Understanding Risk

September 22, 2009

Every medical intervention has risks and benefits. As an internal medicine physician, it's my job to help manage risk for my patients. I keep an eye on your risk for a heart attack, the risk of medication side effects, even the risks of surgery. But over the years, I've learned that doctors and patients don't always understand risk the same way. Lots of patients only think of the benefits,whereas others only see risks. It's similar to the old adage about seeing a glass half empty or half full!

This doesn't mean you should assume that medical care is a game of chance. Far from it! We have a strong arsenal of knowledge and a wide range of treatments that can help keep you safe. But as a patient, you do need to understand that practicing medicine is actually a series of judgments about risk. The more you know about how doctors think about risk, the more you'll be able to participate in your care and ask smart questions about your health.

It's common for a doctor to tell a patient that his or her risk of a heart attack is high, or to say, "If you don't lose some weight, you'll end up with diabetes." But what do those statements really mean? It turns out that your doctor's assessment of risk might not be the same as yours. Researchers have shown that different people can have very different ideas about what words like "rare" and "common" mean. Interpretations can even depend on what you're discussing. Before you make a decision based on something your doctor says about risk, make sure you're both on the same page.

Once your doctor has drawn a conclusion about your risk, he or she will usually use that information to help make decisions about treatment. One example of how this works is the use of risk calculators, which are worksheets or computer programs that tally up different types of health information and estimate your chance of having a problem like a heart attack, stroke, or cancer. The Framingham risk calculator is a common one. Based on age, gender, cholesterol levels, blood pressure, and smoking status, it estimates how likely you are to have a heart attack in the next 10 years. (You can try it yourself at Framingham Risk Calculator.) Doctors use the results to help us know when to start medication for high cholesterol, or prescribe aspirin to help prevent a heart attack. What we're really doing,though, is deciding at what point the benefits you'll gain from treatment are large enough to make a significant change in your risk -- and at what point benefits from treatment will likely outweigh any risks the treatment brings.

My patients often believe that if a doctor prescribes a drug, it must be perfectly safe to use. But, what does "safe" really mean? When the Food and Drug Administration considers approving a new drug, they're weighing risks and benefits, too. Each medication goes through three types of tests. Phase I studies are designed to see how the drug works in the body. They involve small groups of healthy volunteers. Phase II trials test the drug in people who have the illness it is supposed to treat, demonstrating that it works and establishing the correct dose. Phase III trials are usually much larger. They provide more evidence that the drug does what it's supposed to do, and they're also the main source of information about the drug's safety and side effects. With some drugs, Phase III trials show that there are hardly any side effects at all. With others, side effects may be troubling or even dangerous. Sometimes, most people who take the drug do well, but for some reason -- maybe genetics -- there are a few who can't tolerate the medication.

In all these situations, the FDA can still approve a drug, as long as it's more likely to help certain patients than to hurt them. So why doesn't your doctor explain all this when he or she writes you a prescription? Some doctors hesitate to tell you about risks because they don't want to scare you. Others aren't sure you’ll understand the numbers. Often, doctors are so rushed for time, they don't want to get into a math lesson! But it's important that you bring up questions you have about potential treatments.

Once you understand that risk is a normal part of medical practice, you'll be able to ask your doctor the important questions and get a sense of what's behind his or her recommendations. Here are some of the questions you might want to bring on your next visit to the doctor:

• What is the risk that an average person would develop this disease? How does my risk compare?
• How likely do you feel it is that this therapy will work for me?
• How often does this side effect happen? Were the people in the study you're describing similar to me?

With these answers, you can decide along with your physician whether a therapy is best for you.

To Sleep, Perchance to Dream...

July 27, 2009

Can you believe the lazy days of summer are almost over? When I think of summer and being lazy, I like to think of sleeping...mostly thinking about how I would like more sleep. Too many of us seem to believe that sleep can be optional, or that we can minimize the number of hours we sleep so we can seemingly be more productive. But did you know that sleep may actually make parts of your brain bigger and help it recover from injury? Like most things in life, it’s about moderation - you don't want too little sleep, but then again, you don't want too much sleep.  How much is enough?

According to the National Sleep Foundation, teenagers should getup to 9-1/2 hours of sleep a night, and adults from 7 to 9 hours. If you're like most folks, getting enough sleep can be challenging.  And I know many of you have trouble falling asleep or maintaining sleep. So here are some tips to get those 7-9 hours of restful sleep.

• I'm sure you've heard to keep the room as dark as possible.  The reason why is that the dark apparently triggers your brain to release melatonin, a hormone that helps with sleep.
• Many of you know not to eat right before going to bed or your digestive system will keep you up. However, a glass of warm milk an hour before bedtime might help. It has a substance called tryptophan which is broken down in your body into serotonin which helps induce sleep. Other foods with tryptophan include turkey, honey, oats and bananas. Eating a bit of these foods (don't go eating a turkey sandwich at 9 pm!) will enhance this sleepy effect by increasing the level of tryptophan in the blood.
• Cut down on the alcohol. It doesn't help with restful sleep. Studies show it can cause shallow sleep, night sweats, early awakenings, as well as headaches.
• EXERCISE! The more active you are during the day, the better you will sleep that night. Just avoid doing it right before sleeping because the hormones that exercise release will keep you awake for a while.

Follow these tips and you can enjoy the remaining days of summer!

Letting The Sun Shine In

July 09, 2009

Do you wear sunscreen? I bet many of you don’t! Unfortunately, nearly one third of Americans still don’t wear any sunscreen. And yet, the evidence is clear: you don’t even need to get a sunburn...just being in the sun increases your risk of skin cancer. There are lots of wrong ideas floating around out there, which might explain why skin cancer is the fastest growing cancer in men right now, and the second fastest in women.

Here are some tips to keep you out of the danger zone:

• Put on sunscreen at least 15 minutes before going into the sun. How many of you had planned to put it on at the beach or the pool, and then you forget about it once you’re there?  It’s happened to all of us...don’t make it a habit.
• I tell all my patients to wear sunscreen under their clothes. They often look at me funny since most of them believe that if you are wearing clothes you don’t need sunscreen. That’s a myth!  Sun rays penetrate clothing.  A white shirt typically has the equivalent SPF of only about 4. That means your skin might start to get damaged in about 1 hour without more protection. 
• While we’re on the topic of clothes, wear clothes with tighter fabrics, in darker colors, and keep them dry to let less sun through.
• Don't think that because your skin is dark you are safe! Paler-skinned people do get more skin cancer, but darker-toned people can get it too, often under the nails and on the soles of the feet, and it is often not caught in time! With skin cancer, timing is critical...it is almost completely curable if you get it early. If not, it is very hard to treat.
• Ditch the tanning beds; they are not a safer way to get color. Twenty minutes on a tanning bed is like spending four hours under the sun.  I know you may think it makes you look healthy, but there is no such thing as a "healthy" tan.
• Wear non-shiny lip gloss; the shiny ones make your lips more vulnerable.
• Protect your children! Children can get skin cancer too, so check your kid’s skin, and remember: getting sun damage when you are young gives you more risk for cancer than getting sun damage when you are older.

Preventing skin cancer can even be romantic! After a long day at the beach, try undressing in front of your honey to look each other over, head to toe. A likely spot for skin cancer is on your back, especially in men. Women should especially check their legs. Even look on your scalp, between the hairs! You can also use a mirror and some creative yoga to check those hard to reach spots. Skin cancer can happen on any part of your body, even the places that don't see the sun. Only one third of us have ever checked our skin for cancer.  Three out of four skin cancers are found not by doctors, but by patients and their families, so go for it!

With these few small steps, you are all set for some fun in the sun.

What Are Your Pet Peeves?

June 29, 2009

We all know that stress impacts our health. Our daily goal should be to reduce stress. That's a tall order, since life seems to be getting more stressful. Let me share with you some of my pet peeves that cause me a lot of stress.

Aisle Hogs. If you sit on the aisle in an airplane, you cannot go to sleep. I can't tell you how many times I've been in a middle seat on a cross country flight and the person next to me decides to fall into a deep slumber (except of course to miraculously wake up for food!). Given the decreasing size of seats and the growing size of people, it's impossible to either climb over them or wedge between the seat and the person without touching either. Honestly, it's like you're a hostage! So if you want to sit on the aisle, ya gotta stay awake.

Parking Incompetents. I park at a Starbucks every morning on the way to work. Yes, I know....I am addicted to caffeine! But my peeve is when SUVs occupy two spots. Or worse: when they park in the spot next to you, and it's too close to your driver's side door. It becomes impossible to squeeze in. Don't people know they need to be equidistant from both parking lines!?  Now granted...my Starbucks has a Bikram yoga studio above it, and yoga-ites are probably in a rush to get all hot. But seriously, watch where you park! Otherwise, you're hot and I'm bothered!

Sweaty Gym-Goers. I try to go to the gym 4 days a week, to relieve the stress of the aforementioned peeves. But I am surprised how many people don't wipe the equipment after they're done with it. Seriously, it's gross! I know it's a gym and we're sweating, but I really don't want to come into contact with other people's sweat. Ya don't need to walk around with antibacterial wipes, but if ya shvits a lot, carry a towel.

So what do I do when I get in these situations? Here's how I try to relieve my stress:

Deep breathing. Sounds simple, but most people don't do it right. Stand or sit up straight. Put your hand on your stomach, and slowly breathe in through your nose. Feel your hand move up. Then slowly breathe out through your mouth, feeling your hand go down. Try it a few times next time you get stressed. It works for many folks.

Laugh at the absurdity of it. Laughter is always good medicine.

Listen to music. I talked about what's in my iPod in my last post...and honestly, music does help to relieve stress.

What's your pet peeve that causes you stress, and how do you deal with it?

What’s in Your iPod?

June 05, 2009

I usually use this space to talk about different therapeutic options like drugs and medical devices for diseases and other conditions.  Like most people, I sometimes overlook simple things.  For instance, did you know that listening to music can improve health?

A recent study showed that listening to music dilated people’s blood vessels by nearly 25%. Participants listened to 30 minutes of their favorite music daily.  At the end of the study, they actually had lower cholesterol levels as well as improved heart function.  It’s unclear exactly how music caused these improvements but it may be because the music-induced dilated vessels increases blood flow to the heart. Listening to music may also cause the release of nitric oxide which might help prevent buildup of clots and cause reduction in cholesterol formation.

Another study showed that stroke patients who listened to music daily actually had improvement in their vision, and actually had shorter recovery times.  There’s even some data to show music might improve memory.

Granted, these studies are preliminary and more research needs to be done but it’s hard to argue that listening to your favorite music is a good thing to do.  Who hasn’t found some reduction in anxiety by popping in their favorite CD into their stereo?  Who hasn’t had certain songs bring back special memories from childhood or momentous occasions that allowed you to escape for a few minutes?  Listening to music you enjoy can have real value in improving your health.  But remember – make sure it’s music you like!  Listening to Meatloaf if you’re a classical music aficionado will not be a good thing to do!

So what’s in your iPod?  I have quite a mix of songs in mine…I listen to rock and pop during gym sessions to get the heart pumping and give me the added energy to run further or lift heavier.  If you don’t think music makes a difference, see how your exercise varies if you listen to slow music or none at all! Sixty minutes will seem like 2 hours.

My iPod has become invaluable in keeping stress levels down while I’m navigating through airports and train stations.  Listen to a little Coldplay or The Fray, and those long lines don’t seem so troublesome.  And turning up Bach or Puccini while in traffic jam is a convenient way to tune out the blasting horns from other cars.

So remember the simple things when it comes to your health - take some time today to listen to 30 minutes of your favorite music.  Your heart and brain will thank you.

What Every Future Mom Needs to Know

May 07, 2009

It’s Mother’s Day today, so here are good wishes to all the moms out there! 

For most moms, the health of their children is a top priority.  So I thought today would be a good time to share a message about a way to help women have healthier pregnancies and healthier babies.  Did you know that even though we’re one of the richest countries in the world, we don’t have the best birth outcomes?  About 13 percent of babies in the U.S. are premature, eight percent have low birthweight, and seven out of every 1,000 babies die before reaching one year of age.

If you’re thinking about a pregnancy, how can you increase the odds that the baby will be healthy?  Most people have heard of prenatal care, but there’s something else you should know about.  It’s called “preconception care.”  At least three months before the pregnancy, the future mom should pay a visit to the doctor to talk about getting ready.  The visit should cover a wide range of topics including genetic background, past pregnancies, nutrition, and more.  The dad’s health can affect a pregnancy, too, so future fathers should check in with their doctors as well.

If you’re a woman thinking about pregnancy, here are five especially important steps to take before conception:

 

1.  Take folic acid, 400 mcg per day, beginning at least three months before you conceive.  Folic acid can reduce the risk of your baby having a neural tube defect, such as a deformation of the spine or incomplete development of the brain.  It’s important to start getting enough folic acid before you become pregnant, because these defects occur very early in the baby’s development.  Neural tube defects can happen before you even realize you’re pregnant.  If you have any personal or family history of neural tube defects, or if you have a chronic illness like diabetes or epilepsy, tell your doctor.  You may need a higher dose of folic acid.

The easiest way to get the recommended amount of folic acid is to take a supplement.  Most multivitamins contain at least 400 mcg (0.4 mg), so a daily vitamin may be all you need.  You can also find individual folic acid supplements.  In each case, check the label to be sure of the dose.  Some foods are fortified with folic acid.  You could get your daily dose by eating a breakfast cereal with at least 400 mcg per serving.  Enriched breads, pastas, and other cereals contain folic acid, but far less than the full 400 mcg.  It can be hard to make sure you get at least 400 mcg per day from these types of foods, so be sure to check labels.

 

2.  If you smoke or drink alcohol, stop.  Women who smoke are more likely to have decreased fertility, pregnancy complications, premature babies, and babies with low birthweight.  Alcohol puts your baby at risk for mental retardation, learning disabilities, heart defects, and other problems. 

 

3.  Make sure any medical conditions, such as diabetes, high blood pressure, or epilepsy, are under control and that your vaccinations are up to date.  Obesity is also considered a medical condition.  It has been linked to pregnancy complications, birth defects, and fetal death, so aim for a healthy weight before you conceive. 

 

4.  Tell your doctor and pharmacist about any medicines you take.  That includes over-the counter medicines and herbal treatments or supplements, not just prescriptions.  Make sure that nothing you’re taking could be dangerous to a developing fetus.

 

5.  Check your home and workplace for hazardous chemicals, toxins, infectious materials, and other exposures.  Avoid contact with cat litter, which may harbor a parasite called Toxoplasma gondii.  It can cause birth defects if a woman becomes infected just before or during pregnancy.[1]

Even if you’re thinking that pregnancy is a long way off, it’s a good idea to start a conversation with your doctor about what you’ll need to do.  It’s never too early to start planning for a healthy baby!

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[1] Toxoplasmisis—pregnant women.  Centers for Disease Control and Prevention.  Page last modified 1/11/09.  Accessed online 4/14/09 at http://www.cdc.gov/toxoplasmosis/pregnant.html#cat

Health Care Costs Just Keep Going Up

April 20, 2009

I usually use this space to talk about diseases and conditions.  Lately, I’ve been talking to friends, patients, and other physicians about the broader topic of health.  If you’ve been following the news lately, you know there’s been a lot of talk about health care reform.  Right now, spending on health care in the U.S. is more than $2 trillion each year, and costs keep rising!  We spend about twice as much as other developed countries.  But if you look at health outcomes, on many measures- such as infant mortality and life expectancy -- our system is not as good as it should be.

I think it’s important that we all have a say in any changes to our health care system.  It’s our health—and it’s also our money that pays for private insurance and government programs.  That means we all should be informed about where the money is going.

The $2 trillion is a sort of snapshot of the whole system.  In order to make sense of such a huge number, you need to know how the money is divided.  People often think that expensive drugs must be one of the main reasons for our nation’s high healthcare spending. This is probably because you often have a co-pay when you go to your local pharmacy.  Actually, outpatient prescriptions make up only 10% of the total.  Thirty-one percent goes for hospital care.  That includes your actual hospital room, medicines you receive, nursing care, and any other services the hospital provides.  Twenty-one percent covers doctors’ fees and clinic services, mostly for outpatient care.  Nursing home stays account for 6%.  Public health programs are only 3% of the total.  Seven percent of our health care dollars go to administrative costs and overhead.

Guess how much health care spending is already financed by our tax dollars.  The amount may surprise you!   It’s nearly half!  That includes Medicaid, Medicare, and other government programs.  This amount increases every year, so you need to be informed.

Now that you know where the money is going, another big question is why costs keep going up.  It turns out that there are some drivers of spending we can’t change.  About 6% of the increase we see is due to the aging of our population.  The baby boom generation is getting older, and they are going to need more health care! As we get older, we typically develop health problems – that’s also a big reason why we need to focus more on prevention and healthy living!   The influences can also shift from year to year.  There was a big increase in Medicare spending in 2006 when the new prescription drug benefit kicked in—but interestingly, growth slowed down again the following year.  The growth in prescription drug spending actually slowed down last year. For reliable ways to lower costs, experts are looking at things like improving efficiency within the system, lowering overhead, and making sure we’re using the best and most effective treatments.

As you listen to discussions about health care reform, keep these numbers in mind—and keep an eye out for more details.  Knowing more about where our spending goes can help you make your own judgments what we need to address and which plans for reform make the most sense.

Weight-Loss Isn’t Always a Good Thing

March 23, 2009

I know for the last several weeks I’ve been preaching about the need to lose weight and effective strategies as to how to shed those unwanted pounds!  Many of you have commented about your success in the weight-loss department and I offer you my props!  There are some instances, however, where weight loss should cause a concern.  I’m focused on those of you who aren’t trying to lose weight yet still are losing pounds.  Typically, people will say that their pants are loose, or someone told them they look like they’ve lost weight. Physicians typically refer to this as unwanted or unintentional weight loss.  Some of you might be playfully thinking “how do I get that condition?”—but it can be a symptom of something more serious.

Like we’ve talked about before, weight loss is still simple math – calories expended are more than calories taken in.   So something is going on that is causing you to eat less, or calories are not being absorbed properly, or there is a hyperactive or catabolic process going on in your body.

Beyond the Challenge – Motivation for the Rest of the Year

February 17, 2009

Is motivation created or is it an inherent trait?  Certain events in our life can motivate us – maybe it’s an upcoming wedding or reunion, a New Year’s Resolution, or maybe it’s the National Body Challenge.  But each of those comes and goes.  How do you then keep your motivation beyond your particular event? 

Here are 4 strategies that will help you reignite that burning desire to get in the best shape of your life!

1.    Realize it is not that easy.  The initial motivation is powerful, but that’s often short lived.  Small steps each day mean big changes in the long run; nothing will happen overnight and it’s important to continually encourage yourself.  Habits weren’t created overnight and they won’t be broken overnight.  Changing behaviors is difficult, but it can be done.

2.    Understand Motivation.  Why do you want to lose weight?  People often give very superficial, general reasons why they want to lose weight—lose a few pounds, improve health, etc.  These are not specific enough.  If you ultimately want to change behavior, you need to dig a bit deeper so you can determine what will really help you commit.  “Lose weight”, for example, is very general and is not likely to keep people motivated to continue for the long haul.  These same folks were likely motivated when they purchased a fad diet book, supplement off an infomercial, or what have you.  Remember, you need to find the underlying issue(s) and help change those. 

3.    Self-Monitor.  One of the most valuable tools you have at your fingertips is to self-monitor behaviors.  Self-monitoring is the observation and recording of a specific behavior.  Self-monitoring can be as detailed as writing everything down regarding that behavior (i.e. specific details, date, time, location, emotions, etc) to as little as placing a checkmark on a calendar indicating that a desired behavior was achieved. 

Many times individuals are not aware of their own behaviors.  Self-monitoring can help increase awareness.  Self-monitoring can be useful to gather a baseline for behaviors or as an ‘as needed’ measure when struggling.

4.    Work in groups.  Social support has been shown to improve the ability to lose and maintain weight loss.  Use this to your advantage.  Get a group of friends, family members, or co-workers together to get on a plan and work towards a goal.  It’s much more likely that you make time for exercise if you know you are meeting other people; it is just another way to be held accountable. 

These 4 strategies can reignite that motivational flame – remember, baby steps will go a long way to permanent success!

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Related Links:

Join the National Body Challenge FREE today! 

Use our National Body Challenge Community to stay motivated!

My Flabby Family – How to Keep the Entire Family Fit

February 09, 2009

“Do as I say, not as a do” is surely not a principle that is encouraged when it comes to shaping your life.  Exercise is encouraged for everyone, from young children to their great grandparents, and everyone in between.  As parents, it’s important to be good role models for your kids and walk the walk, not just talk the talk. Exercising together as a family can be great for the physical health of the individuals, but it’s a wonderful way to enhance communication between family members and the overall relationships as well. You’ll be surprised what people say when walking together!

In addition to exercising together as a family, eating together as a family is important too.  Unfortunately, few families set aside time for family dinners; both parents often work and kids are doing many different activities that dinner time is often no time.  How do you create time together?  The key is making time to be together, not finding it.

Find a time everyone can be together.  Now schedule this, just like any other important event; it’s something that can’t be put off, or pushed aside for a more convenient time.  There are a few ways to help make eating together possible and enjoyable.

1.    Choose 1 night each week where the kids are in charge of cooking.  Depending on their ages, this can be a meal they plan and prepare 100% on their own.  Or maybe, if the kids are younger, you help them put things together, but still give them important roles.

2.    Allow your children to pick 5 foods they want each week to add to the grocery list.  Work with them to then educate them on their choices.

3.    During the warmer months, try gardening as a new activity.  And keep a spot for the kids to have their “own” garden within the family spot – they can pick their favorite vegetable to grow and cultivate themselves.  Those who have their own garden eat more produce. 

When everyone is on board, success is easier to come by.  No one is immune to disease.  No one is immune to weight gain.  Share your healthy habits with your kids and your entire family will benefit!

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Related Links:

Join the National Body Challenge FREE today! 

Use our National Body Challenge Community to stay motivated!