweight or obese.

Theoretically, we could all have Type 2 Diabetes at a certain weight. As our fat cells, also called adipose cells, get bigger they release hormones that can trigger the high blood sugar of diabetes. Some people are more genetically prone to diabetes than others but anyone can get the disease if they stress the body with too much body fat. You could be eating your way to diabetes if your weight is going up.

How could you tell this? There are some early markers of developing diabetes. What is your fasting blood sugar? Diabetes is a level of 126 or higher. Levels of fasting blood sugar from 100 to 125 is called prediabetes, clearly on your way. Normal fasting blood sugars are between 60 and 90. Is yours closer to 90 than 60? Has your fasting sugar gone up since you gained weight. What about a sugar between 90 and 100? Many diabetes specialists think that any level above 90 should be considered prediabetes. I agree.

What happens to your blood sugar 1-2 hours after a meal? Above 200 is definitely diabetes. Above 140 is considered another type of prediabetes. Has yours gone up? You may not have diabetes yet, or even the official levels for prediabetes, but you may be on your way. Better to find that out before it is too late. The complications of cardiovascular blockage leading to heart disease begin before the blood levels reach the diabetic level.

Another thing to watch is your HDL (good) cholesterol. As your fat cells expand, the hormones released cause the HDL cholesterol to go down, which is not a good thing. The LDL (bad) cholesterol often goes up with weight gain as does the total cholesterol. If you have gained weight, you might recheck your lipid panel and see if it has changed from previously.

Realize that you too could get diabetes if your weight is going up. Maybe the scare of developing this disease is enough to motivate you to exercise, control your eating, and lose weight. You do not catch diabetes, you develop it. Find out if that is happening to you and do something about it if you are moving toward diabetes.

What Does it Mean for the Patient to be in Charge of their own Health Care?

2009-01-02T06:37:00.000-08:00

Robert Veatch's book: Patient Heal Thyself: How the New Medicine puts the Patient in Charge is reviewed in the December 25th issue of the New England Journal of Medicine. Of two of Veatch’s main points, one is correct and one misses the point entirely. The first point: “Patients alone are in charge and have no choice but to assume this role” is correct and is essential to any patient's aspirations to stay healthy. After all, physicians' recommendations are worthless unless the patient understands, accepts, and follows them. So, if that doesn’t make the patient in charge, I don’t know what does! Any notion that the physician is "in charge" is more the physician's fantasy than anything else. A physicians role is not to be in charge of the patient's health, but to use their training and experience to guide the patient and to help coordinate their care and, in some cases, to directly provide some of that care.

Even more passive patients, who prefer to relegate decisions to the physician, are really still "in charge" in the sense that they are choosing not to question recommendations made or seek a second opinion. While it is true that many patients just don’t feel they have the resources or the information to do this, the internet has shifted the balance and now makes it possible to effectively and objectively research almost any medical question.

The second point, that “physicians will no longer be seen as capable of knowing what will benefit their patients” inappropriately relegates the role of the physician to a technician or an information resource. In truth the physician, by himself, has never been in a position to determine the best choice for the patient any more than a lawyer can determine what sentence a plea bargaining criminal can choose rather than going to court and taking a chance with the jury. The patient/client must do that.

But, there are a wide range of approaches that patients and clients use to arrive at decisions, whether they be health care, investing, legal, personal and otherwise. Wise ones inevitably choose their own course after appropriate due diligence. But there is a wide range of variability on how they go about this, from those who still prefer that their doctor make their decisions for them to those who simply want to do the research and have the doctor provide the support to proceed along their chosen course of action.

Most patients end up somewhere in the middle, whether that be in the office or through an online dialogue, and would like to at least hear the opinions of a trusted health care professional and use that information to help them make a decision. If someone is going through a painful divorce and needs legal help, does she prefer to go to the internet, pull up the relevant state law and tell her lawyer what to do? No! She prefers to tap his judgment and experience to make recommendations in response to which she makes a considered decision and moves ahead.

This is no different from the appropriate role of the physician: to enter a relationship with the patient, listen to their story, investigate their problem utilizing their training and experience, assisted by health care technology, then provide recommendations and then do it over and over again, many, many times, as often as the patient needs them to.

I believe the primary reason that this doesn't work as well as it should is because too many of us maintain the illusion that we are still in control of the patient's health and seem to think that status quo needs to be maintained.

So, what lessons does Mr. Veatch's book leave with us? In my opinion, it is a good wake up call for physicians. We need to embrace the "ePatient Revoution", recognize that the patient MUST be the one who is in control of their own health care, assist them in achieving this, and not be tempted to allow that to interfere with our professional self esteem because, in my view, it in no way threatens it!

Your comments and dissenting opinions are welcome.

Online Follow up for Hospitalized Patients

2008-12-19T13:57:00.000-08:00

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

2008-12-12T12:08:00.000-08:00

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

2008-12-07T13:35:00.000-08:00

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?

2008-11-09T22:24:00.000-08:00

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

2008-11-04T14:33:00.000-08:00

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?

2008-10-10T06:17:00.000-07:00

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?

2008-09-04T06:43:00.000-07:00

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?

2008-08-06T06:52:00.000-07:00

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

2008-07-10T12:22:00.000-07:00

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

2008-07-06T15:52:00.000-07:00

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!

2008-07-01T08:05:00.000-07:00

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?

2008-06-28T07:39:00.000-07:00

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

2008-06-13T09:41:00.000-07:00

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

2008-06-11T07:21:00.000-07:00

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

2008-06-05T13:55:00.000-07:00

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

2008-05-11T16:21:00.000-07:00

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

2008-05-07T12:20:00.000-07:00

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

2008-04-17T07:44:00.000-07:00

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

2008-04-11T08:28:00.000-07:00

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?

2008-04-08T08:53:00.000-07:00

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?

2008-04-04T17:40:00.000-07:00

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?

2008-04-02T13:17:00.000-07:00

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

2008-03-30T06:49:00.000-07:00

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!

2008-03-23T07:16:00.000-07:00

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

2008-03-07T13:37:00.002-08:00

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?

2008-03-05T12:55:00.000-08:00

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

2008-02-25T12:45:00.000-08:00

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

2008-02-25T10:25:00.000-08:00

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

2008-02-21T11:25:00.000-08:00

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!

2008-02-16T19:07:00.000-08:00

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

2008-02-12T06:29:00.000-08:00

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!