Food Addiction

Do you struggle with your weight?  Are you obese?  Have you tried again and again to lose weight, and had short-term success but then slip back into old patterns?  Have you lost weight only to find yourself gaining the weight back with interest?

As a physician who enjoys helping people lose weight, I am almost as frustrated as my patients when things aren’t going well.  One thing that makes weight loss particularly difficult is food addiction.

Food addiction is just starting to be recognized as a major underlying factor in overweight and obesity.  Just like alcoholism and drug addiction, there are changes in the brain in some overweight and obese people that make it difficult or impossible for them to lose weight without help.

Researchers at Yale developed a questionnaire, published in 2009, to assess food addiction.  This questionnaire, the Yale Food Addiction Scale, is a 25-question tool that helps dig into symptoms and behaviors of food addiction.

What is addiction?  Psychiatrists and psychologists recognize addiction as a persistent pattern of abnormal behavior that results in significant distress in the patient.  Abnormalities include

  • Tolerance (needing more of the substance in question to get the same effect)
  • Cravings and withdrawal symptoms when not using
  • Consuming larger amounts than intended
  • Unsuccessful attempts to cut down in spite of wanting to cut down or abstain
  • A lot of time spent using or recovering from use
  • Continued use or overuse in spite of known consequences
  • Giving up important activities in order to use

You may already recognize some of these markers in yourself.  I certainly do.  For instance, I have a really bad sweet tooth.  I sometimes find myself eating more sugar than I know is good for me.  If I stop eating sugar, I will have sugar cravings, headaches and body aches.  Sugar is addictive and I know I have withdrawal symptoms if I overuse it for awhile then stop.

The same group that developed the Yale Food Addiction Scale published an article looking at almost 200,000 people, and found that about 25% of people who were overweight or obese met the criteria for food addiction.  Food addiction was more common in women, those over 35 years of age and those with clinically disordered eating, like binge eating, anorexia and bulimia.

Addiction is a complicated topic and I could write for days about it.  A VERY over-simplified explanation of addiction is that the reward centers of the brain have low levels of dopamine, the pleasure hormone.  Using the drug of choice (opiates, food, sex, sugar, etc) raises dopamine levels in these areas.  Also, these substances interact with the endogenous opioid (endorphin) systems, giving a morphine-like “high.”

Taken together, the presence of the “high” with use and low dopamine levels without use make it very difficult to resist the urge to overeat and very difficult to stop overeating once started.

Do some foods trigger food addiction more than others?  Well sure, nobody really binges on green beans and broccoli, right?  So called “highly palatable” foods are much more likely to trigger overeating.  The food industry knows this, and adds saturated fat, salt and sugar to processed foods to create this super-tasty addiction trigger.  Chips, cookies, candy, soda, cheeseburgers, French fries, white bread and ice cream are examples of foods likely to trigger an addiction response and binge eating behavior.

My personal belief is that weight loss is much harder than dealing with alcoholism, smoking, even heroin addiction.  You can’t just not eat, right?  However, when you understand what foods and situations trigger addiction, you can avoid them like an alcoholic avoids beer and stays out of bars.

What about people who are motivated to kick their food addiction for good?  What is available to help them?  There are twelve-step programs for food addicts, similar to Alcoholics Anonymous.  One such program is Food Addicts In Recovery Anonymous.  (I have no experience with this program, I just know it exists.)  And like alcoholism and opiate addiction, medications can help.

There is a medication called Contrave which has been shown to promote weight loss.  When you understand food addiction, it’s easy to see how Contrave would be helpful.  Contrave is a combination of bupropion, which raises dopamine levels, and naltrexone, which blocks the endorphin response.

Bupropion, an antidepressant, is well known to help people quit smoking and is the only antidepressant that promotes weight loss.  Raising dopamine levels decreases the need to eat, or smoke, or do other things to raise these levels in the brain.  Naltrexone blocks the “high” from drinking alcohol, using opiates like heroin, or binge eating.

While Contrave is very expensive and only rarely covered by insurance, both bupropion and naltrexone are available in generics and are inexpensive to purchase if not covered. can give you an idea what prices would be like near you.

If you believe you may be a food addict, please print and fill out the Yale Food Addiction Scale and take it to your doctor.  You can also print out the scoring instructions, it’s a little tricky to score.  This will help your doctor help you.

Like many similar problems, a combination of medication and counseling is going to be the most effective way to deal with food addiction.  If you are overweight or obese and feel out of control with respect to your eating, don’t give up!  See your doctor and ask for help.  If he or she isn’t comfortable diagnosing and treating food addiction ask for a referral to a bariatric center near you.

Like alcoholism and opiate addiction, food addiction can impact every part of your life.  It can alienate you from friends and family, and can even take your life.  Proper treatment starts with recognizing the problem and asking for help.

QUESTION: Do you or someone you love have a food addiction?  Will you do something differently based on the information in this post?


Managing Urge Incontinence

Have you seen that cute commercial with the little red “bladder” character who pesters the woman until she takes it to the bathroom?  Imagine that little guy just grew horns and a bad attitude.  It doesn’t pester.  It gives one warning and then unless she finds a bathroom RIGHT NOW it makes an embarrassing mess all over.

That’s urge incontinence.

Frequent urination.  Strong urges which quickly morph to an irresistible urge to void. Accidents.  Getting up at night frequently to pee.

Can you imagine if this was you?  Wouldn’t you be hesitant to leave the house?  I would.  It would be hard to go to the grocery store or do any other shopping, go to church, or function at work, let alone travel anywhere.

It’s hard to turn on the TV anymore without seeing ads for adult briefs and constipation products.  The large number of such ads would make it easy to assume this is a “normal” part of aging.  But it’s not.  Urge incontinence is NOT normal.  And it is definitely treatable.

My friend and colleague Dr. Holly Wyneski is a urologist in practice in Richfield, Ohio.  She specializes in female pelvic and bladder problems.  I reached out to her to get a little information about management of urge incontinence.   Please check out her website at 🙂

When dealing with urge incontinence, Dr. Wyneski’s advice is to start with behavioral change.  First, take a close look at diet (including fluid intake) and avoid foods and beverages that irritate the bladder.  Dr. Wyneski’s website has a list you can download here.  Examples include alcohol, caffeine, carbonated beverages and spicy and acidic foods.  Next, do your best to get enough sleep, and be aware of your stress level.  In addition to helping with stress and sleep, a number of my patients have found that magnesium supplementation helps calm the bladder.

In addition, your weight also influences how well your bladder works.  (Go figure, right?  Your weight affects everything ELSE in your body so why not your bladder!)  If you are overweight or obese, losing as little as 5-10% of your body weight can go a long way towards getting your bladder working better.

If the above measures don’t correct your bladder problem, bladder training is a very important behavioral treatment.  This starts with listening to your body.  Dr. Wyneski advises that you should empty your bladder every 2-3 hours.  It is also not considered abnormal to get up one time at night for every decade over age 70.  If you’re drinking enough fluids you will need to go at least that frequently.

Are you holding your bladder for 5-6 hours?  (HELLO all my nurses and teachers out there!)  If so, you are setting yourself up for problems down the road.  If the bladder gets stretched out it will get weak and not empty as well as normal.  This can lead to incomplete emptying (where there is still urine left in the bladder after voiding) and can cause infections and kidney damage.

The other side of the coin is the overactive bladder, where every time the bladder gets a little urine in it you feel like you need to go.  People with overactive bladder may need to go every hour, or even more often.  If you know every gas station with a clean bathroom on the east side of the city, this may be you!

Some people are very sensitive to the “stretch” sensation and may feel they need to go even if it’s not needed.  You may also have a bladder that tends to spasm and contract when it’s not time to go.  Men may have problems with their prostate that make it feel as if they need to go more frequently than normal.

Bladder training for the overactive bladder consists of waiting a few minutes after it feels like you need to go.  This will gently “stretch” the bladder and de-sensitize the urgency sensation.  Even starting with just a two-minute timer will make a difference.  You can gradually lengthen the time you wait.  It takes patience, but it is so important!

If these behavioral changes don’t help, please see your doctor.  Also, if you develop sudden bladder symptoms you should see the doctor, this may be an infection that needs treated right away.

If you’re like the woman in the commercial and you feel like you’re a prisoner of your bladder, there are things you can do to improve your symptoms yourself.  Your doctor can help too, and if all else fails, urologists like Dr. Wyneski have got lots of tools in the toolbox!

QUESTION: Do you have problems with your bladder?  What has helped you?


Reduce Colds And Flu With Vitamin D

How many colds and bouts of bronchitis do you have in any given winter?  Two?  Three?  Or are you one of those people who gets over one cold just to come down with the next?

Are you envious of those who don’t ever seem to get sick?  What if I told you the difference could be in your blood?  AND that it’s something EASY to change?

Turns out taking a vitamin D supplement reduces the risk of acute respiratory infections!  I’ve written about vitamin D before.  This nutrient has a lot of health benefits that we’re just starting to understand.  It helps keep bones strong.  It has mental health benefits.  Vitamin D levels are linked to the risk for multiple sclerosis.  We really don’t understand everything about how vitamin D works.


Researchers in the UK wanted to know if there was a link between vitamin D levels and risk of colds and flu.  Specifically, they wanted to know if vitamin D supplements helped prevent respiratory infections.

Last year their study was published in the British Medical Journal.  They analyzed 25 other papers involving over 11,000 people to see if there was evidence that vitamin D supplements protect against respiratory infection.

They found that people who took vitamin D supplements did have a lower risk of acute respiratory infection, but the effect was pretty modest.  Overall, those who took vitamin D supplements had a 40.3% risk of acute respiratory infection, while those who didn’t had a 42.2% risk.

Not a big effect, right?  Well let’s look deeper, OK?  The authors looked at those who were deficient to begin with, having a blood level less than 25 nmol/L, and found that with supplementation the risk dropped from 55% to 40.5%

The authors also wanted to know if it mattered how you took your vitamin D.  In Europe apparently it’s common to give a huge dose (>30,000 IU) every once in awhile, called bolus dosing.  In the US we usually dose daily or weekly instead.

The study found that bolus dosing was NOT effective, and if you just looked at the studies that gave the vitamin D supplements on a daily or weekly schedule the effect was quite dramatic.

Those who started with low vitamin D levels saw their risk of upper respiratory infections drop from 59.8% to 31.5%.  That is a huge drop!  The fact that correcting deficiency had such a big effect is good evidence that this is real and not just statistical fancy footwork or a coincidence.

They also found a big drop (46.2% to 33.6%) in children aged 1-16 years who were supplemented with vitamin D.  Since kids in school are exposed to germs all the time, this reduction is very important.

How can we use this information?  If you live in northern Ohio (or anywhere north of 40 degrees north latitude) you ARE vitamin D deficient unless you are taking a supplement.  So everyone in Cleveland needs to take a supplement all year ’round.  You also should have your levels checked periodically by your doctor or health practitioner.

I prefer to have my patients take their vitamin D every day rather than once per week.  It is easier to remember to take something every day, just make it part of your morning routine.  The best dose I’ve found is 2000-3000 units daily.  What is in your multivitamin is NOT enough.

While taking a vitamin D supplement is helpful, there’s more to staying healthy and warding off colds and flu than taking vitamins.  Make sure you’re washing your hands regularly.  Drink plenty of fresh clean water, get enough sleep, and watch your stress levels.  Stress depresses the immune system so if you’re feeling overwhelmed make sure to beef up your self-care routine!

If you’re a Shaklee customer of mine, please check out Vita D3.  It’s an inexpensive way to add insurance for heart, bone AND immune health!  If you’re not already a Shaklee family member, why not click this link to get your personalized health assessment?  There’s no cost and no commitment, just individual recommendations for diet and lifestyle changes (and smart supplementation of course) to meet your health goals.

I have so many friends and patients suffering cold after cold this winter.  Now you have one more tool in the toolbox to keep you well!

QUESTION: Do you take vitamin D every day?


Mediterranean Diet Better For Older People

Falls and fractures.  Getting weaker.  Memory loss.  Inability to take care of oneself.  Nursing homes.  This is the grim future that many people see as they get older.  The truth is that poor lifestyle choices, heart attacks, diabetes and other health problems DO increase the risk of this future.

Is there anything we can do to prevent it?  Is there any way to prevent this grim future from becoming a reality?

In January an article was published by a group who wanted to look at diet as a risk factor for frailty as people age.  They analyzed 4 studies and found that there is a link between the Mediterranean diet and decreased risk of frailty.

What is frailty?  I think everybody can look at one older person and classify them as “frail” and another older person and classify them as “robust.”  Frailty is difficult to define!  However, it is generally described as a syndrome that gets more common with older age.  It is the accumulation of physical deficits and low physiologic reserves that make it hard to recover from and increase the risk of injury and illness.

There are a number of ways doctors measure frailty but one of the more commonly used scales uses 5 criteria:

  • unintentional weight loss
  • self-reported exhaustion
  • weakness
  • slow walking speed
  • low physical activity

People who are more frail are more likely to fall, more likely to have a fracture, more likely to be hospitalized and more likely to wind up in a nursing home and to die prematurely.  So whatever we can do to prevent frailty, we need to do it!

We know that nutrition is very important in preventing frailty.  Lots of research has been done on using nutrition to prevent frailty, and most of the research shows that it’s the overall quality of the diet, not individual nutrients, that is most important.  Preventing nutrient deficiencies and getting enough protein seem to be particularly critical.

Dr. Kojima and his colleagues found that people were less likely to become frail if they followed a Mediterranean diet.  They analyzed research articles published from China, France, Spain and Italy that compared risk of frailty with dietary patterns.  People who ate a more Mediterranean-style diet were less likely to become frail over the study period (an average of about 4 years).

What is the Mediterranean diet?  The Mediterranean diet consists of mostly plant foods (like vegetables, fruits, beans, cereals, root vegetables, nuts and seeds), olive oil as the main source of added fat, and small amounts of dairy, eggs, fish and poultry.  Alcohol (particularly red wine) is consumed in low to moderate amounts.

This study showed that the more the participants ate a Mediterranean diet, the less likely they were to become frail over the follow-up period.  The authors believe that the effect may be tied to inflammation.  More frail individuals generally have higher inflammatory markers, and the Mediterranean diet is known to produce less inflammation in the body.

What are the limitations of the study?  Well this study was an analysis of four other studies, all of which were observational.  That means they asked people what they ate, then watched to see what happened over a certain period of time.  They didn’t assign people to eat a Mediterranean diet.  It’s possible that there are other characteristics of people who choose to eat a Mediterranean-style diet that also contribute to lower risk of frailty.  This is called confounding, and is difficult to assess in studies like this.

Still, there’s a principle of behavior change that if you want what someone else has, you find out how they got it and do that same thing.  If the goal is to avoid becoming frail as you age, then eating the Mediterranean diet is one good way to begin.

Not sure how to start?  Here is a link to Amazon’s list of top-rated Mediterranean diet guides for beginners.  The food is tasty, the recipes are simple and the health benefits are amazing.  Please consider giving the Mediterranean diet a try!


When Vertigo Sets You Spinning

Imagine you’re going about your business as usual.  You finish a long day and go to bed, but in the middle of the night you roll over and wake up suddenly feeling like you’ve been strapped into the Whirling Teacups ride at the amusement park!  Nausea, trouble walking and vision problems add to the fun.  Hooray, you have vertigo :-/

A number of patients have come in to the office recently with vertigo.  Vertigo is usually a minor annoyance but rarely it can be a sign of a very serious problem.

Vertigo is actually a symptom, not a medical illness in and of itself.  It is defined as the illusion of movement.  This means you feel like you’re moving but you’re actually not.

Everyone has had vertigo.  Do you remember when you were a kid and spun around in a circle over and over to make yourself dizzy, then fell down on your back to watch the sky whirl around?  That was vertigo.

Vertigo is a problem with the inner ear.  There are delicate fluid-filled tubes in the inner ear called semicircular canals that sense the movement of the head.  When the fluid can’t shift the way it should, or the ear can’t sense the movement properly, the brain gets mixed signals.



Have you ever been seasick or carsick or airsick?  Motion sickness is a problem when the brain gets signals from the eyes and ears that don’t match.  If the ears say you’re moving and the eyes say you’re not (like turbulence in an airplane or trying to read in the car) the brain can’t make the signals match.  Nausea and dizziness are what happens.

You can get vertigo as part of a viral respiratory infection if the virus infects the inner ear.  Swelling will keep the fluid from moving properly and may keep the inner ear from sensing movement properly.  This is called labyrinthitis.

You can also get symptoms if a little bit of debris blocks fluid from moving properly in the canals.  This is called benign positional vertigo and happens with movement and stops when you’re not moving.

There are a few times when this can signal a serious problem.  Vertigo in combination with hearing loss can be a sign of an illness called Meniere’s disease which happens when there’s too much fluid in the inner ear.  The unusual combination of vertigo and hearing loss in just one ear can be a sign of a benign tumor on the acoustic nerve.

Very rarely, vertigo can be a sign of a stroke if it affects the part of the brain related to balance.  This is of course more likely in those who are at risk for strokes.

What can we do to help vertigo?  Well most cases of vertigo are just annoying, not scary or dangerous.  So most of the time we focus on keeping the patient reasonably comfortable while the body heals the problem on its own.  Antihistamines like diphenhydramine and cetirizine are helpful, as are over-the-counter motion sickness medicines like Bonine and Dramamine.

If simple measures don’t work, sometimes steroids are useful to decrease swelling and inflammation in the inner ear.  Other treatments are used based on the cause.

If you develop dizziness and a feeling like you’re moving or spinning or off-balance, please see the doctor if the symptoms don’t subside right away if you sit perfectly still.  Most of the time it’s just an aggravating, temporary problem that feels better with some simple treatments.  However if it keeps up or you’re very uncomfortable or there are signs of a serious cause, more tests may be needed.

QUESTION: Have you ever had vertigo? How was it treated?


Is Marijuana Use Bad For Your Health?

Over the last few weeks I have had several young patients (and some older patients too) admit freely to smoking marijuana regularly.  When asked if they have considered stopping, they answer “No, why would I stop?”

Well that question kind of brought me up short, and I realized I hadn’t done any recent research into the health effects of marijuana.  It was easier for us doctors when it was illegal, LOL!  Now that Ohio has legalized medical marijuana and several states have legalized recreational use, it’s important that I have facts and figures to discuss.

Does marijuana have good effects?  Yes, there are therapeutic reasons to use marijuana, which is the basis for legalizing the medical use.  However, it’s important to realize that the medical marijuana law does NOT allow smoking pot.  Legal forms include vaping, edibles, tinctures, oils and patches.

Marijuana helps patients with seizures, anxiety, post-traumatic stress disorder, chronic pain, nausea and vomiting from cancer therapy, fibromyalgia, inflammatory bowel disease, multiple sclerosis, and a host of other medical problems.  Ohio’s medical marijuana program should be deployed later this year.  Doctors have to undergo education before they can be licensed to prescribe medical marijuana.

What are the health risks of marijuana use?  Smoking a joint increases the heart rate and slows coordination, interferes with thinking and remembering and increases appetite.  States with legal recreational marijuana use have recorded an increase in car accidents attributable to people driving while stoned.  I’ve seen a number of young women who smoke marijuana regularly and complain about weight gain.  (Go figure!)

Marijuana IS addictive.  Research has shown that about 1 in 10 habitual users of marijuana will become addicted.  Signs of addiction include inability to stop using marijuana, continued use in spite of negative social and health consequences and difficulty maintaining relationships with others that don’t smoke pot.

Marijuana causes changes in the brain, specifically in areas related to learning and memory.  It’s worse when teenagers smoke pot, because their brains are still developing.  Pregnant women who use marijuana have children with higher rates of attention, learning and behavior problems.  Secondhand marijuana smoke also contains THC so parents who smoke pot around their children are exposing them to an addictive substance that affects their growth and development.

While it’s not proven that marijuana use causes lung cancer, it definitely causes problems with the lungs, including cough and phlegm production and an increased risk of bronchitis.  Also, most people who use marijuana also smoke tobacco, with all the risks tobacco smoking brings.

Even though use of small amounts of marijuana (the equivalent of one or two “hits” on a marijuana cigarette) can alleviate anxiety, using more actually can worsen anxiety.  Marijuana users are also much more likely to develop mental disorders like schizophrenia.  Teens in particular are more likely to have depression, anxiety and suicidal thoughts if they smoke pot.  It’s not clear whether this is a causative relationship (i.e. do they smoke pot because they’re depressed and anxious, or the other way around).

There is also a risk of poisoning with edible marijuana products.  Absorption through the GI tract is unpredictable and it can take 30 minutes to 2 hours to take effect.  It is easy to over-indulge if it takes that long for the drug to make itself felt.  Also, children can easily overdose if they get into marijuana edibles.  In states where marijuana is legal, ER visits for accidental overdoses in children have gone up significantly.

Marijuana use is on the rise.  Both adults and teens are using marijuana and have the mistaken impression that because it has been legalized for recreational and medicinal use that means it is safe.  Marijuana use is NOT safe, it has real and significant health and social consequences.

QUESTION: Do you think marijuana use should be legal?  Why or why not?


Excessive Work Stress Is Bad For Your Health

Long days.  Unpleasant coworkers.  Low pay.  Child care hassles.  Work stress is really hard on us working parents and others as well.

However, you might want to pay a little more attention to your level of work stress, especially if you’ve got a family history of diabetes, heart attacks and strokes.  Excessive work stress may actually put your health at risk!

Last month a research study was published showing a link between high work stress and risk for diabetes.  Other studies have shown that excessive work stress increases the risk of heart attacks and strokes as well.

The study published last month showed that people with increased work stress were over 50% more likely to develop diabetes over a 12-year follow up period than those who had less work stress.  This is huge!  Diabetes is an enormous risk factor for heart disease, our country’s number-one killer.

Other studies have showed similar findings.  It would be tempting to assume that the increased diabetes risk is due to unhealthy lifestyle habits.  You know, you’re working long hours so you’re not exercising and you’re eating too much fast food.

Not true.  There was a study published in 2014 that looked at this idea.  Looking at almost 125,000 people, they were able to show an increased risk of diabetes even after controlling for unhealthy lifestyle habits.

So what might causing this increased risk?  There are a lot of possibilities.  Stress raises cortisol levels in the body which over time can change the way the body metabolizes sugars.  Cortisol metabolism also strongly correlates with fatty liver disease, which is associated with diabetes.

The mechanism really isn’t well understood.  There may be numerous mechanisms.  What is clear, though is that excessive work stress raises the risk for a number of serious health problems.

What should we do with this information?  First of all, DO NOT assume that just because you eat healthy and exercise regularly you are protected from the health effects of stress.  The research is very clear that stress is one of many determinants of health and they are ALL important!

DO eat healthy.  DO exercise.  But also please make sure you are managing your stress in healthy ways.  Get plenty of sleep.  Practice your faith and practice gratitude.  Make time to play and have fun with the people you love.

Have perspective on the influence of your career on your life.  Don’t let your work become the end-all and be-all of your life.  Your work is how you earn money to support yourself and your family.  Your work is one way you strive to leave your mark on the world.  Don’t let it consume you and become the way you define yourself.

Remember, no one ever looked back from their last days on Earth and said, “I wish I had spent more time at work.”

QUESTION: Does this research about work stress and health risk surprise you?  Will you change anything about your work habits based on this information?


Infectious Mononucleosis

When I was seventeen, one day I found a lump on the left side of my neck.  It was in a funny place, lower down on my neck than it would be if I had a cold.  It didn’t hurt, so I shrugged and thought I’d show it to my mom or dad that evening.

Turned out a few hours later I had a fever and a horrible sore throat, like someone had used razor blades in there.  It hurt even to sip water.  Eating was out of the question.  My lump developed a bunch of friends all around my neck.  My mom called the doctor and the next day took me in.

The doctor took one look at me falling asleep in the exam room, checked my throat, admired my collection of swollen glands and the lovely jaundiced yellow of my skin, and informed my parents that I had infectious mononucleosis.

I don’t remember much of the next few weeks.  I had hepatitis, tonsillitis and hugely swollen glands in my neck, my armpits and other places too.  (Who knew there even WERE glands in some of these places!).  I slept nonstop unless my mom woke me up and made me eat macaroni and cheese or pudding and drink some water.

Infectious mononucleosis is a contagious illness usually caused by the Epstein-Barr virus (EBV).  This virus is a member of the herpes virus family, like chickenpox and the cold sore virus.  The illness can be very mild, sometimes with no symptoms at all, or it can be serious enough that a person has to be hospitalized.

The virus is transmitted from person to person in saliva, through kissing or by sharing eating utensils and beverages.  This is one reason why teenagers are the ones who usually come down with infectious mononucleosis.  Dating!  Studies have shown that more than 50% of people have antibodies to EBV when they graduate high school.

Typical symptoms of infectious mononucleosis include fever, swollen glands, severe fatigue, and swollen, painful tonsils.  Almost all patients have hepatitis (inflammation of the liver).  Some patients, like me, actually get jaundiced.  Lab testing shows a high percentage of atypical lymphocytes and monocytes in the blood, which gives the illness its name.  Steroids like prednisone are used to relieve the symptoms.

One concerning problem in teens with mono is that the spleen can get swollen.  If a patient has trauma to the abdomen (like getting tackled in football or kicked in martial arts) the spleen can rupture and the patient can bleed to death.  If a teen plays contact sports they should be screened with an ultrasound of the spleen before returning to play after a bout of infectious mononucleosis.

When I had mono as a high school senior, I missed several weeks of school and work and it took me a long while to get back to normal.  Luckily it didn’t have any long-term impact on my academics and my part-time job at a fast-food restaurant was happy to wait until I was ready to come back.

For most patients infectious mononucleosis is an inconvenience, an annoyance that causes some significant short-term misery but no long-lasting consequences.  The illness can cause life-threatening complications but thankfully this is rare.

QUESTION: Have you had mono?  What was your experience like?


Is This Year’s Flu Shot Less Effective?

This week in the office I’ve been hearing and on the internet I’ve been seeing reports that the seasonal influenza vaccine for 2017-2018 is less effective than expected.  My patients are anxiously asking me, “Is this year’s flu shot less effective?”

The short answer is yes, unfortunately.  Before the conspiracy theorists and anti-vaccine folks ramp up, though, I’d like to explain in a little more depth.

The vaccine is not INeffective, mind you, it still gives some protection against the flu.  However, this year’s dominant type-A flu strain is the H3N2 variety, and the flu vaccine is not as effective against this flu strain.  Even if the flu vaccine is a perfect match for a given year’s outbreak, this strain mutates very rapidly and can quickly change so that it evades the immune system.

Also, there seem to be two influenza B strains circulating.  If you got the quadrivalent (4-strain) vaccine, both type-B strains should be included.  If you got the trivalent (3-strain) vaccine, only one type-B strain will be covered.

One cool new development this year is that, for the first time, in one of the available vaccines the H3N2 component virus was grown in a cell culture rather than in eggs.  H3N2 doesn’t grow well in chicken eggs, and the antigens shift a little while growing in eggs.  This also makes it harder to get a good crop of virus and interferes with the effectiveness of H3N2 strain influenza vaccines.

While there isn’t any data (yet!) about whether cell-culture-produced vaccine virus is more effective than virus grown in eggs, they are watching carefully and research is ongoing to discover whether this method is better than growing virus in eggs.  One major benefit to using cell culture rather than eggs is that the virus can be grown much more quickly, and vaccine can be produced without having to decide 6 months in advance which strains to include.

There are a few additional things to keep in mind about this year’s flu season:

  • If you haven’t had your flu vaccine, you should consider getting vaccinated ASAP.  Vaccine will continue to be administered.  Even though flu is here, new cases will continue to develop for several more weeks.
  • If you have a chicken egg allergy, you should NOT automatically avoid vaccination.  Hives from chicken eggs is not a reason to avoid the vaccine.  If you have had anaphylaxis, angioedema or breathing problems with past vaccinations you can still be vaccinated but it should be done in an allergist’s office where they are prepared to handle possible severe allergic reactions.
  • Whether or not you’ve been vaccinated, you should take steps to protect yourself from influenza.  Wash your hands regularly.  Get plenty of sleep, drink plenty of water and take your vitamins.  Consider giving a fist-bump instead of shaking hands when you meet someone new.
  • If you develop a fever, body aches, headache and a cough which comes on suddenly, STAY HOME.  Do NOT go to work or visit with friends or family.  If symptoms are reasonably well controlled with OTC meds it may not be necessary to see the doctor.  Most healthy young people handle influenza without much trouble.  If you are short of breath, feel dizzy, pass out, have chest pain or symptoms last longer than 7-10 days, definitely contact your doctor.

It is estimated that we need to vaccinate 30-40 people to prevent one case of influenza in any given year.  This year the number needed to treat (NNT) is probably a little higher, but it’s still much better than other vaccines.  As I wrote not long ago, the brand new Shingrix vaccine has a NNT of 99 patients per case of shingles in 1000 person-years, and with Zostavax it was 435 patients.

Flu is here.  And while the flu vaccine is not as effective as we would like it to be, it is still worth getting.

QUESTION: Did you get your flu shot?  (I did!)  Are you happy you did?


Do You Need An EKG?

Would it surprise you to know that sometimes I refuse to do what my doctor wants?  It shouldn’t – doctors are people too, and we have opinions that may differ from each other.

At my annual physical yesterday, the medical assistant explained that my doctor likes to do EKGs on all her adult patients when they have physicals.  I declined and I’ll tell you why.  Do you need an EKG?

Currently it is NOT recommended by the United States Preventive Services Task Force OR the American Academy of Family Practice to do routine EKGs.  That means that unless you have symptoms of heart problems (chest pain, dizziness, fainting, heart palpitations, etc) or risk factors for heart problems (high blood pressure, high cholesterol, diabetes or a strong family history of heart disease) you do NOT need an EKG.

Some people would say, “Dr. Jen, what’s the harm in getting an EKG?  It doesn’t hurt, it’s not invasive, it’s simple and inexpensive and can be done right in my doctor’s office.”  While that’s correct, you have to remember that no test is perfect.  Even a simple test like an EKG can have what’s called a false-positive result.  That means the test result is abnormal, even though nothing is wrong.

If a person is very unlikely to have the problem that we’re looking for, then positive results are more likely to be false-positive than truly abnormal.  And remember, the next test done for a patient with an abnormal EKG (to find out whether it’s a false positive or not) is a stress test.  That’s a much more expensive test that still has a risk of false-positive results.  Remember what I said before, no test is perfect!

If your doctor wants to do tests, it is important that you understand why they are recommended, what problems the doctor is looking for, and what the next test would be if the test is abnormal.

Want to see what the current recommendations are?  There are two commonly used places to look.  The United States Preventive Services Task Force is a government agency that examines the research and makes recommendations about what preventive services people should have at different ages and stages of life.  This agency is important because in some respects their recommendations are used to determine whether testing is covered by Medicare, Medicaid and commercial insurance companies.  You can click the USPSTF link above to check current recommendations.

My professional organization is the American Academy of Family Practice.  For the most part, the AAFP follows the USPSTF, but not always.  Sometimes the AAFP doesn’t agree.  You can see the American Academy of Family Practice’s recommendations at the link above.

Every doctor is responsible for keeping up on the current recommendations.  In fact, a lot of our continuing medical education is focused on the changing world of screening tests.  As more and more research is done and published, testing recommendations will continue to change.

It is confusing for patients when screening recommendations change, but that’s what doctors are for!  Doctors have to explain these changes and the reasons for them to patients so they understand.  We want to do the right tests for each patient to keep them healthy. We have to look for problems that need to be diagnosed and treated early.  Doctors should also avoid spending health care dollars on tests that don’t contribute to meeting these goals.

QUESTION: Does your doctor do routine EKGs for you when you have your physical?  Will you talk to him or her about this topic when you go in next time?