Four of the best things to do for your health.

Correlation between smoking and lung cancer in...

Correlation between smoking and lung cancer in US males, showing a 20-year time lag between increased smoking rates and increased incidence of lung cancer. (Photo credit: Wikipedia)

Four of the best things to do for your health.

1) Don’t start smoking. Stop smoking if you’ve already started.

 If someone asked you to pick up a habit that increased the risk of all of the following (and would cost you roughly $33-77 dollars a week depending on where you live, brand, etc), would you do so? Here are some of the things that smoking increases the risk of: lung cancer, colon cancer, bladder cancer, esophageal cancer, kidney cancer, pancreatic cancer, cervical cancer, vascular disease including aortic aneurysms and strokes. It increases the risk of fractures in post menopausal women. It increases the risk of low birth weights in infants. There is an increased chance of developing cataracts. For men in their 30s and 40s, it increases the risk of erectile dysfunction by 50%.

According to the CDC, smoking contributes to 443,000 deaths annually in the U.S.

2) maintain a healthy weight.

obesity raises the risk of multiple diseases: Diabetes Mellitus – type 2, high blood pressure, colon cancer (though the mechanism isn’t known how). It increases the risk of breast cancer (adipose tissue has an enzyme that converts testosterone to estrogen), osteoarthritis and more. There are no easy ways of doing this. At its simplest it means taking in the same amount of calories you expend. Granted if you’re overweight, you need to expend more calories than you take in.

3) Exercise

On top of helping maintain a healthy weight, excercise has many beneficial effects. Exercising reduces the risk of alzheimer’s disease, some cancers, it can improve mood, helps reduce blood pressure and can help prevent and treat diseases such as type 2 diabetes.  The suggested minimum is 150 minutes of moderate physical activity a week, which comes out to approximately 20 minutes a day. It can be something as simple as walking. The what of exercise (what kind) is less important than the regularity of actually getting exercise.

4) Have a healthy diet.

Potential health benefits of apple consumption...

Potential health benefits of apple consumption. (See Wikipedia:Apple#Health_benefits). Model: Mikael Häggström. To discuss image, please see Template talk:Häggström diagrams (Photo credit: Wikipedia)

Diet is the mainstay treatment in a lot of diseases. Whether it’s DM-2, high cholesterol, coronary heart disease (even if you’re on medication for any of these, maintaining an appropriate, healthy diet becomes no less important). In one study coming out of Lydon, France (known as the Lydon Study), people who were put onstandard treatment and who were switched to mediterranean diet with N-3 fatty acid supplementation (as opposed to just the  standard treatment) decrease their mortality after a heart attach by 66% (their mortality went from 17% down to 10%). This was independent of weight loss, decrease in cholesterol, etc. A dietary/lifestyle program promoted by Dr. Ornish which uses lifestyle changes, exercise and a vegetarian low fat diet (10-20% of calories from fat rather than the 20-30 used in the AHA step II diet) has been shown to reverse Coronary Heart Disease and is covered by medicare. A mediterranean style diet is also associated with decreased death from heart disease, a decreased risk of certain cancers as well as a decreased risk of dementia. At this point I won’t go into a huge discussion about diet (I’m likely to blog more about this in the future on multiple occasions).



(of a person or animal) able to withstand or recover quickly from difficult conditions.

DERIVATIVES:resilience noun, resiliency noun, resiliently adverb

It’s taken me a bit longer to do this post than I originally had hoped it would. Given the events in Boston this past  few weeks, this word resilience has been going through my mind a lot. Though it did also go through my mind due to other recent events as well (Newtown CT, Aurora CO among others). I do not want to sound as if I am medicalizing whatever caused the people who killed and maimed over 170 people. However, being the optimist that I am, I think people’s basic makeup is to be nice to other people and have a “live and let live” attitude to others that they disagree with or have no particular connection to.  I sometimes wonder what happened to people that would drive them to commit such acts of horror, that overcomes whatever resiliency that would otherwise keep them functional, reasonably happy people.

As a practicing physician I often get to see a side of people that they don’t often show others. There are the people who have gone through whatever traumas life has presented them and are married, have children and work. Others don’t seem as lucky, as if somehow given the same number and intensity of  shocks to their system used up whatever resiliency they have. They seem to go from moment to moment as if their lives are going to collapse. Anxiety seems to seep from their pores when they come into my office.

I have no answers as to why some people are more resilient than others. Often people who grew up in tough situations (few resources at home, single parents, drugs/violence in the neighborhood) make the news for getting into Harvard, Yale or some other school and “made it”. Was it that their parents and teachers helped them stay resilient. What about the people who are mirror images … they have caring parents who model being nice, giving to others, tolerance, don’t have  to worry about where if they are getting their next meal and where it’s coming from but somehow end up being unable to say no to whatever demon (now I’m speaking figuratively here, not literally) overwhelms whatever their resiliency can handle and they end up having issues (for lack of a better word) with drugs, violence or whatever.

Perhaps this will be my only foray into making any sort of commentary on society or sounding like I’m living in left field (or perhaps the peanut gallery) but: perhaps in addition to the three ‘Rs that are taught in school, Resilience should be added as a fourth R. Does it need to be  separate class? Probably not, life doesn’t happen in discrete blocks (I don’t spend one hour doing math, another hour ‘doing’ history, another ‘doing English’  i.e. reading writing, explaining things to people either verbally or in writing, and so forth)  and some things in school shouldn’t  either. Just learning that a bad grade in one test or class doesn’t mean the end of the world. Nor does having difficulty with one class or multiple subjects if given the skills/help in figuring out what helps someone learn. Ideally it’s something people should learn at home.

For something that affect health and quality of life, resilience is probably underrated. It is not the cure for all ills (if one is resilient, it doesn’t make one immune to getting cancer, diabetes, hypertension, etc). I suspect those who are more resilient are more able to deal with any chronic illness they might have and are more likely to take medication (if needed), follow up with any lifestyle changes that would affect their health (diet and exercise don’t become less important in diabetics once they start medication).  Would someone who’s resilient be less likely to do something that the  bombers did, that I don’t know. The answer to that, I leave to the psychiatrists, public health officials, philosophers, and those who actually do research in the area.

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Evaluating health care claims

In some ways this post is a continuation of my previous one titled “…because it’s natural”. In a lot of diseases such as DM-2, Alzheimer’s, and heart disease, there are multiple mechanisms that contribute to either the disease itself or to it’s complications. Two mechanisms of disease that seem to get a lot of space on TV, print and on the internet is that of inflammation and oxidation. Whether it is someone promoting a “super food” that has a lot of antioxidants in it (or a lot of anti-inflammatory activity), or a pill that has plant extracts in it that reduce oxidation or inflammation, the claims should be  taken with a grain of salt. For example in some cases, there may be multiple good studies that show taking said supplement does act as good antioxidant. However this doesn’t mean that the supplement will improve one’s health or lengthen lives. This is a problem with using what’s called a surrogate endpoint. Don’t get me wrong, using surrogate endpoints can be useful when the more significant and relevant endpoints are things to be avoided (death or disability for example) or might not happen for years  – I don’t think a study that would take 30 years to start showing something works would get funding – or finding enough people to study would be practical. It helps if a change in the surrogate endpoint has already been shown to be related to reduction in a particular disease’s morbidity or mortality.There are also observational studies that show certain things (high vitamin A levels, higher beta-carotene intake) are associated with lower levels of a particular disease state. Sometimes using a surrogate endpoint  (or  noticing an association between two things such as high levels of vitamin A and lower rates of a particular disease) ends up leading to people doing negative studies. For example, many deaths after a heart attack are related to arrhythmias. A study called the CAST (short for Cardiac Arrhythmia Suppression Trial) showed  higher mortality in people who were on anti arrhythmia drugs. It doesn’t mean that the drugs didn’t have a role in other disorders. I have a feeling it means that we were just asking the wrong question (even though it needed to be asked and answered) about treating arrhythmias after heart attacks. I use the example of the CAST study to make the point that showing something changes the level of something (either up or down) that is thought to be involved in causing disease – be it inflammation, oxidation, arrhythmia or otherwise – doesn’t mean it affects the disease it is said to. It may be that to treat a disease with anti-inflammatory medications (or substances), one also needs to block other pathways of that disease as a well for any to be effective. This is why most cancers are treated with more than one drug. This is why people are often on more than one blood pressure medication. As I mentioned in my last post, any claims should have data supporting that they work. The results should be reproducible, hopefully other by other researchers. Getting back to my original assertion from the start of this particular blog post, if someone is touting a “superfood” for health, It is appropriate to ask if it actually improves health, decreases complications, etc. In my opinion, just to say something is a “super food”  because it is a ‘super anti oxidant’ is blowing smoke.  That isn’t to say that anti-oxidant rich foods don’t promote good health. There are too many studies that are negative that to look at one thing and say “this is the holy grail of food”. This also undersimplifies things too greatly. It’s better, in my opinion, to say “these are the types of foods/eating (or habits if one is talking about other aspects of lifestyle) that are associated with good health. For examples, many of the studies that show that olive oil intake is inversely related to cognitive decline are more agnostic about what role each component in olive oil plays, despite showing benefits. Is it the kinds of fatty acids in olive oil? Is it the polyphenols that act as antioxidants?  Is it the anti-inflammatory chemicals in olive oil? I suspect the answer is yes, it is all three. Is it the answer to everything: just have olive oil and you’ll live to 100? I doubt it. My bottom line on health care claims:

Be critical but open minded: ask the following questions: “Does it actually affect or prevent disease? Does it decrease complications of the disease and not just something thought to be associated with disease or complications thereof?”. If the answer is “yes, it does reduce _fill in the blank_ and there is a proportional reduction in the amount of deaths/strokes/people going on dialysis/etc then you have a winner. IF the answer is “it does reduce _fill in the blank_” but there is no reduction in _fill in this blank as well_” it may mean that the answer is more complicated than we think. It may mean that the wrong question(s) were asked, or the right ones hadn’t been asked.

Also be wary of claims that make a product or procedure seem that it’s THE ANSWER for a particular disease. It may be a piece in the puzzle, but in order to be considered as such, the answer to the question ‘where’s the proof’ should be along the lines of “here are the studies…”

If the person makes statements like “doctors are in the pockets of ‘big pharma’ and aren’t interested in curing disease”, then be wary. I think most doctors get into this business to make people better. If there was a pill that taken once or twice cured someone of his or her type 2 diabetes (and did not cause some other severe life threatening disease), I think most doctors would use that pill.

Also ask if this the first study of something? Often a treatment is found in a study to be helpful. The numbers of people may be small. Due to the nature of studies, the participants are typically more homogenous than the population as a whole. Once larger studies are done, the benefits of a medication/procedure, etc may not be as large as initially thought.

Another question ot ask is this better than what we have now? Though it could be asked of a new medication, I’m primarily thinking here of new surgical procedures (eg, robotic surgery for certain things). If offered ask: is the rate of complications less with the new procedure? Is mortality less? Is the recovery time quicker with the new procedure?

… because it’s natural.

I think with this post I am going a bit off topic (or at least getting on a soap box for a bit). Occasionally a patient will say that they don’t want to take a medicine because they want to try other treatments first, like loosing weight or exercising, if,  for example, they were just diagnosed with adult onset diabetes (also known as Diabetes Mellitus, type 2). Now if their numbers (eg, a glycosylated hemoglobin) that is at or near goal for a treated diabetic, that might not be an unreasonable approach. After all, even if someone is put on a diabetes medication, anti-hypertensive, etc, diet and exercise don’t become less important in treating whichever disease they have.  What concerns me at times is if the reason someone doesn’t want medication for a treatment is because the medication is “not natural” and that they want to try something that is derived solely from natural products.

Now on one hand this might not be totally unreasonable in that many common medications are derived from natural products. Think of aspirin and penicillin (the latter produced by fungi known as penicillium).   Streptomycin is another drug initially derived from a natural source. Digoxin/Digitalis is produced by the Foxglove Plant (which was used to treat what we now call congestive heart failure.  Digoxin and digitalis are still used at times). Morphine is derived from Poppies. The list goes on. As I don’t work for a pharmaceutical company, I don’t know how many of these medications are 100% man made vs being derived from plant sources. Given that a pill has a known quantity of a known medicine, I’d rather take that than risk a stroke or some other complication. My biggest issue is someone wants to take a  supplement to treat a disease “because it’s natural” and because “it’s safe”. I want to see the proof that it works before I’d recommend it. Note, if we’re talking about a disease that won’t kill you tomorrow, or next week, I try to be open minded if a patient wants to try something else first.

Having said that, when someone’s reason for wanting to use an herbal treatment, a supplement, etc to treat a disease because natural products are safe/safer than medications, I am apt to give them a list similar to this: Carbon Monoxide, Snake venom, Radium, Ricin, Atropa Belladona (nightshade), Botulinum toxin, etc. Aside from being toxic, they are all natural products as well. It is my way of hopefully, and gently, pointing out that natural doesn’t always mean safe or non toxic.  If someone is hawking a natural product as a “cure” for something, it’s reasonable to ask the following questions:

1) Is it safe?

2) Does it work? What is the proof that it works? For medications it’s multiple trials that are reproducible and show (usually) a clinically significant difference in cure/length of disease/significant decrease in morbidity or mortality. In some cases it is a change in a surrogate end point. Do the natural products have the same level of proof? Of note, a celebrity spokesperson or the fact an infomercial exists isn’t proof. In my mind if someone is saying that “studies show…” then they should be able at some point to tell you where to find the studies, or provide the references themselves. Obscure or non peer reviewed journals don’t count. Nor should there only be one study showing benefit (it should be a really compelling article if there is only one).

3) What are the alternatives?

Aging Well

I think that when most people think of aging well, they think of what adults do to become healthy older people. Another line of thinking, which I happen to like, is that successful aging starts  in childhood (may be even in utero) as many things that occur in childhood can affect health as adults. Think of people whose mothers had rubella while pregnant with them. For those of us old enough to have gotten chicken pox rather than the vaccine, we’re at risk for shingles as adults. Severe iodine deficiency can lead to hypothyroidism and developmental delay (a more politically correct term for mental retardation). Growing up bilingual seems to protect against developing dementia, as well as having other beneficial effects on growing brains. The list goes on.

Though many people associate older age with disability and frailty, it doesn’t necessarily have to be that way. One thing I was taught throughout my training is that the older old (people in their 80’s and 90’s) are healthier than those in their 60s. At first this might sound counter intuitive. However, if one considers that those who are sickest die sooner, then it makes sense. The person whose only health issue is well controlled diabetes or well controlled hypertension is much more likely to reach his or her 80s than one who is overweight, diabetic with a glyco-hemoglobin of, for example, 9.5%, high cholesterol and has poorly controlled hypertension.

However, as I am assuming most if not all people reading this are adults, and as a time machine that would let people go back and vaccinate themselves against chicken pox, or somehow convince their parents to make them grow up bilingually (unless they did already)does not exist, I will limit myself to what an adult can do to age successfully. Nothing is guaranteed to prevent illness or frailty but what I suggest below does seem to help protect from or delay such things.

1. Stay Active. Our ancestors did not sit in cubicles all day earning enough money to buy food. They had to do any one of the following to get food: hunt animals, gather food, tend/harvest crops in the field or herd cattle/sheep etc. Only in the past few millennia was it possible for farmers to support a population where everyone didn’t need to be involved with procuring food/housing/etc. Not that getting food was a 24/7 job, but took more physical effort than driving to a supermarket. Even then people walked or rode horses to get places on land. Now it seems like to go more than 50 feet people drive their cars. Our bodies were made to be used. We should all be taking at least 10,000 steps a day (this comes out to walking approximately 5 miles/day).

2) Avoid bad behaviors. By this I mean, don’t do things that can shorten your life. Avoid smoking (not only is it bad for your lungs and increased your risk of lung cancer and of COPD, it raises your risk of bladder cancer, kidney cancer, esophageal cancer, raises your blood pressure and risk of heart disease). Drink in moderation (no more than 1 drink/day). Avoid any street drugs and sharing needles.  If you are sexually active and not in a monogamous relationship, use condoms. Having a discussion about your partners(‘) HIV status isn’t a bad idea either.

Don’t forget to embrace good behaviors. By this I mean not just those things I mention above and below, but also keeping any chronic diseases you have under control as best you can.

3) Be part of a community. Whether it’s a church (or synagogue or mosque), club for a hobby you enjoy, volunteering or any other activity that regularly gets you out with people, do something where you interact with people. The more positively the activity affects your community, the better. Humans are a social species. It helps keep your mind active if you remain part of a community.

4) Watch your diet. Eat healthy. What constitutes a healthy diet could (and likely will) take up a whole other blog post or two. Eat more vegetables. Cut back on meat – processed and otherwise. Eat more fish. Don’t drink to excess.

5) Be curious and educate yourself throughout your lifetime. Whether it’s people with more neural connections that end up in college and graduate school (and that is what makes people with college degrees less likely to develop dementia) or whether the education helps the neural connections stay healthy isn’t known. It could also be that the more educated someone is the more likely it is they will maintain doing healthy behaviors. In any case,  your brain is like a muscle, use it or loose it. If you have the time and inclination, learn another language. Take up a new hobby. Take a course in something you don’t know anything about. Take a refresher course in Italian (or spanish, or multivariable calculus, whatever floats your boat). If it’s another language, try and get good enough you can go to a foreign country where that is the official language and use that without having to speak English.

6) I realize not everyone has as much money as Warren Buffet or Donald Trump, but watch your financial health as best you can. If you retire, you don’t want to have to choose between a co-pay for medication or rent +/- food. If you can afford it, consider getting long term care insurance. If you need long term care, it can mean the difference between being at home with help or needed to go into a nursing home (policies are different, some might pay for nursing home stays as well).


Tough conversations and Paperwork.

Two kinds of conversations with patients are particularly tough, and sometimes related. One conversation is delivering bad news, such as the diagnosis of cancer or of a diagnosis such as HIV/AIDS. Sometimes the conversation can be tempered by a positive such as having caught the disease in an early stage, or that enough treatments are available so instead of being a virtual death sentence, it becomes a chronic disease.

The other conversation that can be difficult is talking to patients about end of life issues. Part of it is resistance as facing one’s mortality is difficult. Unfortunately people often wait until it’s too late to have conversations with family and their physician. This can put a person’s physician and family into difficult positions. By this I mean, if a disease such as Alzheimer’s has advanced enough, a patient may not be able to voice an opinion on whether he or she would want CPR, Intubation etc in the case of a heart attack. Anyone who has practiced long enough has seen patients who are unable to live independently due to dementia and have no family or other person to act as a proxy to make decisions on his or her behalf. It can take weeks or months to go through the court system to have a healthcare proxy, guardion or some similar decision maker legally assigned. In other circumstances, someone may be incapacitated by the effects of a disease, stroke, etc and unable to speak for him or herself and end up getting far more treatment at end of life than they would have wanted when they come in unconscious, unable to breath for themselves, etc and end up on a ventilator (breathing machine).

There are several ways around this. All start with conversations with family and/or friends in deciding who will be a health care proxy. There are health care proxy forms that can be filled out. Also a form known as “five wishes” is also a good place to start. The site it can be found at is aging with dignity. The first two pages act as a health care proxy form as well. The pages on the five wishes allow for more narrative as to what one’s wishes are for end of life care. Once either a healthcare proxy form or the five wishes form are filled out, they do no good if left in a drawer where no one can find them. A copy should be given to your primary care physician. Another copy should be kept in a place where you or your proxy can easily access it (preferably he or she should have his own copy as well). As circumstances arise (for example, if your healthcare proxy dies or decides they can’t/wont potentially act as a health care proxy and you appoint a new one), a new form can replace the old. However your doctor should have the updated forms for your chart.

At some point someone might decide that based on whatever set of disorders they have, that should their heart stop or that they require CPR for whatever reason that they want to be “DNR” this stands for “Do Not Resuscitate”. This often is a point of confusion when talked about in a hospital setting. This does not mean stopping treatment for cancer, heart disease, lung disease, etc. It simply means that if some’s heart stops or they stop breathing, that CPR or advanced life support measures won’t be started. There is a form such as the which is used to inform EMTs and other responders about your choice should they be called. Hospitals have their own forms that are used for inpatients.

For people with a disorder or set of disorders where one’s life expectancy is a year or less, a MOLST form can be considered. It delineates what life sustaining interventions (eg, feeding tubes, dialysis, etc) will accept.

Lastly a “File of Life form” can be filled out. I referred to this, perhaps a bit indirectly, in my last post. This is a form that can be filled out indicating whether one has a health care proxy, who that person is, where the form can be found. It also lists medical problems, medication lists, doctors’s names and phone numbers. Often they are put on the the refrigerator door so if one is unable to speak, EMTs and other responders can have important, and perhaps even life saving, information without having to search for it. Some forms are also small enough to be placed in a wallet.

Not all of these forms need to be discussed at one visit with your physician. To find them online you can search for the terms of “health care proxy”, MOLST, DNR, “file of life” and add the state you reside in for forms specific for your state.