Heart Disease

The Mediterranean Diet - It's Nuts!

2008-12-10T22:58:00.022-05:00

Metabolic syndrome is a group of risk factors, including high blood pressure, high blood sugar, high cholesterol levels, and fat in the midsection that increase one's risk of heart disease and diabetes. Diet, exercise, and medications have been shown to improve metabolic syndrome and lower the risk of these complications.

Currently a study called Prevención con Dieta Mediterránea (PREDIMEDD) has enrolled 9000 high-risk participants aged 55 to 80 years who are assigned to one of three interventions: Mediterranean diet with the provision of 1 L/week of virgin olive oil, Mediterranean diet with 30 g/day of mixed nuts, or a low-fat diet. This is a long-term, multi-center, randomized controlled clinical trial is designed to assess the effects of the Mediterranean diet on the primary prevention of cardiovascular disease. (Primary prevention means the prevention of a disease that the person has never had before. Compare this to secondary prevention which means preventing a person who is known to have high cholesterol and blockages in the arteries from having a heart attack).

Already data from 1224 participants in the study have shown that adhering to a Mediterranean diet supplemented with mixed nuts appears to provide benefit to individuals with the metabolic syndrome. Investigators observed a reduced prevalence of metabolic syndrome at one year among individuals adhering to the Mediterranean diet plus mixed nuts compared with those adhering to the traditional Mediterranean diet alone.

"The novelty of our findings is that a positive effect on metabolic syndrome was achieved by diet alone, in the absence of weight loss or increased energy expenditure," wrote lead investigator Dr Jordi Salas-Salvadó (University of Rovira i Virgili, Reus, Spain) and colleagues in the December 8/22, 2008 issue of the Archives of Internal Medicine. At the beginning of this study, nearly 62% of the participants met the criteria for metabolic syndrome. After one year the rate of metabolic syndrome dropped by nearly 13.7% in the patients assigned to the Mediterranean diet plus mixed nuts, 6.7% in those consuming a Mediterranean diet alone, and only 2% among those on the traditional low-fat diet. (Is there anyone left out there who still thinks the ill-advised, poorly researched, low-fat diet benefited anyone but the companies making carbohydrate-rich junk foods?)

The beneficial effects of the diet happened without an increase in exercise habits, calories burned, or weight loss and add to the evidence that diets enriched with nuts do not induce weight gain, noted the authors. This author does note however that the amount of nuts was limited to 30 grams a day, which is one ounce or about 2 tablespoons). The researchers aren't sure yet what caused the improvement, but think that the diet plus mixed-nuts intervention may have positive effects on insulin resistance. Another possibility is the diet's effects on other factors such as oxidative stress and its related inflammation in the blood vessels. Previous analysis of the data have shown that the Mediterranean diet coupled with nuts protects against oxidative damage and reduces cardiovascular risk factors better than a low-fat diet.

Source: Salas-Salvadó J, Fernández-Ballart J, Ros E, et al. Effect of a Mediterranean diet supplemented with nuts on metabolic syndrome status. Arch Intern Med 2008; 168: 2449-2458.

Take care,

Laurie

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World Diabetes Day

2008-11-14T22:37:00.009-05:00

Today is World Diabetes Day (11/14). Stop for a moment and think about these facts:

Every 10 seconds someone dies from diabetes-related complications. In that same time period two new individuals develop the disease.

Over 250 million people in the world have diabetes; in less than 20 years this number will reach 380 million.

More than 200 children develop type 1 diabetes a DAY. This type of diabetes is increasing in preschool children at a rate of 5% annually.

Type 2 diabetes has been reported in children as young as eight. Type 2 diabetes is becoming increasingly common in school-aged children as a result of obesity. Just a generation ago this was a disease of adulthood, called "adult-onset" diabetes.

Even controlling for other risk factors, people living with diabetes are twice as likely as those without diabetes to die from cardiovascular disease (heart attack and stroke).

If you have diabetes or are at risk for developing diabetes, or you are one of us whose lives have somehow been touched by diabetes, take a moment today to talk about diabetes with anyone who'll listen. We need to increase awareness of this disease in the same way that heart disease and breast cancer have been recognized.

For more information: http://www.worlddiabetesday.org/

Something Fishy

2008-11-04T09:29:00.002-05:00

Did you know that the American Heart Association recommends adding fish to your diet at least twice a week? The American Diabetes Association recommends 2-3 three ounce servings of fish per week for people with diabetes. Fish is a source of quality protein, vitamins, and minerals, and fatty fish are high in the heart-healthy omega-3 fatty acids known as EPA and DHA. Omega-3 fatty acids (FA's) are known to reduce inflammation in the body; inflammation is now thought to play an important role in the development of heart disease. Omega-3 FA's are also thought to decrease the risk of developing other inflammation-related diseases, such as Alzheimer's and vascular dementia. These fats are thought to be "brain food" for developing children's minds and for maintaining brain health in adults.

A recent study of women who have type 2 diabetes found that higher fish intake was associated with a significant decrease in risk of developing heart disease over a 16 year period of follow up. The fatty fish include salmon, mackerel, and tuna. While other fish such as cod, flounder, talapia, shrimp and shellfish aren't high in omega-3 FA's, they are a great source of protein that is low in calories and fat per 3 ounce serving, as long as it's cooked in heart-healthy ways. These include broiling, baking, steaming, and grilling your seafood choices.

Think you'd like to eat more seafood but don't know where to start? Try WebMD's Health and Cooking Resource page or do a web search for the particular item you want to cook and recipes, such as "cod recipes" or "shrimp recipes" and see what you find. Look for recipes at web sites that are promoting a healthy lifestyle, such as Eating Well and Weight Watchers.

If you are concerned about food safety and our environment as I am, you may be aware of some of the issues that surround the seafood industry, such as over-fishing some species, the loss of fish that are unwanted but are caught in net fishing, and the environmental damage done by some fish-farming methods. If you'd like more information on eating fish in an environmentally friendly way, try these resources at the Monterey Bay Aquarium and the Environmental Defense Fund (EDF). The EDF site also has information about mercury in fish and how to avoid it, and a link to recipes. Both sites have printable pocket guides to assist you in making sustainable choices in the grocery store.

Try some healthy fish soon; your mind, heart, and waistline will thank you for it!

Take care,

Laurie

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Blood Test to Detect Heart Disease?

2008-10-13T12:16:00.001-04:00

A blood test that may identify those with heart disease is being tested by researchers at Duke University (North Carolina). Based on a set of genetic markers that indicate both the presence and the level of artery blockages, researchers are hopeful that this test will one day replace more expensive and time consuming preliminary testing, such as echocardiogram and exercise stress tests.

If a person having chest pain could be assessed for the presence and degree of coronary artery disease (CAD) based on a blood test, they could proceed directly on to catheterization and either stenting or bypass surgery. This kind of test could be very useful to assess a person acutely having chest pain who presents to the emergency room, or to streamline the assessment of a person at risk for heart disease who presents to their health care provider with symptoms suggesting heart disease.

Currently individuals who are suspected to have CAD undergo other tests first, because they are less invasive and less costly than going directly to catheterization. These tests also limit exposure to x-ray radiation. Insurance companies often require these preliminary tests to "prove" the presence of CAD before proceeding to the cath lab. Unfortunately these tests don't always determine the presence or absence of CAD, resulting in cardiac catheterization anyway. This process is both time consuming for the patient, expensive to our health care system, and allows time for an untoward event to happen.

The researchers report that the current study, published in the journal Circulation: Cardiovascular Genetics, is based on a small number of participants and will need to be verified in a larger number of people before the blood test is approved for use. It is currently undergoing additional trials at 28 sites around the US, with a wide variety of study recipients.

Commenting on the study results, Dr. Sidney Smith, a UNC-Chapel Hill cardiologist, noted, "If these findings hold for this broad group of population, the test could prove to be a valuable supplement in our management and treatment of patients with coronary heart disease."

Dr. Joe Falsone, an invasive cardiologist at Wake Heart & Vascular Associates, called the discovery "potentially exciting news," and said "we could probably use this as a screening tool for patients we thought were at high risk."

For more information about participating in clinical trials at Duke please see "Research at Duke Medicine." ClinicalTrials.gov is a registry of federally and privately supported clinical trials conducted in the United States and around the world.

Take care.

Laurie

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Preventing "Brain Drain"

2008-09-11T13:50:00.001-04:00

This week I'm thinking about time. It seems to me that my daughter was just born yesterday, yet next week she begins her senior year of high school. Where does the time go?

One thing I notice as I age is that my memory has days where it's not as sharp as it used to be. I resist making lists, because that makes me feel so old, but there are times when I know that my brain is on overload and I just have to do it, or something will be missed. For me these are the times when my life is very hectic, with many projects to be addressed, keeping track of family appointments and obligations, all thrown into a busy summer week of work in the ED. Whew! Makes my brain overwhelmed just thinking about it. These are the weeks when I have to take really good care of myself by getting plenty of rest, eating well, and making those darn lists. I have to admit though, I am less stressed when I have a list to fall back on.

A lot of things affect memory, including poorly controlled blood pressure, which contributes to "hardening of the arteries," (medically called atherosclerotic heart disease," or ASHD). Other causes include poorly controlled diabetes, stress, and certain diseases like dementia. Medications used to treat these health problems and others, such as those for chronic pain, can also cause difficulty with memory.

ASHD and poorly controlled diabetes both affect memory because they decrease circulation to the brain. With loss of circulation comes loss of oxygen and nutrients, and without them we can become forgetful. So if you are having difficulty remembering things start by seeing your health care provider to see if there is a cause for your memory loss that can be fixed. Once any so-called "organic" causes of memory loss are ruled out or corrected, you can try the following ideas to keep your brain sharp.

These suggestions are consistent with the types of successful strategies used in a study of 3,000 adults (average age 73 years), that was recently published in the Journal of The American Medical Association (JAMA). The brain training the study participants received consisted of three types: memory training, such as organizing a grocery list into categories which made it easier for them to remember, reasoning training, such as finding patterns in their daily activities, and speed training, which included quickly naming items as their pictures flashed on a screen.

Even before this study there had been evidence from other research that mental activities such as crossword puzzles and learning a new language helped to keep the brain fit. One small study even suggested that these types of activities might lessen the chance that a person would develop dementia. So here are the ideas, recently found in Diabetes Self-Management (July-August, 2008):

Keep up your social life by visiting friends, volunteering, or joining a club.

Keep learning by taking a class (you can audit a college or university class and learn the subject without paying for the class, although you won't get "credit" if you want it), buying a language program, or learning a new game that is challenging, such as bridge.

Do puzzles, crosswords, Sudoku, or play cards or other games with friends.

Move it! Exercise helps improve circulation, lowers blood pressure, and lowers blood glucose, which all affect memory.

Challenge your brain by changing your daily routine, such as exercising before breakfast.

Eat well: certain foods are good for our health, including the brain. These include the same foods you read about in relation to cardiovascular disease and diabetes prevention: green leafy veggies, blueberries, broccoli and cauliflower, the "good fats" in olive oil, avocados, nuts, and fish, fruit juice, calcium in dairy products, and even alcohol in moderation.

Ok, now off to make my "to do" list for tomorrow and get a bowl of blueberries and yogurt for my declining brain! Take care, Laurie

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The "Flat Belly" Diet

2008-08-18T17:58:00.001-04:00

Hope this finds everyone well! I noticed this week that there is a link from my Google homepage to this "flat belly diet." Funny, Web MD just happens to have an article about it too. I generally have a lot of faith in Prevention Magazine and I think that a lot of information contained in it is well researched and worth while, but sometimes I think they get swept up in the nonsense too.

This "diet" is one such example and I think that WebMD's registered dietitian (RD) does a great job of supporting what is right about this eating plan, as well as dispelling the myths about it. This plan is a healthy, Mediterranean-diet based plan, and you will certainly lose weight on on it, as well as probably lower your cholesterol and improve your blood pressure, but it won't melt away fat from any particular body location.

It is important to realize that any diet that seems to have a "magic" ingredient to melt away fat/pounds, no matter what the source of the information, is full of horse feathers! Please look to a trusted, well-researched source for your dietary information, such as your own RD, or a site such as WebMD or a university-based health site. The critical thing to ask yourself is, "does the writer of this diet article have something to sell, such as food items, food supplements, or a book?" If they don't, then you'll be more likely to get unbiased information.

On another note I have been away in Washington, DC this past week at the American Association of Diabetes Educators meeting. This was a mixed business and site-seeing vacation trip, and my traveling companion and I had a wonderful time. If anyone is going to DC and wants a recommendation for a place to stay, please check out the B&B called the Aaron Shipman House; you will not be disappointed!

Lovely hosts, fabulous food at breakfast, and a great neighborhood location (less than 15 min walk to the convention center at a moderate pace). While there I began reading Animal, Vegetable, Miracle by Barbara Kingsolver. If you are at all interested in the topics of eating locally (aka "relocalizing" food or being a locovore), and the environmental impact of our food choices, you'll want to read this book. Here is a factoid taken from her pages that amazes me: "If every US citizen at just one meal a week (any meal) composed of locally grown and organically raised meats and produce, we would reduce our country's oil consumption by over 1.1 million barrels of oil every week." That's not gallons - it's barrels! Think about how fast this would decrease our dependence of oil.

Eating well for our improved health and the environment are important. Be certain that the recommendations that you follow are from an informed, unbiased source.

Take care.

~Laurie

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Technorati Tags: healthy diet, belly fat

Women and Hypertension

2008-07-29T09:50:00.004-04:00

Photo Credit: Lisa Brewster

As reported this week in HealthDay News, more than 73 million adults in the US have high blood pressure (hypertension); half of them are women.

As a group, women are more likely to be overweight and have elevated cholesterol levels, and they are less likely than their male counterparts to meet the target "goal numbers" for well-controlled blood pressure as set by various health organizations, such as the American Heart Association or the National Institute of Health. Women are less likely to have appropriate prescriptions written for them than men, such as blood pressure and cholesterol lowering drugs. This is partly because women aren't educated in the need to control their blood pressure to prevent an increased risk for developing cardiovascular diseases such as heart attack and stroke.

Simply put, women don't think it's going to happen to them, when statistics tell us a different story. Heart disease is the number ONE killer of both men and women, but annually it takes the lives of more women than men. Hypertension is so damaging to the inside of the blood vessels, that controlling it to 'goal' (top number less than 120 and less than 80 on the bottom) will cut a woman's risk of stroke and heart attack in by 25%!

Women should ask about there blood pressure measurements, and if they are high, ask for advice on how to improve them. This can be as simple as eating more calcium-rich foods, or more challenging, such as losing some weight or exercising more. Research has indicated that as little as a ten-pound weight loss will have a significant impact on blood pressure.

For more information, look to these WebMD resources:

Take care.

~Laurie

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Technorati Tags: hypertension, high blood pressure, heart disease, womens health

Emergency Room Follow Up

2008-07-22T13:00:00.001-04:00

I am very glad to see all the thoughtful comments on the last "Tales From the Emergency Room" post. I was inspired by your comments to post this follow-up, because I think there is a critical misunderstanding about the abilities of medicine to diagnose illnesses among those who have to be the recipients of that care.

Medicine is not black and white. There is no "x + y = z" to diagnosis. When faced with a diagnostic challenge a practitioner of medicine must take a thorough history, including all the details of the present illness, as well as the person's past medical and surgical history, and current and recent medication use (prescription and over the counter). He or she then synthesizes all this information and places it in the context of the "odds" of various things being wrong. Let's take a common example, chest pain (CP). As I approach the room in the ED with the CP patient I have a "differential" list in my head. A differential list is all the possible causes of chest pain I can think of: heart (ischemic heart disease/heart attack/angina), lung (congestive heart failure, pneumonia, blood clot, tumor, pneumothorax, pleurisy, dissecting aneurysm), musculo-skeletal (contusions, costochondritis, rib fractures), and GI (reflux, heartburn, esophagitis, ulcer, gastritis, referred pain from the gallbladder or pancreas).

When I go into that room I notice a few things right off:

age (less than 40 vs. over 40), because a young person doesn't usually have heart attacks, dissecting aneurysms, angina, or CHF, but is more likely to have GI tract or musculo-skeletal problems.
level of current distress and other clues, such as a low blood oxygen level or being short of breath, which pushes me in the direction of heart or lungs.

Then I get the story: 51 year old woman with not 'typical, heart-related' chest pain presents with waxing and waning discomfort all day, which she describes as "I just didn't feel right" and "I was restless, like I couldn't get comfortable, and a little short of breath." She is a smoker with high cholesterol and anxiety disorder and whose brother had a heart attack at under age 50. First heart enzymes are in the abnormal zone, but not high enough to suggest a heart attack. EKG is normal x's two; D-dimer (a measure of blood clots) is normal. The odds are that this is not pain from her heart, but she has too many risk factors to ignore and will spend the night in the hospital having serial heart enzymes just to make sure her heart is ok. My diagnosis: atypical chest pain, admit to rule out heart as source. Once that is cleared she'll face the diagnostic dilemma of, "if not heart, then what is it?"

Another one: 17 year old with 24 hours of chest pain that started after eating pizza quickly while at work at the pizza joint. Now feels that it hurts to swallow. No prior history of stomach problems, no significant heartburn in the past. Has also been away at camp and exposed to lots of other teens, and has a minor cough. Chest x-ray is normal and pain gets better with some Maalox mixed with lidocaine (a numbing agent), suggesting that there is a problem in his stomach or esophagus. My diagnosis: esophagitis, basically inflammation in the esophagus (swallowing tube between mouth and stomach), possibly after injury to the esophagus from hard pizza crust eaten quickly. Plan-home on antacids and acid-blocking pill, follow up with own MD. But if not better, then what? The patient is a little over weight, has a little chest wall tenderness but it Does the person actually have inflammation in the stomach or a stomach ulcer? Does the person actually drink alcohol with friends on the weekends, but won't admit it in front of mom? Is it really muscle pain from sports activities at camp? If my medicine doesn't work, the patient will be back to their own MD and "back to the drawing board" in terms of having a correct answer.

Third one: over weight mid-30's year old woman on birth control pills with sudden chest pain and increased heart rate; non-smoker, recent cross-country flight with layover of 1 hour in Philadelphia before changing planes. Asked for wheelchair ride between gates due to "pulled muscle" in her right calf that caused her to walk too slowly; she was afraid of missing her connection. No personal of family history of blood clots or clotting disorders; positive elevated D-dimer in her blood work, chest CT positive for blood clot in left lung. My diagnosis: pulmonary embolus (blood clot in lung) secondary to long plane trip, being overweight and on birth control pills. Admit to hospital until improved on blood thinners.

So the last patient is pretty clear-cut, but the other two are not. In this field you must put together a set of potential explanations, figure in the odds, test for the most likely scenarios, and then "pick a path and go down it," as my first mentor used to tell me. But there is always a chance that one can be wrong, and that is why follow up, with your own health care provider who knows your personal and family history well, is so important. This is the single biggest problem in medicine today in my opinion: people are uninsured or under-insured and thus they don't think they can have a personal health care provider. Many don't realize that there is someone in their community who will take care of them, or there is an option in the nearest large city. It takes some effort, but finding someone to have a relationship with, and getting established with them, is a much better source of care than you can get in the ED, unless it is a true emergency.

Stay cool and out of the midday sun.

~ Laurie

My definition of an expert in any field
is a person who knows enough
about what's really going on to be scared.

P. J. Plauger, Computer Language, March 1983

Cold Weather and CVD Risk

2008-07-02T14:04:00.002-04:00

Summer's here and so is the heat. Last week on the day that I read about this study it was 91 degrees Fahrenheit and 57% humidity in my surroundings, and I found myself thinking about winter heart attacks. This is because of a research announcement that may explain why there is an increase in cardiovascular disease (CVD) related deaths in the winter months. Apparently cold weather stimulates inflammation in the body, a factor that was demonstrated in the levels of inflammatory markers in the blood in the study subjects.

In this study researchers observed that 5 consecutive days of colder weather lead to an immediate increase in levels of the inflammatory markers C-reactive protein (CRP) and interleukin-6; levels of a third marker of inflammation, called fibrinogen, rose 3 days later than the other two markers. The research team measured levels of these markers in nearly 6,000 blood samples from 1,000 adults who had had a heart attack within the last 6 years. These adults were located across a wide range of climate zones.

The study, reported in the May issue of Epidemiology, suggests that one mechanism by which cold weather increases cardiovascular mortality is by increasing the body's inflammatory response. The investigators report that a 10 degree decrease in Celsius temperature (1 °C = 1.8 °F, so 10 x 1.8= 18 degrees F) over a 5 day average temperature before subjects blood was tested resulted in a 4% increase in CRP, a 3.3% increase in interleukin-6, and a 1.3% increase in fibrinogen levels in the blood.

The researchers suggest that this may indicate a biological mechanism for the observed seasonal increase in death from heart disease and stroke in the elderly. Since it is known that cold temperatures increase blood pressure and this leads to additional strain on the heart, this increase in inflammation may be an additional risk factor in patients already susceptible to cardiovascular events. Since fibrinogen is directly involved in clotting in acute heart events, cold stress may be a trigger that leads to events that thicken the blood, making clots more likely.

This is interesting research that needs additional study, since it is my understanding that we still aren't sure whether the CRP factor arrives as a marker of increased CVD risk or appears only after CVD is established. Despite this information, I'd given anything for an 18 degree drop in Fahrenheit temperature at the moment, but I guess I'll have to settle for a cold glass of iced tea!

Take care,

Laurie

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Technorati Tags: heart disease, inflammation, C-reactive protein, CVD, cold weather, heart health

Tales from the Emergency Department: Seriously??

2008-06-16T07:00:00.002-04:00

Fans of Gray's Anatomy will recognize the mantra of the show, stated when a character really can't believe what they are seeing in front of them and says, "Seriously. Seriously?" Frequently in the ED I have these moments where I want to say "Seriously. Seriously, you came to the ED because of THAT?"

Of course one never says that to a patient because it would be insulting to them, but having this blog allows me to vent a bit about how silly the human race can be! So here's my favorite from the day: a middle-aged person drives 45 minutes in the hot car (no AC, windows down) to the beach, where it is 90 degrees in the baking sun. She proceeded to sit on the beach for four hours in that hot sun, drinking an iced coffee. When she and her friends decided that it was time to head home, she jumped up from her beach chair, gathered her belongings, and started up the beach for the car.

Suddenly, to her surprise, she feels "a little dizzy," and sits down in the sand. Now, what do you think she does next? Does she have someone get her some water? Does she get out of the sun? No, she calls "911" and comes to the ED! Where, before I enter her room to evaluate how dehydrated she is, I say to the EMT's who have delivered her to our doorstep, "Seriously. Seriously?"

Please, learn something about dehydration and heat-related illnesses. For every 30 minutes of outdoor activity that you do, you should be drinking 8 ounces of water or other hydrating fluids. This doesn't mean iced coffee, because caffeine (and alcohol) containing drinks increase urination, and this will make your dehydration worse. Whether you go to the beach, the ballpark, the kid's soccer or softball games, or go for a walk in the midday sun, take a periodic break from being in the direct sunlight by getting into the shade somewhere and have your cool, hydrating drink. If you get dizzy, sit or lie down, and again, have something to drink. When you think you are ready, get up slowly...and have someone else drive the car home.

Should you fail to follow these instructions, please feel free to come to see your friendly ED staff, but don't be surprised if we say with a smile, "you didn't drink your water, did you?"

Stay cool and don't forget your sun screen!

~Laurie

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Technorati Tags: heat, heatstroke, dehydration, beach, summer safety

Legislation We Should All Support

2008-06-06T07:00:00.003-04:00

Despite the number of deaths from cardiovascular disease and stroke that occur annually from smoking, there is no government agency with the authority to regulate tobacco products. As a result the tobacco companies are free to use addictive substances in cigarettes without disclosing their presence and they are free to market to children and teens.

Recently a piece of legislation, the Family Smoking Prevention and Tobacco Control Act (S. 625/H.R. 1108), was introduced in both the House and Senate. This proposed law would prohibit the marketing of tobacco products to children, stop illegal sales to them, and outlaw candy cigarettes, which are a product starter for many kids. It would require the cigarette makers to disclose what is in their products and it would give the FDA the authority to require manufacturers to remove or reduce the amount of harmful additives in tobacco products. It would also stop confusing health claims from tobacco manufacturers. such as those which suggest that "lite" or "natural" products are safer or less addicting.

Each year 400,000 individuals die from smoking-related causes; of these 150,000 die from cardiovascular diseases. Another 35,000 die from exposure to second-hand smoke. Don't you think that it's time we regulated tobacco in a way that helps to protect our children from becoming addicted and helped current smokers to reduce their dependence on tobacco? Don't you think it's silly that the FDA has authority over foods and not tobacco?

If you are interested I urge you to write a letter to your state legislators encouraging the passage of this legislation. For more information and a sample letter look to the American Heart Association and the Campaign For Tobacco-Free Kids. I love the Tobacco-Free Kids web site, and have long referred people there to read about the incredible job that "big tobacco" does with advertising. I especially like this slide show about marketing to target audiences. Do you see a reference to a certain perfume campaign of the past in the product for women?

I think this legislation is well worth our efforts to support and encourage you to inform yourself and to contact the offices of your elected officials to ask them to pass the Family Smoking Prevention and Tobacco Control Act (S. 625/H.R. 1108).

Take care.

~Laurie

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Technorati Tags: Family Smoking Prevention and Tobacco Control Act, smoking, FDA, healthy heart

Food as Medicine: Does it Bother You?

2008-05-19T13:00:00.000-04:00

Are you at all concerned that food is becoming medicine? Every day I hear an advertisement for one food item or another and how it's been enhanced to be better for my health. Yogurt now has to have "active cultures" to be worth eating. Eggs are being created with more omega-3 fatty acids. Bread is now "Wonder" soft yet made from "white whole wheat" flour so that it's nutritious again. It seems to me that food is getting so complicated with health claims that individuals are going to become increasingly confused about what they should eat. It also occurs to me that there has got to be something wrong with food that is manipulated in such a way as to "improve" upon it.

What happened to food being food?

I recently read a study* in which a pair of epidemiologists documented a large body of evidence that a diet rich in whole grains reduced the death rate for all causes. But the really interesting thing was that when they looked at individuals who got the same levels of dietary fiber, vitamin E, folic acid, phytic acid, iron, zinc, magnesium, and manganese in the diet as the whole grain eaters, they found that they did not obtain the same level of health benefits.

It would appear from this study that there is an additional health benefit to eating whole grains that cannot be obtained by eating these nutrients alone or together from other food sources. The authors suggest that it appears that "the various grains and their parts act synergistically" in a manner that means that an individual food item is more than a 'sum of its parts.'

I think that nutrition science in this country is being hijacked by commercial entities to sell products. By enhancing foods with 'good for you' nutrients they have a selling point for their products. By marketing it to us in a manner that suggests that this food item is "necessary" in our diet for optimal health, they have yet another selling point. By putting "whole grains" into children's sugar-laden breakfast cereals they convince us that we are somehow feeding them a product that is good for them!

Does anything bother you about this?

Laurie

Related Topics:

* David R. Jacobs and Lyn M. Steffen, "Nutrients, Foods, and Dietary Patterns as Exposures in Research: A Framework for Food Synergy," American Journal of Clinical Nutrition, 2003: 78 (suppl): 508S-13S

Technorati Tags: healthy eating, diet, nutrition, whole grains

Photo: istockphoto.com

The Best Exercise

2008-05-06T21:23:00.005-04:00

Look here: Doing The Perfect Push-up.

I've always said that the simple push-up, requiring no equipment and only a stretch of floor in your home (or hotel room!) is the perfect exercise, and now even WebMD and fitness experts agree! Although it offers no aerobic benefits, the push-up can be done in a way that works your whole body, and as a resistance exercise, it can help prevent osteoporosis. This is important for both women and men, both of whom may suffer from bone thinning. So in addition to your aerobic routine, add some push-ups to work multiple muscle groups, improve your core strength, and protect your bones. That's a lot of bang for no bucks!

Be well, Laurie

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Technorati Tags: pushups, exercise, healthy living

Confused by Research on What to Eat? Here's Why

2008-04-29T12:07:00.001-04:00

Readers warning: what follows is a brief review of some of the flaws in nutrition research. If you're like me, your eyes glaze over whenever you try to get through study results, and frequently you end up with a headache and no more enlightened. Please try to bear with me because I hope I put this information in plain English, and that you actually will be enlightened by this discussion.

A new study published in the April issue of the Archives of Internal Medicine suggests that the "DASH" diet reduces women's risk of heart disease and stroke, and lowers their blood pressure. "DASH " stands for Dietary Approaches to Stop Hypertension. The DASH diet is comprised of lots of fruits, vegetables, and plant proteins (beans and nuts), and is low in animal protein. It includes a moderate amount of low-fat dairy products.

The DASH diet has previously been shown to lower blood pressure and reduce "bad" LDL cholesterol. Both are factors in the risk of developing cardiovascular disease (CVD) and stroke. Teresa T. Fung, ScD, of Simmons College, Boston and colleagues studied the eating patterns of 88,517 female nurses aged 34 to 59 to determine if sticking to a DASH diet affected a woman's risk of such diseases. The women did not have CVD or diabetes when the trial started. This type of study is called an "observational" study; it takes a group of individuals and follows some aspect of their life and how it influences their health over time.

In their study the researchers followed the nurses for 24 years. Over that time they asked the women to report what types of foods they regularly consumed over the previous year. The researcher's then divided the foods into specific categories, and assigned those categories a DASH score. The more fruits, vegetables, whole grains, nuts, and beans the woman ate and the more she adhered to the recommended low-fat dairy choices, the higher her DASH score became. Scores were lower in women who consumed more red and processed meats, salt, and sweetened drinks. Women with the highest DASH scores had a 24% reduction in heart disease and an 18% lower risk of having a stroke when compared to the women with the lowest DASH scores. The authors point out that the women with the highest DASH scores also appeared to live overall healthier lifestyles. They were less likely to be current smokers, more likely to exercise, and tended to consume high amounts of fiber and omega-3 fatty acids than the other study participants. This is a problem with an observational group; the study design doesn't control for other things that might influence the study's outcomes.

I mentioned here recently that I am currently reading In Defense of Food, by Michael Pollan. In this book Mr. Pollan points out, with numerous examples, how nutrition science is very flawed. One of his examples is the Nurse's Health Study (Belanger, C.F., Hennekens, C.H, Rosner, B., et al. "The Nurses' Health Study." American Journal of Nursing. (1978):1039-40), which is not the same study currently being discussed by Dr. Fung. The Nurses' Health Study of 1978 was also a long-term observational study that collected data on eating habits and health outcomes of more that 100,000 women over several decades. It is still considered one of the best studies of its kind, yet it has significant flaws.

One of these is it's reliance on food frequency questionnaires, which appear to have been used in this DASH diet study as well. A food frequency questionnaire asks an individual to recall what they have eaten over a certain period of time. In the 1978 Nurses' Health Study the questionnaire asked such things as "Did you eat chicken or turkey in the last 3 months?" and "When you ate chicken or turkey, how often did you eat the skin?" Other questions asked about vegetable intake, and whether or not the vegetable was steamed or fried, and if fried, in what kind of fat.

Now think about your diet for a minute. When was the last time you ate french fries? When you ate them, did you fry them yourself, or did you eat them at a restaurant? If cooked at a restaurant, what are the odds that you know what kind of fat they used to cook your fries? What are the odds that you recall how many times you ate french fries in the last 3 months? How about the last year, which was the period of recall for the DASH study? Do you see how unreliable this data might be?

There are several problems with relying on individuals to report their food intake, including the difficulty with recall and knowing how things were cooked, as I pointed out above. Another problem is that people don't tell the whole truth. Scientists know that people underestimate their food intake all of the time; they have even developed scientific figures to measure the degree of error that occurs with self-reporting of dietary intake. The studies that assess the validity of the food frequency questionnaires indicate that on average people eat 1/5 and 1/3 more volume than they indicate on these questionnaires, and it is likely that this underestimates the problem. This is because scientists know that there are 3,900 calories of food produced each day in America for each person living here, yet we admit to only eating 2,000 per person. So although there is some food waste, it can't be enough to make up the other 1900 calories per person and someone is eating them!

To try to improve the odds that a person's recall is accurate, scientists match the results of the food frequency questionnaires with the results of an individual's recall of their intake in the last 24 hours, which is thought to be somewhat more reliable. But again, think about what you ate in the last 24 hours. How typical of your "usual" diet was this intake? Personally, I ate fried onion rings tonight, from a restaurant. I rarely eat fried foods, and I have no idea what kind of oil they used. So this is not in any way typical of my intake, and would totally skew my data if this were the day of my 24 hour recall.

Research into how we eat and how our food intake influences our health are full of potential errors; the examples above are a portion of those errors. Let me tell you about one more study to really make this point clear.

My mom participated in the "Women's Health Initiative" study, specifically in the Dietary Modification arm of it. She was randomly assigned to the group that was supposed to decrease their fat intake to 20% of their total daily calories, increase their consumption of fruits and veggies to 5 or more servings a day and whole grains to 6 or more servings per day. They monitored their food intake (through those dietary recall sheets), attended nutrition education sessions monthly for the first year and then four times per year for the remainder of the study. The comparison group kept us their usual eating habits, received only standard nutrition guidelines, and filled out health records every six months. This was a large group, 48,800 women, who were followed for 8-12 years.

The researchers believed that they had removed the bias that was a problem with the DASH study because they randomly assigned women to the two groups, modified diet versus usual diet. This would divide the women who tended to eat better, exercise more, and not smoke into both groups and this would result in those factors having equal influence on the outcome of both groups. This was supposed to mean that the only factor being measured was the change in diet versus the "usual" diet of the control group. But once again nutrition "science" fails us. In addition to the problems outlined above about basing data on dietary recall, consider this: women in the dietary modification arm of the study got their dietary fat intake down to about 24% at their best point in the study period and at the end their fat intake had drifted back closer to 29%.

During that same time, women in the control group were hearing in the media that "low fat" was the way to go (WHI enrollment began in 1991 and the entire study period from enrollment to completion lasted 15 years; during that time the "low-fat diet" came into mainstream media discussions and into eating vogue). Hearing this low-fat mantra meant that the "controls" began to decrease their fat intake resulting in a reduction in fat in their diets that approached the percentage of dietary fat in the study group. This influence is called the "treatment effect." Additionally there was no effort made to control where the fat came from, so women who get their dietary fat from animal sources were lumped into the same group as those who get their fats from things like soy products, avocados and olive oil! When the results were announced in 2006 the New York Times printed the headline, "Low-Fat Diet Does Not Cut Health Risks, Study Finds." This is because in the end there was likely very little difference between the diets of the two groups!

I hope that this little research lesson has both enlightened you on a complicated subject and led you to a few of the same conclusions that I have come to: nutrition "science" is fraught with research errors and it's no wonder we're confused about what to eat!

Frankly I think I'm going to follow some of Michael Pollan's simple advice, the first of which is stated on the front of In Defense of Food:

"Eat Food. Not Too Much. Mostly Plants."

How does he define food? For that you'll have to read this really great book.

Bon Appetite! Laurie

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Technorati Tags: DASH diet, heart health, Michael Pollan, In Defense of Food, nutrition research

Reading Lists

2008-04-19T02:31:00.002-04:00

I am totally dry on what to write about today, and I am overdue to post (based on my plan to try to post twice a week). So while I was staring at my blog I noticed all those blog links that are on the side of the page. I thought, do I actually read these people? I don't mean the links to the other WebMD bloggers; it makes sense to put them there because the whole point is to promote the site and many of them I actually DO read, but what about those under the heading "Blogs We Read"?

I think I'll have to see about updating that list with the people that I actually read. Who are they? Well, there's Michelle the anesthesia resident in NYC who's about to graduate and has one of the cutest kids on the planet! There's the doc in Manhattan who cooks (and supplies recipes!) and talks about medicine, especially women's health issues. There's John, the ED nurse who's a glutton for nursing education punishment (I love school too John!), and Nurse K, also an ED nurse who has a great sense of humor about the chaos that is ED nursing. Then the ED docs, Ten Out of Ten, White Coat Rants and ER Stories. The folks over at M.D.O.D represent several areas of medicine, including a pathologist, and a handful of ED docs. Finally there's Dr. Smak, a family practice doc whose young son is fighting a brain tumor. That's all my medical favorites at the moment, but then there's the gardeners...one at NPR and my current favorite. So I hope you enjoy some working links to really good bloggers; it gives me great pleasure to share them with you!

While I'm at the updating, I think it's time to update my photo too....

Have a great day! Laurie

From the editor: We liked so many of Laurie's suggestions that we added some to the list on the sidebar. Thanks, Laurie!

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Tired? Get Off the Couch!

2008-03-30T22:45:00.001-04:00

From Reuters, 2/2008:

Feeling tired all the time? The solution is a steady effort of low intensity exercise, such as a daily stroll. Researchers at the University of Georgia have demonstrated that regular exercise can increase perceived energy levels as much as 20% and decrease fatigue by 65%, particularly in those who are currently sedentary.

The researchers gathered 36 people who did not exercise regularly and who said that they were always tired; they divided them into three groups. One group did 20 minutes of moderately intense exercise on a stationary bike three times a week for six weeks. A second group exercised for the same amount of time each week, but at a much lower intensity. The third group, who served as the controls, did not exercise at all. Both groups of exercisers reported a 20% increase in energy levels over those who did no exercise, but to the researchers surprise, the group exercising at the lowest intensity reported a greater reduction in tiredness than those who worked out harder.

Patrick O'Connor and his team at the university's exercise physiology laboratory previously studied individuals with cancer, heart disease, and other medical problems and published a study in 2006 that indicated that these individuals fatigue levels were reduced by exercise; in the current study the participant's fatigue was not associated with any known medical cause. The researchers are a bit puzzled about why the group who exercised less intensely seemed to fair better than those who exercised at higher levels. "It could be that moderate-intensity exercise is too much for people who are already fatigued and that might contribute to them not getting as great an improvement as they would had they done the low-intensity exercise," O'Connor said in a statement discussing their results.

As I've previously discussed here in the blog, many of us are not getting enough sleep, and many of us are overworked. O'Connor notes that there is a scientific basis for exercising improving energy levels; I have previously read studies that demonstrated improved mood and sleep with increased exercise time. As O'Connor says, "there's a scientific basis for it and there are advantages to it compared to things like caffeine and energy drinks."

I'm glad I took that gentle stroll with the dog today; despite feeling rotten with a cold, it did make me feel better. I've fallen off my exercise habit since I returned from vacation and I can tell the difference. Let this be a reminder to all of us to rededicate ourselves to at least a little daily exercise. Now that you have proof that you don't need to work out hard to feel better, what are you waiting for?

Take care, Laurie

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Colorectal Cancer

2008-03-24T15:25:00.000-04:00

Since a close member of my family is suffering from a colon cancer I thought I would take this opportunity to remind you that March is Colorectal Cancer Awareness Month.

This type of cancer is the second leading cause of cancer death, yet it is totally preventable! Interestingly, some of the same behaviors that are appropriate for preventing heart disease like not smoking, eating lots of fruits and vegetables, and getting regular exercise have all been shown to reduce the risk of developing colon and rectal cancer.

The risk of this type of cancer begins to increase at age 40, and this is the time that you'll be asked to do stool samples for your health care provider. You may be asked to apply a small amount of stool to a card, or to bring samples to the laboratory in a special container. Either way those samples are tested for blood, because the appearance of trace amounts of blood in the stool can indicate the presence of an early cancer.

After age 50, your health care provider will recommend a screening colonoscopy. This test involves giving you IV sedation to make you sleepy, then passing a very small, flexible scope into your lower intestine (the colon) via your rectum. It can be a bit uncomfortable, but not painful, and the outcome is well worth this discomfort. This is because the provider can directly visualize any colon polyps that are present and remove them. Colon polyps are usually a type called an "adenoma," which can develop into a cancer.

If polyps are found in your colon they are removed. This stops the risk that a colon cancer will ever develop in that location. How often this test is done depends upon the results of this test: if you have polyps that are found to be adenomas you'll need a repeat test sooner (5 years) than later. If there are no polyps you may be given a period of up to 10 years before you need to have another colonoscopy. One exception to the colonoscopy after age 50 rule is this: if you have a family member who has been diagnosed with colon cancer, you'll need to start your colonoscopy testing sooner, 10 years before the age at which that person was diagnosed. Since my family member is 82, it doesn't affect my testing start, which only a few years away. You can bet that I'll get it done though, since by having this test I stay on top of a preventable cause of cancer death.

Take care and get your colonoscopy!

Laurie

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Technorati Tags: colorectal, cancer, screening, colonoscopy, prevention

The "Politics" of Food, Health, and Health Insurance

2008-03-16T22:19:00.012-04:00

Well, it's always hard to get back into the routine when one returns from vacation. This past week has been a whirlwind of getting laundry done and put away, getting back into household routines, and of course back to work. This includes blogging. Here is Sunday and I've almost been home a week already and I am just getting back to this.

It's nice to see that people are reading occasionally; it seems that I struck a cord by getting a little political in my post about childhood obesity. Seems some folks think that the government should not be responsible in any way for the country's obesity problem.

Well, lets take a look at the current effort that the government has made to educate the public about food and appropriate eating, namely the "My Pyramid" web site. Has anyone looked at this thing? I bet most of you have not, and if you have, you've walked away shaking your head, wondering how anyone thought that was actually going to help a person with a high school (or less) education learn to eat more healthily. How many people who need dietary instruction know that this educational tool exists or how to find it? How many have the computer access necessary to use it? How many get there and understand it?

Seems to me that it would be much more practical to get kids moving at school and provide them with access to healthy foods first. It's a fact that what many kids learn becomes an influence at home when the child says "let's find the healthy fast foods on the menu", or asks for a piece of fruit instead of chips. The government is already in there folks, and in my opinion they are not meeting people where they live.

One more point before I pass onto other subjects, if you think that the government is not involved in food and health, I strongly encourage you to read two books by Michael Pollan. The first, The Omnivore's Dilemma: A Natural History of Four Meals, and the second, In Defense of Food, An Eater's Manifesto. The first traces how food policy has changed the way we grow and distribute food to the detriment of both the farm land and our health. The second, which I am about 1/3 of the way into, is breaking apart much of the "knowledge" that I was taught about food and health. It seems that we may have been sold a bill of goods when it comes to the idea of a low fat diet being good for our health. But more on that when I finish reading the book.

Finally, if you are following the candidate's plans for health care in the US after they are elected, then this article will likely be of interest. Seems that Hillary and Obama aren't too far off from one another with their plans, but McCain's taking the usual tact of his party: give people money to 'encourage them to purchase their own insurance.'

Yeah, and how many of you are going to pay bills with your "economic stimulus" money rather than purchase a new item to stimulate the economy? People are basic and pragmatic. They are getting behind in their bills due to the current recession and when that check comes, I'll bet at least 75% of them will use the money to pay off a looming bill. The rest will do the instant gratification thing and spend it on an item to make them happy; but they aren't saying to themselves, "Let me spend this money to stimulate the economy."

Same with health insurance. If they are given tax credits it's not like they'll ever see cash that they can spend on insurance. If they are given cash, do you think they will know where to turn to spend their money on health insurance? Do you think they can understand how to get it, what policy will provide their family with the best coverage for their dollar, and how to fill out the paper work? I'd guess not.

In fact, I think they'd spend the money on those bills that are piling up, because right now it works just fine for them to go to the ER when they need medical care. They get assistance there to fill out the paper work for free care, and in the end it never costs them a dime for that visit. Never mind that it's not a good way to get ongoing medical care or that hospital's are having a difficult time with budgeting for all this free care. People deal with what's right in front of them, the bills or the illness, not the best option for the long road ahead.

Take care.

~Laurie

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Technorati Tags: politics, food, health, health insurance, Michael Pollan, heart disease

Vacation - Bon Voyage!!!

2008-03-07T22:58:00.002-05:00

During this week I'll be setting sail on Princess Cruises Caribbean Princess. This is my second Princess cruise and this year we're headed to the Eastern Caribbean.

I'm going to swim in the pools, soak in the hot tub, get several massages in the spa, snorkel in the blue-green waters off of the island of St. John, sail on retired America's Cup sailboats, watch great entertainment, and eat like it's nobody's business! One of the best parts of Princess Experience is afternoon formal tea, complete with freshly baked scones with real whipped cream! Last year I managed to eat like crazy and be active enough to come home only 2 pounds heavier, so wish me luck! See you in a week!

~Laurie

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Getting Your ZZZ's

2008-03-03T22:50:00.002-05:00

Reuter's News, February 28, Washington: American's habits, including late night television and Internet surfing are resulting in less and less sleep, according to the Centers for Disease Control and Prevention (CDC). So what you say?

According to experts at the CDC, lack of sleep can be a nightmare to one's physical and mental health, and sleep loss is a poorly recognized public health problem. Sleep researchers have linked chronic sleep loss with obesity, diabetes, hypertension, stroke, cardiovascular disease, depression, and increased cigarette smoking and alcohol consumption.

The CDC surveyed 19,589 adults in four states. Ten percent reported they did not get enough sleep or rest every single day of the prior month, and 38 percent said they did not get enough on seven or more days of the prior month. Surveyors talked with individuals in New York, Hawaii, Delaware and Rhode Island; they asked how many days in the prior month individuals got inadequate sleep, without asking how many hours they actually slept.

In addition to this information the CDC collected and released additional data that was collected nationwide. The combined results showed that across all age groups the number of adults who report sleeping six or less hours a night has increased significantly between 1985 and the present. The National Sleep Foundation recommends that adults get seven to nine hours of sleep every night.

According to CDC behavioral scientist Lela McKnight-Eily, who led this study, American adults are spending time doing everything but sleeping, including watching TV, surfing the Internet, or in some cases working; in other circumstances there is some type of sleep disorder or physical problem that interferes with a good night's rest. Lifestyle choices place sleep on the back burner, as if we can catch up on sleep when we have more time, such as on the weekends.

McNight-Eily is concerned that adults don't realize that sleep is very important to overall health, and that chronic sleep loss is related to deterioration in both physical and mental health. Darrel Drobnich, CEO of the National Sleep Foundation notes that each year several thousand people die in the US from motor vehicle accidents that occur due to sleepy drivers.

McKnight-Eily recommends that the first step to getting a good night's sleep is to visit your primary care provider to assess whether the sleep problems are related to lifestyle choices or a physical problem. If getting an adequate night's sleep remains a problem after physical health issues are either eliminated, individuals need to address lifestyle choices that are interfering with their sleep. Most important are establishing a routine sleep schedule that is maintained as much as possible, avoiding late-night stimulants such as caffeine and cold medications; they should also avoid excessive alcohol, which can initially put you sleep, but may later awaken you in the night with an inability to go back to sleep.

During the week of March 2 I'll be away on vacation, where I never have trouble sleeping. But right now it's 10:50 PM and I'm writing this blog when I still have to finish packing, shower, and set my clock to get up at 6 AM. Looks like I'll not be getting my 7 hour minimum sleep tonight. Have a great week!

~Laurie

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The Disconnect in Childhood Obesity

2008-03-01T10:33:00.016-05:00

Parents of many children who would be considered as overweight or obese do not see their child as being too heavy; many actually think that their child is about the "right" weight. In research published in the February edition of Diabetes Care, Dr. Asheley Cockrell Skinner of the University of North Carolina at Chapel Hill notes out that this misconception on the part of the parents means that the child will also fail to see their weight as a problem. Dr. Skinner and colleagues say that an important first step in preventing childhood obesity is the recognition that there is a problem. Without this recognition they say, families will not take steps toward diet and lifestyle changes that will prevent continued weight gain.

The researchers interviewed 104 adolescents with type 2 diabetes and their parents about their understanding of the adolescents' weight, eating, and exercise habits. To assess ideas about weight the teenagers and their parents were asked if the teen was "very overweight, slightly overweight, about right, slightly thin, or very thin?" Among the teens in this group, 87% were overweight by standard measurements (weight, BMI), yet only 41% of their parents and 35% of the teens considered their weight to be a problem. Among teens whose BMI was above the 95th percentile 40% of parents and 55% of the teens thought that the child's weight was "about right." For both parents and teens an underestimation of weight was associated with a poorer dietary choices and exercise habits.

The frequency of obesity (BMI greater than the 95th percentile) among adolescents in the US was 4.6% among teens 12-19 years old in 1963-1970, and 6.1% between 1971-74; it rose to 15.5% between 1999-2000. Research has shown that there is a strong relationship between childhood obesity and insulin resistance (a marker of early diabetes) in young adults. Clearly something must be done to improve understanding of what overweight and obesity are, and their implications for health. As these researchers point out, "addressing misperceptions of weight by adolescents and their parents may be an important first step to improving weight in these patients."

One approach may be addressing the kids directly through school programs that target increased activity. In one trial of students in California, decreasing TV viewing and video game playing from 12 to 8 hours per week led to a smaller increase in BMI among the study group versus the controls who continued their usual level of TV and game activities. A "Kids 'N Fitness" program that promotes health and wellness in classrooms across the US has shown to decrease weight among at-risk children.

At my age we laugh about how we used to hear our parents and grandparents say, "when I was a kid..." but now we're in their shoes, aren't we? When I was a kid, we weren't allowed more than an hour of TV a day, and that hour was carefully chosen. When we got home from school we had a snack and then it was out the door until dinnertime to play, actively, with our friends. I was an adolescent in that period between 1971-74, when the obesity rate was 6.1%, and I know why. When is this country going to put physical activity back in the schools and make an active effort toward public education about the consequences of obesity? Isn't it time we stopped wasting money on wars, and created a budget that provides healthcare for all, and TV advertising to compete with Coke, Pepsi, and McDonalds?

Take care and have a salad today, Laurie

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In-Flu-End-za?

2008-02-25T14:52:00.000-05:00

We're seeing a lot of flu "A" in my emergency department. The local university, my grad-school alma mater notes that despite the having the greatest number of students vaccinated this flu season, they also have the greatest number of students on campus who have been diagnosed with flu. So what happened? Vaccine mismatch - that's what.

Each year in February experts meet under the authority of the Food and Drug Administration to decide what flu strains will be included in the vaccine for the following flu season. They try to predict which virus strains will be the most likely to spread in the following year.

Flu season begins in the Far East and this data is used to help predict what will strike the US, but like all medicine, this prediction is partly scince and partly art (a guess based on knowledge). Most years the prediction is fairly accurate, but this year the experts and the manufacturers didn't so so well. Last winter they recommended a certain strain of flu "A" be included in this year's vaccine, but the manufacturers weren't able to find samples that would grow properly in the production process.

Unfortunately for those of us out here on the front lines, this missing strain of flu "A" is the most prevalent one we're seeng this year, accounting for about 60% of all the cases of flu, and next year's production may not be any better. For the first time ever the expert panel has recommended a complete change of next year's vaccine. Each year the vaccine is "travalent," meaning that it is made up of the three currently most common strains of flu; manufacturers have been asked to completely overhaul next year's vaccine, which may make production difficult. It may help that two of the three newly recommended strains were included in the 2007 vaccine for the Southern hemisphere, making it possible that manufacturers will have a bit of a "jump start" on the new production plans.

Let's hope they're right! This year's vaccine is about 85% effective at preventing illness in young, healthly individuals, despite my alma mater's experience. Unfortunately college students aren't really my biggest concern; it's the elderly, the very young, and the chronically compromised that I have to worry about, and this year the vaccine has let them down. Let's hope we get it right in 2008-09.

Wash your hands and stay well! Laurie

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How's Your Blood Pressure?

2008-02-17T22:51:00.001-05:00

How's your blood pressure? Are you at "goal?" Controlling blood pressure is critical to one's cardiovascular health. It is a well-established fact that when a person has uncontrolled hypertension (blood pressure or B/P) there is a significant increase in the risk of heart attack and stroke. Yet despite this well-known fact, the rate of good B/P control has reached a plateau in men in the US, and rates of uncontrolled hypertension in women are actually rising!

In Washington, DC and many southern states one in four women has high blood pressure that isn't well controlled, a deplorable fact given how much we know about blood pressure management, how many inexpensive medications we have available to us, and how many options there are to health care providers to refer their patients to dietitians and exercise programs such as cardiac rehabilitation to learn the lifestyle changes that will lower blood pressure!

In the study that documented these trends, which appears in the February 11th edition of Circulation, study author Dr Majid Ezzati (Harvard University, Boston, MA) notes that while some states are doing better than others with blood pressure control, the trend is consistent: Men are not gaining any better control and women's blood pressures are actually worsening overall.

Dr. Ezzati speculated that some of the contributing factors may be the obesity epidemic, which is hitting women harder than men, and the fact that women are less likely to have access to good health care. Dr. Ezzati also suggests that health care providers may have become complacent about measuring B/P at office visits and addressing numbers that are out of range.

He notes that providers can be reluctant to add medications to the patient's regimens and that they often don't address lifestyle changes. I know that I often hear from my colleagues that they don't have time to address lifestyle changes in a short office visit or that they don't bother, because they don't believe that patients are likely to make behavioral changes. I don't buy that though, as there is evidence that that when a health care provider takes the time to address a needed behavioral change and links that need to the patient's current health status, the patient is more likely to make that change. As an example, I am more likely to get someone to consider stopping smoking if I say to them, "Your chest x-ray shows evidence of damage to your lungs from your years of smoking. You should talk to your health care provider about how s/he can help you to quit smoking." I do this all the time in the ED, and I said something similar to people when they were under my care as a primary care provider.

One of Dr. Ezzati's theories may have been upheld in another recent study, which suggests that both gaining a patient's agreement to follow a medication plan and increased medication prescriptions are needed in order to control B/P. In a study designed to examine barriers to blood pressure control over time, lead investigator Dr Michael Ho (Denver Veterans Affairs Medical Center, CO) reported that although it is important to increase therapy by adding medications, it also matters whether or not a person is actually taking their medications as they are prescribed.

The study looked at 10,000 individuals with hypertension and cardiovascular disease in a managed care setting. The results indicated that approximately 1/3 of patients in the group with consistently elevated B/P did not have either an increase in the dose of their current medication or additional medications added. Another third of the patients had medication changes made by their health care provider, but did not take them as prescribed. Dr. Ho emphasizes that communication between the prescriber and patients is critical to improving outcomes. He notes, "Doctors all want to bring blood-pressure levels under control, but sometimes intensifying therapy might not be the right approach. The correct response might be to simply get the patient to take the medication."

I could not agree more and I have to point out that the best health care providers are those who encourage communication between themselves and their patients, by knowing what questions to ask and how to ask them in order to find out if the medications are being taken correctly. These include, but may not be limited to:

"How often do you forget to take your medications?"

"Are you able to afford the medications that have been prescribed for you?"

"Do you have any trouble taking your medications the way they are supposed to be taken?"

These questions assume that sometimes we forget to take our medications and that it's ok, and gives one an opportunity to strategize with the person to find memory aides that will help them remember to take their medications. It also gets to the root of potential financial problems with obtaining meds and allows the provider to seek out less expensive alternatives to current prescriptions.

Finally, these questions allow for any other concerns the patient has to be brought to light, for example how to schedule medications safely. I once had a patient reveal to me that she'd been getting up in the middle of the night to maintain the medication schedule given to her in the hospital, when she could have easily adjusted her medications schedule to her usual daily home routine. She would not have done that for long, I can assure you! She would also have stopped taking the medication before she would have admitted to me that she wasn't willing to get up in the night, assuming that I'd think less of her because she didn't make her medication-taking a priority. So it pays to ask, and in an inviting manner if you want to hear the truth.

Take care, Laurie

Related Topics:

Your Healthy Heart: Women's Guide

10 Ways to Control Your Blood Pressure

Technorati Tags: hypertension, heart disease, heart health, blood pressure, obesity

Romance is Good for Your Heart

2008-02-13T13:46:00.000-05:00

My plans for bi-weekly posts went out the window this past week due to a family member's surgery. It was elective, but things never go quite as planned, do they? As the token member of the health care community in my family I spent some time at the hospital, and gladly, but that meant I didn't post as planned. Things are going great there now, and I hope to return to my posting plan. I am even going to try to get ahead, so that there will be posts to go up while I'm away on vacation in a few weeks. We'll see how that goes; sometimes I'm a crazy person thinking that I can accomplish all the things on my list!

Thursday is Valentine's Day of course. Here are a couple of interesting valentine facts: the US Greeting Card Association reports that nearly 1 billion greeting cards are sent in the world for Valentine's Day; this makes the holiday second only to Christmas in terms of cards sent. They also estimate that 85% if these cards are sent by women; no surprise there I think!

Although Valentine's Day was originally acknowledged as a celebratory holiday for various early Christian martyrs named Valentine, the first written association with romance appears to be a poem written in 1382 by Chaucer (The Canterbury Tales), called the Parlement of Foules. It was written to honor the first anniversary of the engagement of King Richard II to Anne of Bohemia ,who were married at age 14.

Here at Web MD there is a great article about the benefits of chocolate for your health that will make it that much easier to indulge your sweet tooth this week. I didn't know that it's botanical name, Theobroma cacao, translates to "food of the Gods." For those of you thinking about a little romantic interlude with your Valentine it might be a good idea to eat a little dark chocolate together. It contains the chemicals phenylethylamine and serotonin, which are thought to be mood boosters and mild sexual stimulants.

Planning a Valentine's Day meal for your loved one? Think about your menu carefully and you could make it romantic and heart-healthy! How about starting with a glass of red wine (130 calories, 5 grams of carbs)? It's flavonoids have an antioxidant effect in the body, may raise HDL ("good") cholesterol levels and may help prevent blood clotting in vessels.

For appetizers, try a seafood item, such as shrimp cocktail: three ounces have only 130 calories, 1 gram of fat, and 12 grams of carbohydrate. But here's the good part, it's a low-fat, high-protein treat that contains lots of zinc and mood-brightening, heart-healthy omega-3 fatty acids. Avoid frying your seafood appetizer, which really increases the calories and heart-unhealthy fat. For your main course, try broiled salmon with steamed vegetables (about 590 kcal, 40 g fat, 5 g carbs). Choose colorful vegetables that are high in flavenoids, which boost immunity and heart health. The protein in this meal choice can also increase the production of dopamine, a mood enhancer that will make you feel good.

For desert try chocolate-dipped strawberries: 6 berries contain 180 kcal (that's only 90 for each of you), 9 g fat, and 24 g carbs. Strawberries contain anthocyanins, which are chemicals that improve blood flow to the body, so of course that's good for your heart!

While planning that romantic dinner for two, keep in mind that just being in love can improve your health. Various investigations have shown that loving relationships can help prevent plaque build-up in the arteries and protect against cardiovascular disease, boost the body's disease-fighting antibody levels, reduce levels of stress hormones, and lengthen our lives. All good reasons to treat that special loved one to a special Valentine's Day treat!

Happy, Heart-healthy Valentine's Day to all! Laurie

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A Vote for Health

2008-02-04T11:17:00.000-05:00

Among the current headlines at WebMD is space dedicated to the US Presidential candidates and their positions on health care. Please read this and anything else that you can find about this topic. Then please, vote - vote with you mind, heart, and information! Health care is a critical issue to this election and although I won't try to unduly influence you, here a few thoughts from someone who lives in the system every day, trying to do my absolute best to take care of you and your loved ones.

The US health care system is a bit broken, but it's not a total disaster. There are lots of really great health care providers - docs, NP's (nurse practitioners) and PA's (physician's assistants) - out there working really hard, but there aren't enough of us. Putting restrictions on the reimbursement and ability to practice of advanced practitioners such as NP's and PA's just further handicaps the system, especially in rural areas.

There are great, good, not-so-good, and really bad health care providers in all walks, be it MD, NP, or PA. People should be scrutinized on an individual basis for poor outcomes, not on the basis of their degrees and initials. There is enough work for all of us, and given the declining enrollment in schools for all primary care professions (but especially medical doctors) and the increasing numbers of "boomers" in the system, the country is going to need all of us that it can get!

An emphasis on prevention and wellness promotion is a very good thing. Many candidates SAY they endorse this. My apologies in advance to all of you who are struggling with your weight, or smoking cessation, or addiction, but the system has to stop coddling these behaviors. We need an insurance system that provides people with the support, tools, educational resources, and incentives to improve their health.

We need a system that helps people to find someone to take care of them as a primary care provider and discourages use of the ER for every little sniffle and sprain. By discourage I really mean penalize for misuse and abuse. But first we need to make options for them to do otherwise readily available. In my opinion we have to stop paying for visits to the ER like I see every day, in which an individual says to me, "I have an appointment with my doctor later today/tomorrow/2 days from now, but I just couldn't wait any longer for this stubbed toe/sore neck/ankle sprain/cough I've already had for 2 weeks" (or insert your favorite simple problem here).

We need to give incentives to companies to pay for employee wellness programs and to include adequate breaks in their day for exercise. There are any number of research studies that demonstrate increased worker productivity on the job and improved overall health when they are given the opportunity for a 20-30 minute exercise break or organized stretching session during the work day. So what if companies lose an additional 1/2 hour of work time if the time that is actually spent working is more effective?

Insurers need to provide adequate incomes through reimbursement to health care providers for both sick care and "well" visits in which people are taught to control their diabetes, cholesterol, or diet, or make a quit smoking plan. Health care providers who make the effort to become certified as specialty educators, (certified diabetes educators are one example) and maintain that certification through continuing education, should not have to fight to be reimbursed for providing diabetes education to patients. When a person with diabetes learns enough strategies and effectively applies them to reduce their overall blood sugar readings to a certain degree they decrease their risk of developing heart disease by 25-35% Tell me that doesn't save money!

Finally, we need to find a way to control malpractice claims. There is a role for personal responsibility in health care, and I shouldn't have to look over my shoulder every minute worrying about whether or not an individual is going to follow my instructions and return to see me in the office or the ER if something in their condition changes.

Your vote is an opportunity to influence the country's progress for the next four years. The ability of our country's health care system to improve health outcomes and controlling costs is critical to the health of hundreds of thousands of baby boomers who are coming of age. Please consider your vote thoughtfully.

Take care,

Laurie

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