Sitting in your car in a drive thru window is the new smoking!

 In a new study in the British Medical Journal it was found that between 1980-2010 people in Cuba were significantly healthier during the economic crisis from 1991-1995 when gas and food access were severely limited and people were forced to eat less and walk/bicycle more. Following the resolution of the economic crisis in Cuba the percentage of active adults declined from 80% to 50%, the average person gained 12 pounds, the percentage of obese adults increased by 20%, and diabetes rates almost doubled! Again, it's not surprising that increasing the amount we exercise and reducing the amount that we eat greatly improves our overall health.  I think that it is human nature to conserve energy and find easier ways of doing things such as calling someone from your car instead of parking, walking to their front door, ringing the doorbell and walking back to the car. However, I believe that in the next few years we are going to see more and more studies that reveal that our technological advances are in some ways ruining our health. We are living longer because of advances in medicine but in order to enjoy our prolonged lives we must stay active and the more we can leave our cars behind and take a few extra minutes to walk the better we will be. It is worth clicking through to check out the the BMJ article for a really cleverly designed and thoughtful medical study!

You’re not crazy, there really is something wrong with you!

You’re not crazy, there really is something wrong with you! 

In a 2007 study in the Journal of Clinical Psychiatry, over 900 patients who came to primary care visits were questioned about anxiety and depression.  Amazingly 30-40% of the patients questioned reported symptoms of anxiety and depression and more importantly these patients reported more impairment in their daily lives than people with diseases such as diabetes and heart failure. 

“When compared with patients with congestive heart failure, patients with moderate to severe anxiety or depressive symptoms reported worse bodily pain, vitality, social functioning, role limitations due to emotional problems, and mental health. Furthermore, patients with depressive symptoms also reported worse general health. The only area in which congestive heart failure patients reported worse functioning was in the physical functioning domain.”

These statistics are congruent with what I see in my office and people are always surprised when I ask them if their anxiety is limiting their social, work, and family functioning. When questioned, most people who I suspect have anxiety and depression report that their lives are significanty impacted by their depression and anxiety, but they are reluctant to seek therapy either medical or psychological for a variety of reasons. Most commonly, people state that they don’t believe that a psychologist can help them and even more commonly people are afraid that if start medications they will be on the for the remainder of their lives. When I tell people they have diabetes or early congestive heart failure, people very rarely decline therapy or testing despite the fact that most of them do not have physical or emotional limitations secondary to their disease. 

Before I treat people for anxiety and depression in my practice I try and identify whether or not it is present by asking a few questions at the annual exam. Only in he most severe cases do I offer medications at the initial diagnosis. More often when I suspect depression or anxiety and even Premenstrual Dsyphoric Disorder (PMS), I try and address lifestyle changes that have been proven to decrease anxiety and depressive symptoms. 

For all patients who I suspect may be suffering from anxiety and depression I recommend a few very basic lifestyle changes

1. A minimum of 30 minutes of cardiovascular exercise or yoga daily
2. Regular sleep of 7-9 hours nightly
3. 30 minutes of sun exposure twice daily if possible. 
4. Low fat low carbohydrate diet

These lifestyle changes typically will help with emotional stability and overall mood. When I see patients back in my office almost everyone who has adhered to these recommendations feels better. However, when I see people back for anxiety and depression, most people will report feeling better but continue to have daily symptoms that limit their overall function. For this population I usually recommend psychologic therapy and the addition of SSRI medications such as Prozac, Paxil,  or Lexapro with little reservation because I understand the severe impact that depression and anxiety can have on peoples lives and further feel that side effects of these medications are minimal compared to the lifetime impact of untreated depression and anxiety. 

Donate Your Diesel

As I mentioned in a past post "Dollars for Doughnuts", people do significantly better with exercise and weight loss when they are motivated by an external (usually monetary) reward. Charity Miles is a great app for anyone who does any walking, running or biking.  Using the app you can choose a cause and they will donate money to your charity of choice for every mile you run, walk or bike. I particularly like the social media aspect of this as it allows your friends to support you and track the good work you are doing for yourself and your charity. I think this positive feedback will propel people to exercise even on the days they feel like sitting at home and having pastry and reading the paper!





 

Why does my doc care about my cholesterol?

         For the past 30 years doctors have been able to measure cholesterol levels and use that information to lower the risk of coronary artery disease. When a cholesterol plaque ruptures within your coronary artery a small clot forms over the plaque and a heart attack occurs. It is for this reason that I work so hard with patients to lower their cholesterol levels. Typically when we check cholesterol we check 5 components: Total Cholesterol, HDL (high density lipoprotein), LDL (low density lipoprotein), Triglycerides, and I like a Cholesterol/HDL ratio. There are a number of other particles that can be checked including Lp(a) and Apoprotein (b).

The LDL is what has traditionally been the biggest concern to doctors as it is the primary contributor to cholesterol plaque formation. Ideally, LDL values will be less than 130mg/dl in healthy people and we try to get them below 70mg/dl for patients with diabetes or known coronary artery disease.  We think of HDL as the scavenger or repair brigade, these particles repair damage to artery walls so that cholesterol plaques do not occur, the higher this number is the better, ideally over 50mg/dl in adults. The triglycerides transport fat in our bodies and are not an independent risk for coronary artery disease but they are indicators of Metabolic Syndrome (high triglycerides , low HDL, elevated blood sugar, and hypertension) which make diabetes and coronary artery disease more likely. The ratio of Cholesterol/HDL ratio provides us what proportion of total choles terol is the good cholesterol and we like to see this ratio less than 5.0 (i.e. Total Cholesterol 180mg/dl/HDL 50mg/dl=Ratio 3.6).  Other risk factor for coronary artery disease that we can modify are smoking and hypertension. 

A simple tool that you can use to calculate your risk for coronary artery disease is the Framingham Risk Calculator. The Framingham Risk Calculator was developed using data that was collected during the The Framingham Heart Study which analyzed approximately 5000 men and women from Framingham Massachusetts for over 50 years to determine risk factors for cardiovascular disease. Using the Framingham Risk Calculator we can determine whether or not a patient between 34-74 years old needs medical management of their risk factors for cardiovascular disease. Interestingly, we only can hypothesize about people older and younger than 34-74 years old, but  we can infer that having a good cholesterol profile, a healthy diet, an active life style, and blood pressure awareness prior to age 34 will lower your risk of having cardiovascular disease. I think we will look at other risk factors to help us predict who will develop cardiovascular disease including genetics, infections and associated systemic inflammation, and other small cholesterol particles. For now, I think the most important thing you can do beyond having your cholesterol measured is to stay active and eat a low fat, low cholesterol diet. 

Dollars for Doughnuts

An interesting article came out this week in the Annals of Internal Medicine which reported that people lost considerable weight when give financial incentives compared with people who were encouraged to lose weight because of long term health benefits. In addition, the greater/stronger the reward the more weight people lost. Participants were obese workers at a Children’s hospital in Philadelphia. Participants were divided into 3 groups which were followed over 6 months. The first was an individual payment of $100 per month if you met your weight loss goal, the second was a group payment of $500 where 5 people were eligible to divide the pot among all participants who met the goal, and the third group were asked to lose weight because of long term health benefits and were weighed and encouraged each month but had no financial incentive. Not surprisingly, the people who had the most to win (the $500 pot) lost the most (10lbs ) followed by the $100 dollar group (5lbs), then the no financial incentive group (1lbs). In 12 weeks following the study most of the participants gained the weight back, but some of the weight loss persisted across the groups. 
One interesting insight was that when people are challenged to do something and offered a meaningful reward they can learn new ways of doing things, or reprogram their brain. In the study people who had been obese for some time were able to learn restraint from poor food choices and engage in exercise because they were going to be rewarded. Once the incentives were taken away, the new learned behaviors persisted for some time but eventually faded. 
The study was done to look at strategies that employers could use with the upcoming implementation of of the Affordable Care Act to lower their potential health care costs by encouraging overall better health of their employees. Practically, this study can be applied in our daily lives. Why can’t we incentivize ourselves with a monthly massage or other luxury if we make our goal weight, or form groups to participate in Biggest Loser type competitions with meaningful prizes . The evidence seems clear that if an individual is trying to lose weight they need to be incentivized beyond the health benefits of healthy eating and the benefits must be extended indefinitely. Practically, long term financial incentives do not make sense for all employers but for individuals, families, and groups of friends it is easy to see how by shifting the lens from “I need to lose weight to be healthy,” to “If I lose weight I get something pleasurable,” will lead to better long term weight control and people will reprogram their eating habits. The term for this phenomena is “cognitive restraint” in other words people do better when they are asked to choose between doughnuts and dollars than doughnuts and an abstract concept such as long term health. If cognitive restraint is practiced long enough hopefully the healthy eating habits will replace the old poor eating habits and monetary reward will be replaced by good self esteem and positive reinforcement from our friends and family over our new healthy appearance. 

Just go to the doctor and get that taken care of!

I’m under 50 years old and healthy, do I need to see my doctor every year? 

Surprisingly the answer to this question for both men and women is no, however when poled both physicians and patients overwhelmingly believe that the answer is yes. The premise is that at annual exams of asymptomatic healthy people tests are ordered every year that may need to be ordered less frequently driving up overall healthcare delivery costs. These tests such as blood count, kidney and liver function tests, and cholesterol levels are often checked yearly and the truth is that they probably need to be checked every 3-5 years in a person who is asymptomatic and has normal baseline labs done at some point in the past 5 years. 

Recently, I was speaking casually to a group of 40-45 year old men and women who were praising their doctors’ thorough annual exams where he or she reviewed extensive labs, including annual EKGs and chest X-rays, conducted a thorough exam and conveyed a very deep understanding of the patients overall health. There is no evidence to suggest that these labs and tests do anything in the long term to improve patients overall health. I suspect that it is the conveyance of a deep understanding and connection to our patients that makes the annual physical exam seem so important to all involved.

Should you stop going to your doctor every year? Despite the evidence that suggests that annual exams do not improve patient health, I believe that they are important as the majority of people are not asymptomatic by the time they are 25 years old. On a daily basis, I answer a variety of health, diet, and exercise related questions as well as dispel false pretenses that patients have. There is a plethora of medical information out there and people are generally overwhelmed by the data and want to know what they should be doing and how the medical information relates to them.  This data can create a tremendous amount of anxiety for patients that leads to its own problems. 

An annual exam gives me the chance to see my patients, form a connection to them, and answer questions that they have. We review family history and social history. We talk about current health issues in the media and how it should effect them. We talk about what screening is appropriate and what’s not and have a chance to look at blood pressure and weight.  Most importantly I think that patients leave with a sense of well being that gives them one less thing to worry about. Knowing they are healthy and that that they have been heard and their concerns addressed conveys a sense of well being that may not be able to be calculated on a cost basis. 

Food for Thought-Are Organic Foods Safer and Healthier?

The Annals of Internal Medicine published a study in September 2012  that asked the question are organic foods safer and more nutritious than conventionally grown foods. An interesting question given that the organic food business has grown from $3.7 billion dollars annually in 1997 to $27 billion dollars in 2010. The analysis yielded no significant difference from the perspective of health risks and benefits after comparing the outcomes of 240 seperate studies that met strict inclusion criteria. There was no significant difference in vitamin content, heavy metal presence, or prevalence of bacterial contamination of the various meats and vegetables.  Not surprisingly, organic foods had 30% lower contamination with pesticide residue and lower likelihood of contamination with antibiotic resistant bacteria. However, there was no difference in  the overall contamination with pathologic bacteria in conventional vs organic foods. Finally the study mentioned that there are no long term studies looking at the health benefits in populations who consume organic foods vs conventionally grown foods. 

My Thoughts: 

If your family is like mine we try and buy locally grown organic foods when possible.  This study and its outcomes will not change my buying practices but it will make me less concerned about giving by child a glass of milk that is not certified as organic or a conventionally grown banana. I think that ultimately the most important component of diet is the foods you choose as opposed to the technique used to grow the particular foods. Sensible portions of a low fat, low cholesterol diet, that have very limited exposure to processed foods probably makes the most sense. Regarding choosing organic vs conventionally grown foods the article suggests that making the decision to choose organic foods  may be more of an environmental and ethical decision than a decision based on nutrition and health. Until a study comes out that looks at the long term benefits of eating an organic diet, I think we should not blindly accept that eating an organic diet will make us healthier. If you are interested in learning more about these topics, two websites that I've been following recently are ThePlantEater and LivingMaxwell. 

What's a Concussion?

What’s a concussion and what should I do if I think my child has one? 

A concussion is the result of a head injury that causes a disturbance of brain function. 

Typically a concussion will result in confusion, “feeling foggy”, difficulty concentrating, poor balance and visual problems. There are other symptoms as well but these are the most typical symptoms. Concussion symptoms usually resolve within 3 days, occasionally last for a week, and rarely last longer than a week. Concussions are difficult to prevent but it is possible to limit the long term impact by recognizing and treating a concussion appropriately. 

What should I do? 

“When in doubt take them out!”

If you think your child has a concussion they should be removed from the activity and not allowed to return until they are seen by a doctor or medical professional. If your child has a concussion, their activity should be limited to resting until their symptoms fully resolve. That means no sports, no vigorous activity, no video games, and no loud music. 

What will your doctor do?

The vast majority of time your doctor will not order an MRI or CT scan as there is rarely any useful information revealed by these tests. If your child seems to be getting worse the doctor may order one of these tests, but this is rare.  Your doctor will do a series of tests of memory, concentration, and balance, which are performed in the office.  Once your child can pass these tests their concussion will be determined to be resolved. 

When can my child return to there sport? 

After your child fully recovers from their concussion your doctor will talk to you about “Graded Return to Play.” Essentially every 24 hours for 5 days, your doctor will advise you to gradually increase your child’s activity. If your child passes all these tests, your doctor will advise you that your child can return to full activity. 

Common Questions

1. Do I need to wake my child from sleep if I think they have a concussion? No, nothing will improve or change by waking your child and they will seem groggy when you wake them
2. What should I worry about? If you think your child is getting worse, they are more drowsy, weak, or having symptoms that don’t make sense to you, take your child to the Emergency Room or your doctor. These symptoms can rarely be assessed well by a doctor on the phone
3. What is the biggest mistake I can make? Letting your child return to play before your doctor says it’s okay. 
4. Is it okay to give my child Tylenol or Advil?-Yes, but before they return to play your doctor will want to make sure they are no longer taking these medications for their symptoms