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?

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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?

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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?

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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?

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How To Check Drug Prices

One of my patients was in the office this weekend and she was so mad about the price she was charged for a medication I prescribed.  I was flabbergasted because it is a generic med, not brand, which usually means a less expensive drug.  That’s when I realized she didn’t know how to check drug prices before going to the pharmacy.

There is a website that gathers drug prices from different pharmacies and puts them at your fingertips, like Priceline does for airline tickets and hotel rooms.  This website is GoodRx.com.  There’s an app as well so this info is never farther than your phone!

GoodRx.com also provides information about drug coupons to decrease copay costs.  I try to make sure anyone who takes any brand-name medication knows about this website so they can choose their pharmacy based on the best medication price.

Even those who have good prescription coverage should consider using this app.  After all, drug costs paid by insurance companies are always passed on to subscribers.  Nothing is free, so reducing drug costs to insurance companies will help keep premiums down in the long term.

Here’s an example:  The prescription antibiotic Augmentin (generic amoxicillin / potassium clavulanate) is commonly used to treat sinus infections.  How much would it cost if you had no insurance?Depending on where you go, the price varies a bit.  What if you choose something that went generic recently?

Does generic really matter that much?  Well let’s look at one that I discuss with patients fairly regularly, the thyroid medication Synthroid.  Is it really that much more expensive to get the brand medication?  Here’s the generic, followed by the brand.

And what about a medication that’s not available as a generic?  Here’s the diabetes drug Januvia which has been around for awhile, but not long enough to be generic just yet.

Huge difference, right?  This is why I prescribe generic medications almost exclusively, and why insurance companies push back so hard on us for prescribing brand medications.  Drug prices are a huge part of our health care expenditure, and being aware of what your medications cost, asking for generic medications wherever possible, and choosing a pharmacy that has lower prices are all things each of us can do to keep health care costs down and insurance premiums more manageable.

Please download the GoodRx app and use it to choose your pharmacy.  Every little bit helps as far as cutting costs.  The meds are the same, your treatment will be as effective whether you pay $4 per month or $12 per month.  Multiplied by 300 million people in the US, that $8 per month difference really adds up.

QUESTION: Did you know about this website?  Will it change where you go to get your medications filled?

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Probiotics And Cancer, What’s The Link?

Cancer is an unfortunate reality in my line of work.  Screening for it, thinking about it, looking for it in patients with a large variety of symptoms, and figuring out how to break the news to patients when we find it take up a lot of my time and energy.

I would love it if cancer were LESS of a reality in my job.

That’s one of the reasons I was so excited to read reports of studies showing that a certain type of supplement can be helpful in the prevention and treatment of cancer.  What is the link between probiotics and cancer?

There has been some recent research published showing a role for probiotics for treatment and prevention of some types of cancer.  Those who have a more diverse population of bacteria in their intestinal tracts seemed to respond better to some types of cancer treatment.  Also, those who have had their microbiome (a collective term for all the non-human organisms that live on and in our bodies) damaged by antibiotics don’t respond as well to cancer therapy.

Why does this link to probiotic supplements?  Well we can modify our microbiome by changing our diet and by taking probiotic supplements.

What is the microbiome?

Our microbiome is all the bacteria, fungi, protozoa and viruses that live on and in our body.  In fact, there are 10 times as many organisms in our microbiome as there are cells that are “us.”  We are walking, talking colonies of nonhuman microscopic organisms!  They influence our mood and the inflammatory state of our body, they make vitamins for us and have a huge influence in general on the state of our health.  They even digest our complex carbohydrates for us!

One of the most important ways the microbiome influences our health is by modulating our immune system.  Our immune system interacts with the microbiome in ways we are just starting to explore.  We know there is an association between autoimmune disorders like Crohn’s disease and alterations of the microbiome known as dysbiosis.  Healthy immunity influences our ability to fight infection and also affects our ability to identify and eliminate abnormal cells before cancer gets a foothold and starts to grow.

How can we influence the microbiome?

There are three significant ways we can change our microbiome to be healthier.  First is to eat a healthy diet low in processed foods, artificial food ingredients and added sugar, and high in whole fresh plant foods.  Soluble and insoluble fiber are our healthy helpful bacteria’s favorite food.  We should get at least 30 grams of fiber in our diet every day.  Not sure how much you’re getting?  You can use a calorie tracker like MyFitnessPal which gives you your daily intake of macronutrients like protein, carbohydrates, fat and fiber.

Soluble fiber turns into goo when you cook it.  Think of beans, apples and oatmeal – three great sources of soluble fiber.  Insoluble fiber doesn’t care if you cook it, it stays hard and rough.  The ribs of celery and the brown coats of brown rice grains are good examples.

A second thing that really influences our microbiome is taking antibiotics.  There is research that shows the gut microflora can have changes that persist for years after a single 7-day course of antibiotics.  We really need to resist the temptation to seek antibiotics for every little cold and respiratory illness that comes along.

The third way we can influence our gut microflora is to take probiotics.  These are supplements that contain living bacteria in a form that is protective from the stomach acid.  They deliver the bacteria to the intestine where they can change the balance of bacteria from more-harmful to more-helpful.

There is research that shows that probiotic supplements can have a role in both the prevention and the treatment of cancer which is really exciting, because they are so very safe, inexpensive and easy to take.

Prevention

There isn’t a lot of research yet published about probiotics and cancer prevention.  However, it is feasible that probiotics may be protective against cancer by strengthening the immune system.  Probiotics also can act by changing the microbiome to a more healthy population of bacteria.

For example, one study did show that soy milk fermented with probiotics has been suggested to be protective against the development of breast cancer, although more study is needed.  Also, the cells lining the colon use the short-chain fatty acid butyrate for most of their energy needs.  Butyrate forms from the fermentation of soluble fiber by bacteria in the colon.  It promotes the growth of healthy colonocytes as well as suppression of proliferation (i.e. cancer formation).  Colon cancer is associated with a relative lack of butyrate-forming bacteria as well as with a lack of fiber in the diet.  Increasing fiber in the diet encourages the growth of butyrate-forming bacteria.  This explains the decrease in colon cancer risk with higher fiber intake.

Treatment

This is brand new and really exciting.  The idea that the success of cancer treatment can be influenced by probiotic therapy is pretty radical.  Probiotic supplements can also be used to decrease unpleasant symptoms caused by conventional treatments.  For instance, probiotic supplements were successful in preventing and treating diarrhea caused by chemotherapy and abdominal and/or pelvic radiation.  

Ultimately, it is better to prevent than to treat cancer, right?  Prevention depends on a healthy diet based largely on plants with plenty of fiber.  Fiber may be the single most important nutrient we can take in our diet, as far as cancer prevention goes.  This is largely due to its profound influence on our intestinal microbiome.  Probiotic supplements have their role too as a way to fairly quickly influence the microbiome in a positive direction.

For those who are new to the blog and/or not aware, I choose Shaklee supplements for myself and my family.  I also recommend them for my patients and friends.  You can check this page to see why.  Click this link to browse my online store and this link to specifically check out the OptiFlora probiotic supplement.  Please feel free to email me with any questions you may have.

QUESTION: Are you concerned about your personal risk for cancer?  Do you get enough fiber in your diet?  Do you take a probiotic supplement?

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New Goals For Blood Pressure Control

Well it’s happened.  For the last 6 months I’ve been warning my patients that the powers-that-be are going to be tightening up the goals for blood pressure control.  This week the American Heart Association, the American College of Cardiologists and a number of other professional organizations released new blood pressure control guidelines.

Why now?  For years the definition of hypertension has been a blood pressure over 140/90 for patients under 60 years of age, and over 150/90 for patients 60 and over.

There have been a number of new studies published showing that patients with blood pressure over 130/80 are at higher risk for heart attack, stroke and kidney disease due to the wear-and-tear of elevated pressures on the circulatory system. Our hearts and blood vessels and kidneys were not designed to deal with elevated blood pressures for long periods of time.

My cardiology colleagues hate when I compare the circulatory system to a water pump and piping, but the analogy works.  Too much pressure and the pump wears out sooner.  Too much pressure and the pipes can fail.  In the case of the living tissues of the human circulatory system, too much pressure strains the pipes and the chronic injury heals as scarring which shows up as plaque.  Too much pressure and the delicate filters of the kidneys get damaged.

I’ve known for a long time our guidelines were wrong.  Any number of times I’ve had patients with “normal” blood pressure need an echocardiogram (heart ultrasound) for a murmur or some other problem.  When the echo is done the report mentions that the heart muscle is stiff (called diastolic dysfunction).  Why does the heart muscle get stiff?  From chronically working against too-high blood pressure.  I treat my patients with diastolic dysfunction with blood pressure medication, regardless of the numbers I get with the BP meter.  My goal is typically to lower the top number and bottom number both by 10 points.

Why treat patients with diastolic dysfunction with blood pressure medication?  Because whatever the numbers, their heart is telling us that THE PRESSURE IS TOO HIGH.  The heart is working too hard, “lifting weights” like the big muscle-bound guys at the gym, and the heart muscle is too thick and stiff to function properly.

These new guidelines are actually not as aggressive as I expected.  The SPRINT trial, one of the primary drivers of the new guidelines, actually showed that controlling blood pressure below 120/80 saves lives from heart attacks and strokes and prevented the development of kidney disease.

Here is a picture graphic showing the new guidelines:

What are we supposed to do with patients whose blood pressures are considered “elevated” or “high?” We are SUPPOSED to start with lifestyle changes.  “Aggressive” lifestyle changes, in fact.  Yay!  That is right up my alley!  Unfortunately, many doctors are likely to skip the lifestyle change talk and move right to medications.

We cannot medicate away a bad lifestyle.  This is something I teach my students in no uncertain terms.  If a person wants to be healthy you MUST start with a healthy lifestyle.

A healthy lifestyle means avoiding smoking, excessive alcohol and other harmful substances.  It means eating more fresh whole colorful plant foods, whole grains, beans, nuts, seeds and healthy fats and avoiding or limiting animal foods like animal flesh, eggs and dairy.  A healthy lifestyle means drinking fresh clean water instead of soda and juice.  It means getting plenty of sleep, plenty of exercise and plenty of fresh air and time in nature.  A healthy lifestyle means doing what you can to minimize toxic stress and your exposure to negative, toxic people.  Respecting your body, respecting your mind and respecting your spirit are integral to health.

Supplements have their place as well.  I have patients for whom the only blood pressure “medication” needed is a magnesium supplement once or twice daily.  Fish oil can also help to reduce blood pressure especially in doses over 2000 mg daily.  Please reach out to me if you’d like more information on using supplements to help with elevated blood pressure.

If the next time you’re at the doctor you’re told your blood pressure is too high, please make sure to discuss diet, exercise, other lifestyle changes, weight loss and supplements with your doctor.  If your blood pressure is over 150/90 you likely will need medication right away, but don’t give up on the lifestyle changes.  One of my favorite things to do is to take patients OFF of blood pressure meds!  It definitely happens often enough to keep me hoping 🙂

So these new guidelines mean we’re going to be prescribing more medications but also hopefully that we will be pushing harder on people to make healthier lifestyle choices.  Which ultimately will be good for us all.

QUESTION: Do you have high blood pressure?  Are you sure?  Do you think the next time you see your doctor you will be discussing your blood pressure?

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Shingrix for Shingles Prevention

Remember a few weeks ago I wrote about THIS problem?

Credit: www.zostavax.ca

About 2 weeks ago, the FDA approved Shingrix, a new vaccine for the prevention of shingles in people aged 50 years and older.  They also took the very unusual step of stating that people should get Shingrix rather than Zostavax, the only other vaccine available to prevent shingles.

Not only did the FDA state a clear preference for Shingrix over Zostavax, they also recommended that people who have already been vaccinated with Zostavax should be RE-vaccinated with Shinrix.

Wait, what?!

To my knowledge, the FDA has never done this, showing such a clear preference for one vaccine over another, to the point of saying that a previous vaccination is essentially invalid. Why would the agency do this?

It is much more effective than Zostavax

In the clinical studies, Shinrix was well over 90% effective in preventing shingles and its most devastating consequence, postherpetic neuralgia, in all age groups.  By contrast, Zostavax is only 18-64% effective, and is least effective in patients over 80 years of age, who are at greatest risk of a shingles outbreak.

The protection lasts longer

The protection given by the Zostavax vaccine has not been evaluated in long-term studies.  I found a reference to one long-term study of Zostavax that is supposed to be completed in 2024.  However, no studies that I could find have followed people who received Zostavax longer than about 2 years. (Any science types out there who can find one, please post it in the comments!)

Shingrix studies, by contrast, were carried on for up to 5 years and showed that the vaccine remains effective for prevention of both shingles and postherpetic neuralgia.  The question remains, though, will the protection be lifelong?  After all, if you vaccinate someone at age 50 they have hopefully MANY more than 5 years to live shingles-free.

No live virus

Shingrix is not a live virus vaccine, therefore there is no restriction on vaccinating people who are immune compromised or live with someone who is immune compromised.

What are the downsides of vaccinating with Shingrix rather than Zostavax?

Two shots, not one

The Shingrix dosing schedule calls for a second, booster dose of vaccine 2-6 months after the first dose.  This may be a problem with Medicare, because there are no Medicare-covered vaccines that call for a second dose within one year.  We will have to see how the coverage determinations shake out at the Medicare level.

Much higher rate of side effects

Shingrix’s package insert reports over 50% of patients who received the vaccine complained of body aches, fatigue and headache afterwards.  88% of people reported pain at the injection site (compared with 14% of people who got a placebo shot).  Recipients also reported fever, shaking chills and GI symptoms in fairly large numbers.

Younger people had more problems than older people, probably because they were making a more robust immune response.

A LOT of vaccine

From a population health standpoint, a 90% effectiveness rate sounds fantastic.  However, from a cost standpoint it might not be so great.  Here’s a crash course in how we determine how many people you have to treat in order to prevent an illness or condition.

For Shingrix, 11.1 people aged 80+ got shingles in 1000 person-years if they did NOT get the vaccine, and 1.0 people if they did.  That’s great, right?  90% effective.  But in order to determine how many people you need to vaccinate to prevent one case of shingles, the math is different.  It’s 1 divided by the difference in ABSOLUTE risk.  1/((11.1-1.0)/1000)

You need to vaccinate 99 people over age 80 in order to prevent one case of shingles over 5 years. That’s a LOT of vaccine, but much better than 435 patients with Zostavax.

The bottom line

Shingrix isn’t even available to order yet for doctors’ offices and pharmacies, and already it’s creating a stir.  The unprecedented endorsement by the FDA favoring Shingrix over Zostavax will likely force Zostavax off the market soon.

Shingrix IS much more effective than Zostavax at preventing both shingles and postherpetic neuralgia.  That higher effectiveness comes at the cost of being a more uncomfortable vaccine to receive, and having two get two shots instead of one.

If the goal is preventing shingles, Shingrix is clearly the way to go.  I will hit the age to be eligible to receive the Shingrix vaccine in a few years.  Will I get it?  Probably, because I’ve already had one bout of shingles and I really don’t want to have it again.

QUESTION: Have you had Zostavax?  Will you get Shingrix?

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Should Everyone Wear Sunglasses (Even Kids)?

A friend of mine mentioned recently that he’s been spending a lot of time at Cedar Point and mentioned he was surprised how few kids wear sunglasses.  All the parents wear sunglasses, especially at the waterpark, but very few of the kids are wearing sunglasses.

Does it matter?  Well, it turns out my friend is right to be concerned.  (And kudos to him, in his pics his absolutely adorable son is always wearing shades!)  According to the Vision Council (an eye care industry group), eye health depends on protecting the eyes from UV radiation.  Many people either are unaware or don’t believe that protecting the eyes from UV radiation from the sun is a critical, year-round concern.

There are 3 types of UV radiation – UVA, UVB and UVC.  UVC is filtered by the earth’s atmosphere and not a concern.  UVB is the type of UV radiation that stimulates vitamin D production in the skin, and is partially filtered by the atmosphere.  This is why those of us in northern Ohio can’t get vitamin D from the sun for the wintry half of the year, the sun is too low in the sky and the rays pass through too much air on the way to us.

The type of UV radiation that is most dangerous to the eye is UVA.  The earth’s atmosphere does NOT filter UVA.  If the sun is in the sky your eyes are being exposed to UVC radiation, no matter what season or time of day it is.  Wearing sunglasses as much as possible is important to protect your eyes when you are outdoors.

Here are 3 common misconceptions about sunglasses and sunglass use.

Kids don’t need sunglasses

Children receive about 3 times as much UV exposure per year as adults.  This is because they generally spend more time outdoors than adults do.  However, only 7.4% of adults report their children always wear sunglasses.

UV radiation damage is cumulative which means it builds up over time.  Damage can lead to aging of the skin, skin cancer, cataracts and damage to the retina.  Beginning in childhood, daily sunglass use will decrease the damage and preserve children’s eye health.

The darker the lens, the better the protection

This is not true.  UVA radiation passes right through lenses no matter what their color.  They must be coated to block UV radiation.  Polarized lenses are even better at blocking the UV rays.

In fact, it could be argued that dark lenses without UV protective coatings are the worst option of all, because they cause the pupils to dilate and allow more UV light through to the retina.

When you go to buy sunglasses check for labels to indicate the protection they give.  Make sure you choose lenses that are labeled as protective against both harmful types of ultraviolet light.

Wearing a hat is good enough

Not true.  While wearing a hat protects somewhat against direct UV exposure, it does nothing to stop REFLECTED UV light.

Credit: visioncouncil.org

So how do we get our kids to keep sunglasses on their face?  Hats are hard enough, right?  First of all, having a child pick out their own sunglasses makes it more likely they will wear them.  Make sure to get good quality glasses that fit the child’s face and don’t pinch or rub.

In addition, polarized lenses are more comfortable from a vision standpoint because they reduce glare and block more light.  Kids are more likely to keep them on because they don’t squint as much and they can see better.

Teenagers typically don’t want to be told what to do.  Make sure they understand they will have less problems with red, irritated bloodshot eyes if they wear sunglasses regularly.  Just like with kids, letting them pick out a couple of pairs of cool sunglasses they like will go a long way towards getting them to wear them regularly.

Kids, teens and adults all need to protect their eyes from harmful ultraviolet radiation.  The fronts of the eyes, the lens and the retina are all susceptible to damage which accumulates over time.  You and your family only get two eyeballs and it’s up to us to protect them!

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Diabetic Amputation Rates Rising

Mary is a lady I have taken care of for several years.  Every time she comes in I check her heart and lungs.  Then, when I go to check for swelling in her legs, we have a good laugh.  See, the first time I saw her, I checked for swelling and only then realized something pretty important.

Mary’s lower left leg is missing.

She is diabetic and developed gangrene in her left leg some time before she started seeing me and had to have her left leg amputated below the knee.  She is a very sweet lady but now has some significant trouble getting around.

Why would Mary need to get her leg amputated?  There are a number of possible reasons.  Diabetics can lose feeling in their feet and if they hurt themselves they may not feel it.  They don’t generally have good circulation and wounds take longer to heal.  Diabetics also have immune systems that don’t work right and they have trouble fighting infections.

Unfortunately Mary is in good company.  The rates of diabetic amputation are risking across the country.  For instance, in California, the rate of diabetic amputation rose 31% between 2010 and 2016.  Some counties like San Diego and Riverside counties had over 60% increases.  Across the United States the rate of diabetic amputation rose 27% between 2010 and 2014.  Before 2009 the rates had been dropping.

Why is this happening?  Why are people losing toes and feet, ankles and legs to diabetic amputation?

There are a number of possible reasons.

  1. More diabetics.  The number of Americans with diabetes is on the rise.  This doesn’t explain it all, though, because even just looking at diabetic patients the rates are rising.
  2. Access to care.  Before the Medicaid expansion that came with the Affordable Care Act many low-income diabetics went without care for their illness.  Also, coverage for podiatric care (which includes care for foot wounds and chronic foot infections) is not consistent across the country and across insurers.  If you can’t afford medication and see the specialists you need, you’re at increased risk for complications like amputation.
  3. Health literacy.  Many diabetics don’t understand why they need to see the doctor regularly.  They don’t know all the bad things that can happen as a result of diabetes.  They don’t know they could lose their vision, have a heart attack, wind up on kidney dialysis, have a diabetic amputation.  Education is key.
  4. Lifestyle factors.  If you’ve ever tried to lose weight you know how hard it is to change your lifestyle.  Eating a healthy, mostly-plant-based fresh-food diet, exercising regularly and drinking water are critically important for diabetics but many patients seem to think as long as they take their pills or their shots that’s all they need to do.  NO medication can make up for a crappy lifestyle!

If you are a diabetic, please make sure to see your doctor regularly.  If your doctor wants you to check your blood sugar and blood pressure, PLEASE do it, and keep a written log.  (It’s really hard for us to scroll through your glucometer’s tiny screen, so please bring us an organized log.  It will save time for more important things!)

Don’t smoke.  Whatever you need to do to quit, do it.

Get.  Serious.  About your diet.  NOT kidding.  What we put in our mouths determines the majority of health for ALL of us, not just diabetics.  Even if you have a low income, you can make healthy choices in your diet.

Walk.  Get outside and walk.  Go to the mall and walk.  It doesn’t matter WHERE you walk, as long as you do it.  Research has shown that walking is an excellent intervention for those who have circulatory problems in their legs.  It actually helps grow new blood vessels around any blockages that are there.

Look at your feet every day.  If you can’t reach them, get a mirror on a stick or have a family member check your feet.  All parts of them, tops and bottoms and between the toes.  Report ANY wounds or cuts or scaly, red areas to your doctor, even if they’re not painful.  Remember, diabetics lose feeling in their feet and it can be subtle so that they don’t realize the sensation is not normal.  Wear sturdy protective shoes to keep from injuring your feet, especially if you know the sensation isn’t normal.  Cute little sandals and flip-flops will NOT protect your feet from injury.

A diabetic amputation is a huge deal.  Amputation affects independence, the ability to walk and drive and get done the things that we need to do every day.  We need to do a better job preventing the need for diabetic amputations. That means being aggressive about diabetes and blood pressure treatment, protecting our feet, staying active and being engaged with our doctor and an active member of the treatment team.

God gave you two legs, two feet and ten toes.  There’s a reason for that, and we need to do everything we can to keep all those parts in good working order!

QUESTION: Do you know anyone who has lost part of their foot or leg to diabetic amputation?

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