Preventive Care

My son Chris and I went for our annual physicals yesterday, which prompted me to think about how many people skip their annual preventive care visits to the doctor.  Why is it important for you to get your annual checkup?

One of the most important reasons to take advantage of your annual physical is that it’s free.  The Affordable Care Act states that insurance plans must provide an annual preventive care visit with NO cost sharing to the patient.  That means no deductibles, no copay, no coinsurance.  You can’t schedule a physical because you have chest pain and expect it to be billed as a preventive visit, though, so don’t try it 🙂

There are different reasons to go for different groups of people.  Everyone needs a primary care doctor they can visit if they are sick or hurt or worried about something.  Everyone needs to make sure their immunizations are up to date.  Everyone needs to keep their primary care doctor current on their health problems, medications, allergies, medical and surgical history and family history of illnesses.

Babies have very frequent visits to the doctor.  They need regular checks to make sure they are growing and developing normally.  Parents (especially first-time parents) need regular opportunities to ask questions and receive guidance about keeping their kids healthy.  And of course children under 2 years of age are getting their primary series of vaccinations to avoid preventable diseases like measles, chickenpox, diphtheria and rotavirus.

Older kids and teens still need to be monitored for their growth and development.  School performance, puberty, Internet safety, sports participation and guidance about risky behaviors are discussed at visits.  Immunizations are also part of the plan at certain ages.

My young adults generally disappear on me.  Young men can’t be bothered to go to the doctor for checkups unless their mother, girlfriend or wife forces them to go.  This is unfortunate because we still should check blood pressures, monitor weight, and talk about diet, exercise, smoking, alcohol, safety and mental health topics, among others.

Young women often don’t realize that their primary care doctor can provide all their preventive care.  Some older male doctors are not comfortable performing Pap tests, but many ARE comfortable with it, so they should ask if they can get their routine checkups done at their primary care doctor’s office.  Unless they are pregnant or need surgery, I tell my patients we’ve got you covered for Pap tests, birth control and other screening tests.

Women at 40 years of age need annual mammograms.  Men and women at 50 should have a screen for colon cancer.  Most of the time that’s a colonoscopy which, if normal, is good for 10 years.  Prostate cancer screening is controversial and should be discussed between a man and his primary care doctor.

When a patient hits Medicare age, they start getting Medicare Wellness visits.  This is NOT a physical.  This is a visit where the doctor has a LOOOONG list of questions to ask about everything from last mammogram and colonoscopy to advance directives, falls prevention, dementia screening, depression screening and planning for nursing home care.

Physicals also allow a longer visit for patients and doctors to sit down and get to know each other.  This is really valuable and definitely under-recognized.  A patient is more likely to bring a sensitive concern (like depression, drug abuse or STD worries) to a doctor they know, like and trust.

Please call and schedule your physical.  Talk with your doctor and get to know him or her a little, let the doctor get to know you.  Find out what screening tests are recommended for you.  Make sure your blood pressure and your weight are what they should be.  Make a plan to deal with it if they are not.  Talk about ways to improve your health and help you live well.

QUESTION: Do you get your physical every year?  Why or why not?

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Lifestyle Counseling In The Doctor’s Office

Obesity.  Stress.  Poor diet.  Sleep deprivation.  Lack of exercise.  Smoking and other dangerous habits.  All these things and more contribute to fatigue, poor health, mood problems and increased risk of heart attacks and cancer.

Why then are doctors so reluctant to tell patients how to address these problems?  You would think our health care system would be on top of helping people eat right, exercise, manage weight, sleep properly, handle stress and do all the other things needed to optimize their health.

The reality, though, couldn’t be farther from the truth.  Lifestyle counseling is sadly lacking in most doctors’ offices.  We’ve got lots of time to talk about drugs and surgery and mammograms and Pap tests and colonoscopies, but not enough time to talk about fiber and sugar and sleep and exercise and community involvement.

This is pretty sad.  It’s estimated that 90% of our health is based on how we live our lives, and only 10% is determined by our genes.  Lifestyle counseling is where the money is, so to speak, in improving the health of our patients.

So why do we miss the boat?  Why don’t more doctors spend more time on helping our patients improve their lifestyle choices?  Why isn’t lifestyle counseling part of every patient visit, in every doctor’s office across the nation?

There are a few reasons.  The first one is time.  In a typical 15-minute appointment, between making a diagnosis and deciding on treatment, many doctors are most comfortable spending the limited time available discussing what tests to get and what medications to prescribe.  They may think that a conversation about what foods to eat and how exercise and sleep may help the patient feel better will take too much time.

Another reason is lack of training.  I admit I’m a few years out from my medical school days but I recall just how little time was spent teaching lifestyle counseling.  When I have medical students rotating in my office I ask them whether they get any training on nutrition and other lifestyle factors.  Generally they agree there isn’t much.

Knowledge about the impact of lifestyle on health is mostly self-taught in the American health care system.  Hopefully that will change as the research about the impact of lifestyle on health is exploding as we speak.  Nutrition, epigenetics (the effect of lifestyle on gene expression), microbiome research on how the bacteria on and in our bodies affect our health, and other studies are coming to help guide us in providing solid lifestyle counseling for our patients.

One more reason that doctors may be reluctant to address lifestyle factors when talking to patients is the feeling that patients don’t want to hear it.  We feel that patients don’t want us to tell them to change their diet or to get out and exercise.  I’m not sure why that is, because most of the time my patients are very receptive to lifestyle counseling.  They may not be ready to act on it, but they do want the information.

Sure, I’ve got patients that make me feel as if I’m beating my head against a wall.  They are happy to take their pills and eat potato chips in front of the TV.  That doesn’t mean I’m not going to sing the praises of beans and a big bowl of salad to them, or not tell them about the benefits of 10,000 steps per day and a smoke-free life.  I figure that if water can create the Grand Canyon, patience and persistence will eventually plant seeds of change in the most stubborn patients.

If you are a person who wants to make healthy lifestyle choices but doesn’t know exactly where to start, ask your doctor for some guidance.  Ask for a dietitian referral or see if they have suggestions on a good book you can read.  Make sure your doctor knows you’re interested not in just taking pills, but in improving your lifestyle as well to be as healthy as possible.

I know that when I have a patient who asks me questions that stump me, it sends me to the literature and textbooks to find the answer.  Who knows?  Your questions may be the reason your doctor begins researching lifestyle factors in disease, starting the education journey that generally doesn’t happen in medical school.  This in turn may help him or her be more effective in helping other patients get and stay healthy.

I may be a doctor, but I’m also a patient.  I want the American health care system to focus on wellness and keeping people healthy, not just waiting until things break down to try to paste it back together again.  We can work together to create wellness, one patient at a time, one doctor at a time.

QUESTION: Do you want your doctor to talk to you about lifestyle choices?

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High Protein Diet Blocks Health Benefit of Weight Loss

It’s a tough thing, counseling people on how to eat to lose weight.  There are a gazillion weight loss diets out there.  Plant based, low-carb, low-fat, Paleo, Adkins, you name it.  Everyone has an opinion about what diet is best.

Most of the time doctors tell patients some variation of “any road is fine as long as it gets you where you need to go.”  Meaning, whatever diet you can stick to is fine as long as you get the weight off.

Some recently published research calls that into question.  Dr. Bettina Mittendorfer and her colleagues from the Washington University School of Medicine in St. Louis found that the amount of protein people ate while losing weight impacted insulin resistance.

Why do we care about insulin resistance?  Insulin resistance is a major determinant of risk of diabetes.  We know that obese people have a higher risk of diabetes than lean people, and insulin resistance seems to be the reason why.  What’s the link between a high protein diet and insulin resistance?

Dr. Mittendorfer and colleagues found that when people losing weight ate a modest amount of protein (0.8 grams protein per kilogram of body weight per day) they lost weight and their muscle tissue had improvements in sensitivity to insulin.  When people ate a higher amount of protein (1.2 grams protein per kilogram of body weight per day) they lost weight but their muscle tissue had NO improvement in insulin sensitivity.

One of the reasons doctors tell people lose weight is to improve the metabolic problems associated with obesity.  These abnormalities are tied to insulin resistance.  Insulin resistance is part of the metabolic syndrome which includes abdominal obesity, high blood pressure, diabetes (or high fasting blood sugar, often seen before diabetes develops), high triglycerides and low HDL (called “good”) cholesterol.  Having these markers significantly increases your risk of having a heart attack.

We tell people who are obese and have diabetes, high blood pressure and cholesterol abnormalities that they need to lose weight all the time.  We may need to start telling them HOW to lose weight in more detail.  Low-carb diets (which by definition are high in protein and fat) are touted to decrease cholesterol and decrease the risk of heart attacks, but if they don’t improve the metabolic abnormalities of insulin resistance we might need to rethink this advice.

What does this new research mean in practical terms?  Let’s use my body as an example.  I’m 45 years old and weigh about 160 pounds.  Let’s round me down to 70 kilograms.  (Yay!  Instant weight loss, LOL!)  0.8 grams of protein per kilogram of body weight gives me a target of 56 grams of protein per day.  This corresponds to about 15% of my daily calories coming from protein.  1.2 grams of protein per kilogram is 84 grams protein per day, or just over 20% of my calories from protein.

I use myfitnesspal.com (actually I use the app which is awesome) so it’s easy for me to track my protein grams.  Meat has about 6 grams protein per ounce which means that, if I ate meat, 9 oz of meat would be my entire protein allotment for the day at the lower protein target.

If you are someone who eats Paleo or any other low-carb diet in trying to lose or maintain your weight, I would encourage you to take a look at your protein intake.  Track your intake for a week or two to get an idea of where you are.  It is taken as a given that we need to eat a lot of protein in order to maintain muscle while losing weight, but do we really need to?

Dr. Mittendorfer’s subjects lost weight, and both groups lost the same amount of weight.  The lower-protein group lost a little more muscle, amounting to less than a pound of muscle loss difference between the two groups.  However, the higher-protein group had NO improvement in insulin sensitivity which could be interpreted to mean NO improvement in risk of diabetes and heart disease.

This is not a done deal.  It is far from understood exactly how much protein people need, and what are the dangers of a high protein diet.  For instance, Dr. Mittendorfer’s study enrolled only women.  Would the same findings be seen in men?  Would the same findings be seen if people ate only plant protein?  More research is under way and desperately needed to better understand the impact of protein intake on health.  In the meantime, however, these findings are concerning and should make us take a closer look at our dietary protein intake.

Are you trying to lose weight?  Why?  Is it all about how you look?  Or are you trying to lose weight for the health benefits of a leaner body?  If you are more concerned about how healthy you are than about how you look, think carefully about the weight loss diet you choose.  Think carefully about how much protein you’re eating, or you could be working hard to lose weight and not getting all the benefits you seek.

QUESTION: Do you eat low-carb to control your weight?  How much protein do you get per day?  Will this research change how you eat?

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Non-Drug Therapies For Anxiety

This is a very common thing to happen in my office.  A young woman makes an appointment for anxiety.  When she arrives and we talk, it turns out that she has been struggling with anxiety for years, it’s getting worse, her whole family has been treated for anxiety and depression, and the worry is significantly interfering with her ability to enjoy life.

But she doesn’t want to take medication.

Okaaaay…  I can work with that.  Turns out I’m NOT the typical doctor who would sigh and proceed to try to talk her into trying a pharmaceutical.  I believe drug therapy has its place and is very effective in many patients.  However, as a holistic doctor I feel just as anxiety impacts multiple parts of a patient’s life, ANXIETY is impacted by multiple parts of a patient’s life.

So whether or not a patient is interested in taking a medication for anxiety, I try to make sure to tackle these 3 areas to give them the best chance of feeling better long-term.

Counseling

In large part, anxiety is a failure of coping.  In a person with anxiety, the small worries of life which we all experience get caught in a vicious cycle and spiral out of control.  In severe cases, a person can’t sleep, work or even leave their home because they are paralyzed by worry about EVERYTHING.

Who do you learn coping skills from?  Your parents, right?  If your parents struggled with anxiety and didn’t have the best coping skills, how could they have taught you better ones?  Anxiety is a great example of how both heredity and environment act to produce illness.  Not only do you get the genes that control neurotransmitter levels in the brain from your parents, but you also learn how to deal with life stressors from them.

When you need to learn a new skill, you have to find a good teacher.  Turns out the best teachers for good coping skills to handle anxiety are mental health counselors.  They are trained to break those skills down and teach them to those who struggle with anxiety and depression.

You wouldn’t expect someone who could not drive a car to be able to teach you how.  Coping with life stress is an essential skill.  If you don’t have those skills, finding a good teacher is necessary.  Then practice, practice, practice!

Nutrition

Every part of our body’s health is related to what we put in our mouth.  Mental health is no exception.  Examples abound of children with ADHD whose behaviors and ability to focus improve dramatically when their parents eliminate artificial food ingredients, white sugar and other elements from their diet.

Anxiety is no different.  Junk food, artificial food ingredients and added sugar create stress in the body and in the brain.  Replacing these with fresh whole fruits and vegetables, whole grains, beans, legumes, nuts and seeds, fatty fish and limited amounts of lean meat and dairy make a world of difference in how our brains manage worry and stress.

Supplements definitely can help.  When I have a new patient struggling with anxiety, I ask them to get 2 high-quality supplements right off the start in addition to a good multivitamin.  B complex is helpful because when our brains are coping with stress we go through a lot of B vitamins making neurotransmitters.  Providing extra raw materials helps in this process.

When choosing a B complex supplement it’s important to make sure all 8 B vitamins are included.  Many companies skimp on biotin because it is very expensive (more expensive than silver, by weight, actually!).  If your B complex supplement contains all 8 B vitamins (thiamine, riboflavin, niacin, pyridoxine, folic acid, pantothenic acid, vitamin B12 and biotin) and includes 100% RDA of both folic acid and biotin, it’s a good brand.  I use Shaklee’s B Complex which of course passes this test 🙂

I’ve written in the past about magnesium and its effects on the body and brain.  At least 50% of Americans don’t get enough magnesium in their diet because of our food choices.  Extra magnesium is very safe and is very relaxing when taken before bed.  For example Epsom salts are soothing in the bath for sore muscles and a stressed-out mind because they contain magnesium which is absorbed from the warm water right across the skin.  An extra dose of 200 or 250 mg of magnesium in the evening is optimal.

Other Measures

There are lots of other measures that are helpful in managing stress and anxiety, most of which I’ve written about before.  Exercise is critical because it releases endorphins and decreases stress hormones like cortisol and adrenaline.  (It also feels good mentally to do something you KNOW you should do to take good care of yourself.)  Committing to getting enough hours of sleep at night is important because sleep helps to discharge the stresses of the day and allows the body’s hormones to reset themselves properly.

Hypnotherapy is a form of guided relaxation that accesses the subconscious mind and can help to work out deep patterns of behavior that keep you stuck.  Acupuncture will change the energy patterns in the body and can help particularly with physical manifestations of stress.  Meditation activates the parasympathetic nervous system which counteracts the fight-or-flight reaction.

If you struggle with anxiety, it affects every part of your life.  There are LOTS of ways to improve the symptoms of anxiety before resorting to pharmaceutical medication.  Even in those who choose to take medicine for anxiety, nutritional and complimentary therapies will work with the medication to give the best possible result.

QUESTION:  Do you struggle with anxiety?  What have you found helpful in managing it, other than medication?

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Vitamin D and Multiple Sclerosis

Multiple sclerosis is a terrible illness.  It is an inflammatory disease where the immune system destroys the myelin that protects nerve cells in the brain and help them function correctly.  This can cause numbness, weakness and the inability to talk, walk, eat and generally function independently.

No one knows what causes multiple sclerosis.  However, we do know that a specific vitamin greatly affects the disease.

This vitamin is vitamin D.  Vitamin D is produced in our skin when it is exposed to sunlight.  It is also available in food sources such as fortified milk, cod liver oil and fatty fish like tuna and salmon.  There is a big connection between blood vitamin D and multiple sclerosis.

Researchers recently showed that blood vitamin D levels are linked to how a multiple sclerosis patient’s illness will behave.  For instance, higher blood vitamin D levels are linked to slower development of new active lesions and a lower relapse rate.

The same researchers published a study a year later showing that even in patients being treated with medication for their multiple sclerosis, vitamin D levels are important.  Even when patients receive beta-interferon (an injected medication used to treat multiple sclerosis) higher levels of vitamin D are associated with less development of new multiple sclerosis brain lesions seen on MRI.

So does vitamin D supplementation affect the course of multiple sclerosis?  The answer seems to be yes.  Researchers gave vitamin D supplements to patients with optic neuritis (an eye problem considered a precursor to multiple sclerosis).  Those who used supplements to improve their blood levels of vitamin D had lower risk of developing multiple sclerosis during the study follow-up period.

How does it work?  It seems that vitamin D levels affect the levels of inflammatory molecules in the body.  For instance, interleukin-17 is a molecule that is highly associated with multiple sclerosis activity in the body.  Researchers found that supplementing vitamin D helped keep interleukin-17 levels from rising over time, an effect that may help explain why higher vitamin D levels seem to be protective against multiple sclerosis disease progression.

What does all this mean?  If you or someone you love has multiple sclerosis, talk to your doctor about having your vitamin D levels tested.  If your levels are low (or you live in an area away from the equator, where it’s harder to get vitamin D from the sun) consider taking a vitamin D supplement to get and keep your levels up.

What about those of us who don’t have multiple sclerosis?  Vitamin D supplements are smart for everyone if you tend to avoid the sun or live away from the equator.  Vitamin D receptors are present in EVERY cell in your body.  We don’t know everything vitamin D does in our body, but clearly it is super important!  Make sure your body is getting enough!

If you’re interested in taking a vitamin D supplement, please consider trying Vita D3 by the Shaklee Corporation.  I have been a Shaklee supplement user for 10 years, and a distributor for 8 years.  Want to know why?  Click this link to find out why Shaklee is the company I trust with my patients’, my family’s and my own health.

QUESTION: Do you take extra vitamin D?  Why or why not?

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