Cardiac Rehab After Heart Attack

If I tried to make a list of all my patients who have had a heart attack in the past year, unfortunately I probably would be here awhile. We are NOT good at identifying patients at risk, and many patients refuse treatments and lifestyle changes that are proven to reduce their risk of a heart attack.

AFTER a heart attack, though, we have a very good idea what will reduce the risk of having another one. Sadly, only a very small number of patients take advantage of one of the best measures to reduce the risk of an encore performance: cardiac rehab.

Cardiac rehab consists of 36 one-hour sessions which are covered by Medicare and most if not all commercial insurance. The sessions include

  • supervised exercise training
  • counseling on diet
  • counseling on stress management
  • smoking cessation (if needed)
  • guidance on other measures for heart-healthy living

Researchers at the CDC in Atlanta looked at heart attack and heart failure patients covered by Medicare and found that only 24% of the patients even started cardiac rehab. Of those, on average patients completed only 25 sessions, with only 27% attending the recommended 36 sessions.

Older patients, patients of color, sicker patients and women were less likely to go to cardiac rehab. The study wasn’t designed to figure out why this was seen. However, I can imagine transportation and family support may have been a problem with the older and sicker patients. Access to care is always a problem with patients of color and in this instance doesn’t surprise me. Women in general put their own needs last, and I can definitely see female patients being less likely to attend an extended series of rehab sessions. I can’t even get them to go to 12 physical therapy sessions to address an excruciating musculoskeletal injury!

Cardiac rehab reduces the risk of death in the period after a heart attack. It improves quality of life, mood and functional status. It also reduces the risk of hospital readmission. Every patient with a heart-related hospital stay should be offered (and should take advantage of) cardiac rehab.

If you or a family member find yourself diagnosed with a heart condition, ask your cardiologist or family doctor whether you qualify for cardiac rehab. If you do, GO. Go to ALL the sessions, go until they tell you not to come back anymore. Your heart will thank you!

QUESTION: Did you know about cardiac rehab? Do you know anyone who would benefit from it?

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Setting Goals For The New Year

Happy New Year everyone! Now comes the time of full parking lots at the gym and having to wait for equipment. Diet products are everywhere. Planners are selling out at the bookstore.

By February it seems like things are back to “normal” at the gym and elsewhere. Why does setting goals and meeting them seem like such a hard thing?

Generally there are three reasons why people don’t meet the goals they have set for themselves:

  • The goal is too vague: “I’m going to get healthier.”
  • The goal is too big: “I’m going to lose 100 pounds this year.”
  • No accountability

In management circles there is talk of setting SMART goals. SMART is an acronym that helps with effective goal setting. Goals should be

  • Specific
  • Measurable
  • Achievable
  • Relevant and
  • Time-limited

There are lots of resources to dive deeper into each of these characteristics but let’s start with our vague “I’m going to get healthier” goal from earlier. What would that mean? What does “healthier” mean?

In this case let’s imagine a diabetic patient. For him, “healthier” may mean getting better control of his blood sugar. If he is starting with a hemoglobin A1C of 8, he may set a goal of 6.5 in 6 months. This goal is specific, measurable, definitely achievable, relevant and time-limited.

If this were my patient, I would push him to make more goals to flesh out the plan. What is his food goal? What about an activity goal? Hopefully he already has taking his medication daily under control, LOL! After all, a dream with a plan (and a deadline, per Napoleon Hill) is a goal. The plan is important. How are we going to achieve this goal?

Once you have a goal and have broken it down into smaller pieces, it’s important to share the goal with someone who can support you. A spouse, a friend, a sibling, we need to have an accountability partner to remind you why you set the goal in the first place and pick you up when your motivation fizzles.

It doesn’t matter what your specific goal is. You can rock it this year!

QUESTION: What goals do you have? How can we make 2020 your healthiest year ever?

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Artificial Sweeteners And Health

Bonnie is a patient of mine who struggles with her weight. When she was younger she was slender, active, enjoyed exercise and enjoyed cooking. She is a nurse and has always been drawn to high-stress fields where she feels she can make a real difference for her patients. She married late and had two children and since then her weight has gotten out of hand.

At a recent appointment I asked whether she was ready to make some changes and tackle her weight. She has tried a number of weight loss programs without lasting success. At her last visit she brought a bottle of what turned out to be her favorite beverage with her: Diet Coke.

I asked her about it and she admitted she drinks almost nothing but diet Coke. She doesn’t like coffee so she relies on the caffeine in her soda to get her going in the morning. She justifies it by saying “at least it’s DIET Coke, there’s no sugar, so it’s OK.”

But is it? New research has come out suggesting that artificial sweeteners are not the weight loss magic they were designed to be.

Researchers in San Antonio, Texas, published a very thorough review of both animal and human research studies looking at the effects of artificial sweeteners on a number of health parameters. They found that animals fed a whole range of artificial sweeteners – including saccharin, sucralose, acesulfame potassium, aspartame, or the combination of erythritol+aspartame – had a number of adverse impacts on their health.

They tended to eat more. They gained weight. They developed higher percent body fat. They had worse metabolic markers including those for diabetes and for inflammation.

These changes were more pronounced in male animals and in those with a genetic predisposition to obesity. They were especially striking in those eating high-fat, high-sugar diets and diets meant to mimic our “Western” diet.

In the human studies those participants who reported daily (or more frequent) use of artificial sweeteners had more weight gain. They gained more weight around the abdomen, which is the most dangerous place to gain it. They were more likely to be overweight and obese.

I’ve always said there’s a difference between being fat and being unhealthy. You can be a fit overweight person. But those study participants who used artificial sweeteners tended to NOT be fit or healthy. Those who reported daily or more frequent intake of diet drinks (the most common source of artificial sweeteners) were more likely to have hypertension, metabolic syndrome, diabetes, depression, kidney dysfunction, heart attack, stroke, and even cardiovascular and total mortality.

Obesity studies tend to have a heavy participation of female subjects. Because the animal studies showed the impact of artificial sweeteners is more pronounced in male animals, the dangers of these additives may actually be more than what we are seeing (which is bad enough).

If you are currently drinking diet soda thinking it will help you lose weight, please stop. The science is clear that diet beverages promote weight gain and increase the risk of diabetes and other health problems. If you like fizzy drinks there are plenty of unsweetened seltzer drinks available to choose from. Even unflavored seltzer with a dash of fruit juice is a better option.

The good news is that diet soda consumption is on the decline. But people looking to lose weight are still susceptible to the lure of something for nothing. Remember, if it sounds too good to be true, it probably is.

QUESTION: Do you drink diet soda? Will this information cause you to rethink that?

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When Misleading Ads Harm People

My patient Brian is a gay man who has been taking the medication Truvada to protect him from HIV infection. Recently I saw him in the office and he said he saw an ad on Facebook suggesting this medication causes bone and kidney problems, so he stopped it.

When advertisers mislead people to make a buck, that’s one thing. When misleading ads lead to people being hurt or killed, that’s another.

Brian is at increased risk of HIV infection due to his lifestyle. He is a lovely, gentle man who is a talented musician. Whether you agree with his choices or not, he does NOT deserve to contract a deadly disease if it can be prevented. And Truvada reduces the risk of HIV infection by 99%.

The ads in question are being run by legal firms who, it seems, are attempting to organize class-action lawsuits against the company that makes Truvada. These misleading ads claim the medication is dangerous and imply taking it isn’t worth the risk. When patients without medical knowledge, like Brian, see these ads online they become concerned and sometimes choose to stop their medication.

All medications have risks. Doctors talk with patients and weigh these risks against the proven benefits of the medications. Often doctors run periodic tests to monitor for problems stemming from use of medications. Other medications can cause kidney problems (like blood pressure medications and NSAIDs like Advil) or bone problems (like some contraceptives and steroids used for severe arthritis) but we still use them.

Stopping blood pressure medication because some lots of generic medication have been found contaminated is one thing. High blood pressure is rarely dangerous over the short term – once it’s confirmed your pills aren’t from one of the affected lots you can restart them. However, stopping medication to prevent infection from HIV can be deadly over a short period of time, if one is exposed during that unprotected window.

Almost 40,000 new cases of HIV infection happen every year. Over 1 million Americans are living with HIV, and approximately 15% of these people don’t know they are infected. Gay and bisexual men, sex workers and IV drug users are at highest risk and most likely to benefit from treatment with Truvada.

If you are taking a medication, ANY medication, and you see something reported on TV or radio that concerns you, talk to your doctor before stopping your medication. Your physician should be able to address your concerns and, if not, you can decide together on a course of treatment that makes you comfortable and continues to meet your health goals.

It’s been said before, but bears repeating. Don’t believe everything you see or hear online.

QUESTION: How do you judge when you see concerning information online? How do you know what to believe?

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Meaningful Work And Joyful Play

“What do you do for fun?”

That may sound like a weird question for your doctor to ask you, but what can I say, I’m weird 😉 I’ve been doing some training on how to coach for nutrition and lifestyle change, and one thing I read this week really struck me.

Stress depends largely on a balance between meaningful work and joyful play.

So lately I’ve been asking my patients what they like to do for fun. If I’m seeing a patient for depression, chances are good they can’t tell me one single thing they do that they enjoy. One patient went so far as to tell me (tearfully) that she is not getting any fun out of life at all.

We’ll talk about Part Two in a minute, but I want to start by talking about meaningful work. Many of my patients, especially if they struggle with depression, have trouble with seeing their work as meaningful. They feel like they’re punching a clock, going through the motions.

I read once (probably connected with some small-business training or other) that all business boils down to making someone’s life better. Think about that. Why do you open your wallet and spend money? Because you believe that transaction will make your life better. Subscribing to Disney+, buying a new pair of shoes, sending your kids to private school, saving for retirement instead of taking an extra trip this year. Even paying taxes makes your life better (by averting the likelihood of prison for tax evasion)

There was a talk not long ago I attended about improving quality at a big hospital system. The speaker was talking about a time he visited an aircraft carrier. One of the airmen’s job was to clean up the deck. The speaker asked what his job was. He could have said “I’m the janitor,” or “I keep the deck clean.” But that’s not what he said.

When asked what his job was, the speaker said the airman stood up straight, looked him in the eye and said “Sir, I help planes take off and land safely to protect our pilots and further the mission of the United States Navy. Sir.” Wow! That’s a man with a clear idea of how his job makes people’s lives better!

When you go to work every day, your job will feel much more meaningful if you focus on how you are making someone’s life better. I challenge you in the comments to give me a job that DOESN’T make someone’s life better.

On the other side of the coin, no matter how meaningful your work is, you still need to make time for R&R, otherwise you’re courting burnout. My work is extremely meaningful, all of it, from doctoring to my Shaklee business to writing this blog. But if I don’t take time to play, I start to get irritable. I even have found myself feeling cynical.

For me, “play” means lots of things. I hang out with my kids and play video games sometimes. I practice martial arts with my family. I have a number of fiber crafts I love: spinning, crochet, knitting. I read novels. I practice my faith. I sing along with the radio and my music selection on my phone (not always well but with great enthusiasm, LOL). I do all these things to balance my incredibly meaningful but at times extremely stressful work.

In chasing the elusive “work-life balance,” it helps to focus on incorporating both meaningful work and joyful play in every day.

QUESTIONS: Two today! How do you play joyfully every day? And can you think of a job that would NOT make someone’s life better? Don’t pick politicians – that’s too easy 😉

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Measles Outbreaks In The Pacific

Fever, rash, cough and congestion. These are the hallmarks of measles. Before the beginning of the measles vaccination program in the 1960s, there were 3-4 million cases of measles annually in the United States, almost 40,000 people were hospitalized, over 1000 people developed permanent disability from measles encephalopathy, and almost 500 people died. Every year. Most of these cases happened in children.

Now with vaccination rates falling, we are again seeing outbreaks of measles. Right now, there are measles outbreaks occurring in the South Pacific. It’s estimated that only 30% of the population of Samoa, for instance, have been vaccinated against measles, and they are in the midst of a terrible outbreak right now. Other countries are sending medical supplies, doses of vaccine and health care personnel to help deal with this outbreak.

Samoa is a country with about 200,000 people. 3,149 cases of measles have been reported, 197 people are hospitalized and 42 have died. To give some idea of the magnitude of this outbreak, we can compare to the United States, which has a population of 327.2 million people. This size of an outbreak in the US would result in 5.2 million cases, 322,000 people hospitalized, and 68,712 deaths. Most of Samoa’s deaths have been in children under 4 years of age.

Think about that. Imagine a United States in which almost 70,000 infants, toddlers and preschoolers were killed within a month’s time. Bearing in mind that those deaths are preventable, this outbreak in Samoa is a heartbreaking tragedy.

The good news for the USA is that vaccine coverage overall is still above 90%. However, there are 11 states in which coverage is under 90% and there are pockets where vaccine coverage is much, much lower. Amish people reject most modern medical innovations (including vaccines). Many California communities have vaccine coverage rates at about 50%. This is much lower than what is required to prevent outbreaks of measles.

Measles is the most contagious illness we know. It is a serious illness and potentially fatal. The vaccine is safe, so safe that in 1.5 million people vaccinated in Finland from 1982-1992 no deaths or serious permanent adverse reactions were reported.

If you are not immune to measles and are exposed, you have a 90% chance of getting sick. This is in comparison to influenza, which has about a 50% transmission rate. Parents who choose not to vaccinate their children are making a choice to leave them unprotected against a serious, possibly fatal, horribly contagious illness that is still endemic in parts of the world.

No vaccine is perfectly effective, but the MMR vaccine is pretty close. It eradicated measles, mumps and rubella in Finland in the 1980s with a 12-year, 2-dose vaccination schedule.

Measles is still present in the world. The MMR vaccine is the most effective weapon we have against this illness. Please be sure to vaccinate your children.

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Taking A Break To Cultivate Faith

Hello everyone! I’m sending a short update because I’m taking a break this week from blogging. My son and I are attending the National Catholic Youth Conference in Indianapolis this weekend.

If you are Catholic and have young people in your life, PLEASE encourage them to get involved with their youth ministry at church. Encourage them to come to the next NCYC in November 2021. They will not regret it. This hasn’t been an incredible experience for me and for the teens.

I’ll be back to writing about health topics next week. In the meantime please pray for me – I am praying for you! If you have a specific intention you’d like me to pray for, please drop me an email ❤️

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Picky Eaters: Some Suggestions

“What should I do about my child, he is SUCH a picky eater!”

I hear this a lot in the office.  Parents are struggling to find foods that their child will eat.  Parents cooking several meals every night, one for their child(ren) and one for themselves.

Thanksgiving is a good time to reiterate:  this is a mistake.  Don’t go there.  Just don’t.

When I have a parent struggling with a picky eater, it is exactly that.  A struggle.  A battle.  A fight for control.  The parent trying to control what their child eats.  And the child fighting to control ANYTHING he or she can.

My absolute best suggestion for this situation is to take the fight out of it.  Give the child choices from the time the child can communicate.  Let your child control SOMETHING.  Do you want the red bowl or the blue bowl?  How about the Mickey Mouse plate or the Cars plate?  Do you want to try eating at the table like a big boy or do you want to stay in the high chair?  Straw cup or sippy cup?

As your child gets bigger let them take more control.  Ask for help with meal planning.  Should Daddy put the corn on the grill or should we cook it on the stove?  Do you think green peas or green beans sound better tonight?  Especially if it’s a special dinner like Thanksgiving, simple tasks give children a role to play and something to brag about over dinner (“Mommy let me stir the soup into the green beans AND I got to put the onions on top!”)  Let them say how much of each item they want on their plate.  Not WHETHER they want it, but how much:  a little or a lot.

Taking your children to a farmer’s market in the summer and exploring all the really cool and unusual foods is a way to trigger interest in food as well.  Ever had muskmelon?  I tried it for the first time at forty-two.  My six-year-old loved it.  We found it at the farmer’s market and it was love at first sample 🙂  Now both my kids (17 and 12 now) are pretty adventurous although my senior is still not a big fan of green things, LOL!

What do you do if you have a bigger picky eater?  Suppose your child is twelve and still has only five or six foods on the approved list?  That’s a tough one.  One of the best suggestions I’ve ever read is to have your child take charge of one meal per week.  From meal planning (within limits) to making a list to shopping to cooking (with help), making one meal per week is a great way to expose children to new foods and encourage them to be more adventurous with food.

There are lots of recipe sites and apps out there but my favorite is allrecipes.com. It’s easy to pick an ingredient and search for options.  Sure it’s a lot of work to help a tween plan, shop for and cook an entire meal, but they have to learn this skill sometime!  After a few weeks I think Mom and Dad will enjoy a dinner “off” once a week, and your child will have a new skill they can be very proud of.

PS – I highly recommend the book French Kids Eat Everything and Jim and Charles Fay’s Love and Logic series of parenting books, which have many very helpful suggestions for curing picky eater syndrome.

QUESTION:  Can you add more suggestions for helping parents with their picky eaters?

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Mental Health Professional Shortage

Tiffany came to see me as a new patient this week. She is a very nice young woman with a number of very big problems. She is a single mother to two daughters, one of whom is autistic. As a working mom, she has to juggle childcare and all the other household tasks. Her ex-husband is behind on child support and only rarely takes the girls for weekends. He has trouble managing their autistic child’s behaviors.

It probably won’t surprise you that Tiffany is REALLY stressed. She isn’t sleeping, and her anxiety is becoming harder to manage. She came in this week asking for a referral to a psychiatrist.

If you’ve been following me for a while, you probably know part of me started to do a quiet little happy dance on the inside as I was listening to my new friend. She was in the absolute perfect place because I have so many tools to help her. The one that I DON’T use often (and just sits dusty on the shelf almost all the time) is a psychiatry referral. I don’t need it except in rare cases.

It’s a good thing, too, because psychiatrists aren’t exactly thick on the ground in northern Ohio. In fact, most of the country has a severe mental health professional shortage.

Researchers found that this shortage is impacting how people get care for mental health problems in a big way. They looked at claims for mental health vs. physical health problems. The researchers found that people chose to go out of network and pay a larger share of the cost of treatment for their mental health problems.

While the researchers didn’t speak to patients directly and didn’t ask why they went out of network, it’s pretty obvious to me. Those of us in primary care know it takes months to get an appointment with a psychiatrist. Insurance companies often have only a handful of choices for in-network care, and many psychiatrists don’t take insurance at all because reimbursement is very low. If someone is severely sick or a danger to themselves or others, they are directed to the ER where they may be hospitalized. Otherwise they wait.

Here is my prescription for fixing our mental health care shortage:

  • Every single person needs to have an established relationship with a primary care doctor. This means a family doctor, general internal medicine doctor (NOT A SPECIALIST) or pediatrician for little kids. If you are reading this and don’t have a primary doctor, GET ONE. See him or her annually for your physical at a minimum. If you don’t like your primary doctor, get a new one!
  • Be aware of your lifestyle and its impact on your mood. Sleep, exercise, your spiritual practice, diet, ALL will impact your mood. Take small steps to improve your lifestyle before your mood starts to suffer!
  • If you start to feel stress is getting to you, see your primary doctor before things get bad. Don’t wait until you’re so sick you can’t function at all!
  • Consider seeing a counselor. Cognitive behavior therapy (CBT) is as effective as medication for mild-to-moderate depression and anxiety symptoms. It’s hard work, and requires a special kind of courage to unpack what’s going on in your life, but so worth it!
  • Psychiatrists need to send patients with depression and anxiety who are improved and in remission BACK TO THEIR PRIMARY DOCTOR for management. There is no excuse for psychiatrists to continue seeing patients who don’t need them. This will free up space in their schedule for patients who are truly in need of specialty care.

So what did I do for Tiffany? First I asked her to make an appointment with a counselor. I also asked her to start some nutrition therapy with a good multivitamin, B complex and magnesium supplements. Because she was really struggling I started her also on a low dose of an antidepressant and a gentle non-habit-forming sleeping pill.

As food for thought, we discussed the recent research showing diet’s impact on depression and anxiety and I gave her some suggestions. We’ll continue to discuss this in the future. I’m sure when I see her back in a few weeks she will be feeling better and much more in control.

I can’t fix the things going on in Tiffany’s life that are difficult for her. Divorce, single motherhood, working motherhood, and a child with a chronic illness are real stressors. However, depression and anxiety make hard things just that much harder. Treatment is effective, and doesn’t require a visit to a psychiatrist.

QUESTION: Did you know there is a mental health professional shortage?

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Go Green: Greens Are Good For You!

How many servings of leafy green vegetables did you eat today?  There are so many to choose from, it’s easy to get some every day.  They are soooo good for you and tasty too!  At the end of the post I’ll share my favorite kale recipe 🙂

Why are green vegetables so good for you?  Pound for pound they have the most nutrition of any food on our planet.  They are low-carb, low-calorie and full of good stuff!

1.  Vitamins and minerals:  Vitamins K, E, C, and many of the B vitamins, as well as potassium, magnesium, calcium and iron.

2.  Powerful plant pigments that function as precursors to other vitamins and as antioxidants.  Beta-carotene, chlorophyll, zeaxanthin and lutein are some of the phytonutrients found in dark leafy green veggies.  The brightly-colored pigments in plants help fight cancer by acting as antioxidants.

3.  Green veggies don’t contain as much fiber as, say, beans or lentils or whole grains but they have SOME.  Kale, for instance, has 2.6 grams fiber per 1-cup serving.  They also have a small amount of omega-3 fatty acids.

Nutrition experts estimate that our ancestors ate five pounds of green leaves every day!  They were hunter-gatherers and hunting green leaves was a lot easier than hunting animals.  They didn’t get up and run away, after all!  When game was scarce they simply ate the plants all around them.

So what is the best way to eat your greens?  The same way our ancestors did!  Raw 🙂  You can also lightly steam or saute them.  DON’T boil them (it leaches away the cancer-fighting phytonutrients) and don’t overcook them because that begins to destroy the nutrition.

Try adding a big salad of leafy greens every day.  Mix up your leaves or combine them to take advantage of different flavors.  Use just a little dressing and it’s best to make your own dressings fresh.  If you have a food processor it’s easy to whip up a small amount of fresh dressing for your salad.  Combining different oils (like olive, sesame or walnut) with different vinegars (such as balsamic, red wine, rice wine, or apple cider) and different spices is much healthier than using mass-produced bottled dressings.

One of the most nutritious leafy green vegetables is kale.  Kale is bitter and many people don’t like eating it raw (including me).  I much prefer it sauteed.  Here’s my recipe!

Dr. Jen’s Sauteed Kale

Ingredients

  • 1 tablespoon extra-virgin olive oil or sesame oil
  • 1/2 onion, peeled and chopped
  • 2 cloves garlic, minced
  • 1 large bunch kale, washed, stems removed, and coarsely chopped
  • golden raisins soaked in hot water to plump them
  • Handful of pecans, chopped

Directions

  1. Drizzle a large shallow pan with oil and heat over medium heat. Add the onion and garlic and saute about 5 minutes, until starting to soften.
  2. Add a little water to the pan (for steam) then add the kale.  Cover and steam for about 5 minutes, then drain the oily water out.  Transfer the kale to a bowl and top with plumped golden raisins and pecans.  Enjoy!

Please feel free to play with this recipe.  There are so many fruits that you could use to add a little sweet to balance the bitter kale.  Toasted almonds, walnuts or sesame seeds could also be used for variety.

Want another easy way to get your greens?  Shaklee’s Organic Greens Booster has kale, spinach and broccoli in a form that’s easy to add to soups and smoothies.

For more information, check out 13 easy ways to eat more greens and Fitness Magazine’s guide to leafy greens.

QUESTION:  What is your favorite leafy green vegetable, and how do you like to eat it?

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