Tanning Beds And Skin Cancer

Summer is coming, and so now I’m starting to see teenage girls coming in abnormally brown. There’s a lockdown, you can’t travel, and it’s Cleveland. I know you’re not laying out in the backyard. If you’re tanned, you’ve been in a tanning bed.

For twenty years I’ve been talking to patients and parents about the dangers of tanning beds. The most important risk (although not the only one) is the link between tanning beds and skin cancer.

The good news is that indoor tanning is becoming less common. Educational and public service programs seem to be raising awareness of the dangers. However, millions of adults still use indoor tanning beds every year, increasing their risk of skin cancer.

Credit: CDC.gov

There is good news about tanning bed use in teens. It is clear from surveys that use among teenagers is going down as well. But it is still obvious that tanning bed use is problematic in young women and teens.

Indoor tanning increases the risk of melanoma skin cancer by 15% after only ONE session. Use before age 35 increases the risk by 75%. The damage is cumulative, the more it is used the higher the risk.

If tanning is so dangerous, why do people do it? There is a lot of misinformation about indoor tanning out there. Tanning salons promote questionable health benefits and minimize the risks. Tanning beds often provide very high UV exposure, sometimes as much as 15 times the exposure one would receive from the sun.

One of the misconceptions is that indoor tanning is a “safe” tan. Young women in particular believe that a tanning bed is less dangerous and can provide a “base tan” before being outside in the sun. Research is clear however that the tanning process requires DNA damage. Whether one is tanning indoors or outdoors, it is NOT safe and increases the risk of skin cancer.

The only known benefit of UV exposure is the production of vitamin D in the skin. However, the level of UV exposure received in indoor tanning is complete overkill for vitamin D production. Vitamin D supplements are much safer and more effective for getting to a normal blood level of vitamin D.

Both indoor and outdoor tanning increase the risk of skin cancer, but tanning beds are much more dangerous. Wearing sunscreen, sunglasses and light-weight light-colored clothing, avoiding sun exposure during peak hours and taking a vitamin D supplement is the best approach to protecting your skin AND your health.

QUESTION: Do you use tanning beds?

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3 Best Ways To Survive Quarantine

Raise your hand if you are TIRED of quarantine. (Yes, that’s my hand waving in the air too…) We’re all managing, but are we really thriving? I think we’re all just waiting for life to get back to normal. Feels a bit like the end of pregnancy, if you ask me.

It’s uncomfortable and you don’t really care WHAT happens, as long as SOMETHING happens. And you know perfectly well that “old normal” is loooooooong gone, but you just are so eager to have it over with that you can miss some of the magic.

Everyone seems to have advice on how to make the best of this Great Pause. I have three suggestions of the best ways to survive quarantine, how we can come out of this situation better than when we went in.

Rest

One thing that really characterizes our culture is HUSTLE. We are SO busy that we rarely get the time to stop and take a few deep breaths.

Well the hustle is done for now. Rest assured, it isn’t done for good, but for this period we are forced to do less, to take a break. Take advantage of this time.

Sleep. Really commit to getting 7-8 hours of sleep at night, if at all possible. Do things just for the joy of them, without guilt. Work crossword puzzles or read a book or take long bubble baths. Binge a good Netflix series.

Rest. Take a break. It’s OK, the world can clearly take care of itself for a minute. You can take care of YOU.

Connect

One other thing that characterizes our culture in America right now is lack of connection. We work all day but don’t really know our coworkers. Our kids are in day care, school, after care programs, we don’t spend much time with them. Our siblings and parents and friends are even lower on the list.

Make a commitment to reach out to someone you’ve lost touch with. Call your parent or another older adult EVERY DAY just to say hello and check on them. It means more than you know. Play with your kids. Ride bikes. Learn how to play Magic or Pokemon or Dungeons & Dragons. Teach them your favorite recipes. (Christmas cookies in May? Sure, why not!)

I’ve heard it said that our kids someday may not remember much about fear and death, masks and hand sanitizer, not being able to go to the movies or the mall. But they might very well remember this was a time of pillow forts and board games, cooking and playing outside, going for walks and just hanging out with the most important people in their lives. You.

Learn Something New

If you are REALLY bored, look online for something new to learn. There are lots of community colleges offering courses online. Many museums are offering virtual tours for free. DuoLingo, Babbel and other language-learning apps make learning a new language fun. Start a blog. Take it from me, I’ve learned more from writing this blog than you have!

Life will get busy again very soon. Those on leave or unemployed will go back to work as the economy lumbers back to life. In this time before the hustle starts again, it’s great to rest, to cocoon with your people, and to work on YOU.

QUESTION: What has been your coping strategy for this quarantine period?

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Vitamin D and COVID-19

Wintertime in Cleveland really sucks. Snow. Cold. Gray skies. Did I mention snow? Colds and flu. This year’s winter has really taken the cake, though. COVID-19 has shut down the world, it seems.

I’m finding it really fascinating to read some of the explosion of research about COVID-19. Researchers are furiously trying to figure out what distinguishes those who are prone to more severe cases of this illness from those who have only mild symptoms.

A number of risk factors have emerged. Some are obvious, like diabetes and chronic lung disease. Others are making the medical community scratch their heads, like hypertension.

Recently a protective factor has emerged: vitamin D. It turns out that those with mild cases of COVID-19 are more likely to have normal vitamin D levels than those that have more severe cases or who are critically ill. What’s the link between vitamin D and COVID-19?

We know that vitamin D is important in supporting immune function and decreases your risk of getting colds and flu. Where does vitamin D come from, anyway?

Vitamin D is made in the skin in response to UVB light from the sun. UVB is blocked by clouds and by the atmosphere, so exposure is low in the winter in the higher latitudes and during the rainy season in the tropics. People with darker skin (such as people of African and Asian descent) make less vitamin D in their skin with a given amount of sun exposure.

There are not many dietary sources of vitamin D. Most dairy milk in the USA is fortified with added vitamin D, but there is not much in there. Most dairy milk is fortified to 100 units per cup. Given that it seems most adults need 2000-4000 units of vitamin D every DAY, you definitely can’t rely on dairy milk to get what you need.

So we’re left with supplementation. The best way to make sure you’re getting enough vitamin D is to have your doctor check a blood test. Current guidance is that your level should be around 50 to be optimal.

Black, Hispanic and Asian Americans have higher morbidity and mortality from COVID-19. Older adults have worse disease. These groups also generally have lower blood levels of vitamin D. I don’t think this is a coincidence.

If you can’t get to your doctor to get tested just now, that’s OK, you can definitely add a vitamin D supplement. Click here to see which one I take and trust for my family.

There is a lot of fear right now surrounding the COVID-19 pandemic. Making sure you are getting enough vitamin D every day is a simple thing that will help improve your health and support your immune system, and may help reduce your risk of a severe illness if you do contract COVID-19.

QUESTION: Do you take a vitamin D supplement every day?

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How To Have A Successful Virtual Visit

This is a really weird time in America. Everyone is staying at home. Restaurants and bars, museums, malls, zoos, movie theaters, parks and playgrounds are closed. Hospitals are empty of “elective” cases like knee replacements and spine surgery. At the same time, in many areas the health care system is completely overwhelmed by COVID-19.

Doctors’ offices are empty of patients. My practice is only seeing patients online. I have unfortunately gotten pretty comfortable doing something I never wanted to do – the virtual visit.

virtual visit

I was taught in medical school and residency that good medical care requires an examination. You can’t come to a reliable diagnosis if you can’t examine the patient. For over 20 years that has been “reality” for me.

Now I can’t examine anyone. It is extremely uncomfortable for me as a physician to have to diagnose someone’s illness based only on their symptoms. To know why someone is coughing without being able to listen to their lungs and heart is very difficult! To diagnose a UTI without checking a urine specimen is tough!

The very real danger is in overdiagnosing. Treating the earache caused by a viral infection with fluid in the ear is fairly simple, and doesn’t need antibiotics. However, if I can’t see the eardrum, I’m tempted to treat with antibiotics “just in case” it’s a bacterial ear infection. Antibiotics are potentially dangerous and only useful in certain cases.

But virtual visits are where it’s at right now, and they are safer for my patients, for me and my staff, and for all our families until the risk of this infection has subsided to some sort of “new normal.”

So how can you make sure that, if you need to do a virtual visit with your doctor, it’s as safe and effective as possible? Here are a few pointers:

  • If you are vomiting and unable to keep food or liquids down, or have chest pain or shortness of breath, you will likely need to be seen in the office, urgent care or ER. If you are severely sick you probably should bypass the virtual visit altogether and get checked out in person.
  • Do the visit on a laptop or desktop computer, not your phone or tablet if possible. Interfaces are more glitchy with the smaller electronics. (Also, your doctor doesn’t really want to look up your nose which is what happens when your phone or tablet is on your lap!)
  • Make sure your computer has the webcam, microphone and speaker (or headphones) all enabled.
  • Make sure you are not sitting with your back to a light source, like a lamp or brightly lit window. The light should be in front of you, behind the computer, so the light falls on your face.
  • You should have a home blood pressure meter available to take your blood pressure and pulse and show it to the doctor. If you have a known history of high blood pressure you need to have one of those, it’s a good time to get one. They’re available at your drugstore or on Amazon.com. Wrist meters are not as accurate as the ones that go on your upper arm.
  • While you’re ordering medical supplies, make sure you have a thermometer to take an oral temperature. The forehead scanners used in hospitals are very expensive – oral thermometers are cheap and accurate.
  • I love meeting your pets and your kids (and seeing what you’ve done with the place!) but please make sure they’re not going to be disruptive of the visit.
  • Be aware of and understand the limitations of the visit. There is an inherent risk of a missed diagnosis which is larger in a virtual visit (because there is no physical examination) than in an in-person visit.

I have high hopes that we will be able to start seeing patients in the office again soon. But the virtual visit probably isn’t going to go away. There are instances when it makes a lot of sense. Mental health follow ups. Reviews of lab results. Stable blood pressure follow ups when the patient has a reliable home blood pressure meter. (In fact, some of my patients would be better off having their BP checks at home!)

In this super weird time the virtual visit is what I would consider a necessary evil. We need to make sure we’re doing everything possible to make your online visit as safe and effective as possible.

QUESTION: Have you had a virtual visit with your doctor? Was it a good experience?

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Who Should Be Tested For COVID-19

As a physician working for one of the big local healthcare systems, starting Monday I will have the ability to order outpatient testing for the coronavirus. University Hospitals of Cleveland and the Cleveland Clinic are both offering drive-through swab testing with a doctor’s order.

Credit: bangordailynews.com

I’m anticipating a LOT of phone calls on Monday. Before you call, I want to go over the guidelines for who should be tested for COVID-19.

The very first question that will be asked when someone calls is “ARE YOU SICK.” This sounds silly but the worried well are going to want to be tested. I was at Costco Friday morning, am I at risk? I work in healthcare, am I at risk? Yes, of course. But I do NOT need to be tested because I am NOT sick.

The symptoms of COVID-19 include fever, cough, and shortness of breath. If you have a runny nose and cough, but no fever, you have a cold and do NOT need to be tested. And you don’t need to go to the doctor, urgent care or emergency room either! Stay home, drink fluids, rest and wash your hands until you are feeling better.

Suppose you do have a fever and a cough. If so, I guarantee that anxiety is going to make you feel short of breath! The next question is, have you been exposed? At this point, if you have not traveled and have not been in contact with a known or suspected case of COVID-19, and are well enough to stay home, you do NOT need to be tested. The exceptions are healthcare workers and those at high risk (like cancer patients and those 65 and older with multiple medical problems).

If you or a family member have any of THESE symptoms, you need to call 911.

  • Shortness of breath
  • Chest pain, pressure or discomfort
  • Bluish discoloration around the lips or fingernails
  • Confusion or difficulty waking up

If you need to call 911, let the dispatcher know what’s going on so they can give the paramedics and ER a heads-up and be prepared.

Social distancing, closing schools, avoiding large groups, good handwashing and sanitizing surfaces will help slow the spread of the virus. It’s inevitable that some people will be infected, and knowing who needs tested is important. We don’t have unlimited ability to test the general population. Just because you are scared and MIGHT have been exposed is not a reason to get tested.

If you need more information about this infection, here are some good resources for facts, not hype or hysteria:

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Caregiver Stress And The Sandwich Generation

I’m planning to give a talk on caregiver stress in a few weeks, and I figured I’d ask my lovely readers to help me make this talk awesome.

What is a caregiver?  A caregiver is defined as someone who provides care for another person in need.  Generally the person being cared for is unwell in some way and needs help with daily tasks.  Those with cancer, dementia, and many other chronic conditions may need help with dressing, bathing, eating, medication management and other critical tasks.

Who are our nation’s caregivers?  According to womenshealth.gov, over 20% of adult Americans will provide unpaid care to an elderly or disabled person each year.  61% of informal or family caregivers are women, and most are middle-aged.  59% of women who provide informal care to a family member are also employed. Over half of these employed female informal caregivers have made changes at work to accommodate caregiving, such as scaling back their work hours or changing their schedules.

There is an interesting term to refer to those providing informal or family caregiving:  The Sandwich Generation.  There are several types of Sandwich Generationers:

  • Traditional Sandwich – those caring for both aging parents and their own children
  • Club Sandwich – those caring either for both aging parents and their own adult children and grandchildren (4 layers!) OR aging parents and grandparents and their own children
  • Open-Faced Sandwich – anyone else involved in informal caregiving

Sandwich generation caregivers have an extra level of stress because they have competing priorities.  There is only so much time and they often feel they can’t do justice to any single task because they’re pulled in so many different directions.

Caregivers have definitely Got Stress.  How does one know when caregiver stress is becoming unhealthy?  The Alzheimer’s Association has a lot of information on their website about caregiver stress and burnout.  Symptoms can include anxiety, irritability, trouble concentrating, depression and anger.  Caregivers may be in denial about their loved one’s illness.  They may withdraw from friends and family, have trouble sleeping and feel exhausted.

Caregivers’ own health may suffer due to stress and burnout.  Researchers at the CDC found that 20% of caregivers surveyed rated their own health as fair or poor.

If you are a caregiver and find yourself struggling with stress and burnout, what can you do about it?  Better yet, if you find yourself (or know someone else who is) in the caregiver role, how can you minimize the risk of burnout?

  • Don’t beat yourself up because you can’t do everything.  Recognize you’re only human and be gentle with yourself.
  • Look for resources.  Check with the local Area Agency on Aging to explore what services are available near you.  There may also be disease-specific resources and services available.
  • Be proactive and take a problem-solving approach, rather than worrying and feeling helpless.
  • Do your best to take care of yourself.  Exercise, eat right, and get enough sleep.  See your doctor for your annual physical and other scheduled visits.  Remember, you can’t take care of others if you’re not well yourself.
  • Actively practice proven stress reduction strategies.  Meditation and yoga are good options.  Check out this recent post about Sudarshan Kriya Yoga.  Go to church, temple or other religious services regularly.
  • Don’t be afraid to ask other family members for financial help if you need it.
  • Ask for and ACCEPT help.  Have a mental list of things people can do and let them choose one.  For instance, a sibling can take Mom for visits on weekends to give you a break.
  • Be realistic and don’t be afraid to say no if you can’t commit to something.  Someone else will be able to chair the PTA and run the fundraiser.
  • Stay in touch with family and friends.  Isolation makes stress worse and accelerates burnout.
  • Keep a sense of humor!

I want to make sure you realize that there are significant upsides to the caregiver role too.  Many of my patients are providing care to aging parents and grandparents and find it incredibly rewarding.  For instance, one patient was the full-time caregiver for her father until he passed away in his 90s.  She has told me it was wonderful being able to share that time with him, knowing the time was limited and coming to a close.  Focusing on the blessings rather than the trials and keeping her (boisterous!!) sense of humor helped her keep burnout at bay.

Research has also shown that the healthiest and longest-lived people on Earth tend to live in multi-generational households.  Maintaining close relationships between generations is good for your health and for society.  One of my friends is a caregiver for her grandfather who has Alzheimer’s disease.  She is homeschooling her son and they spend the day together as a family.  Her grandfather is fascinated by his great-grandson’s schooling and the little guy adores spending time with him every day.

Providing family caregiving services to an elderly or ill family member is stressful, no doubt about it.  Caregiver stress is common and falls largely on women.  It doesn’t have to lead to conflict, burnout and physical illness though.  Acknowledging your limitations, asking for help, practicing good self-care, and seeking out the positive can help keep you healthy and make caregiving a rewarding experience for you AND your loved one.

QUESTION:  Are you providing caregiving services for someone you love?  What are you struggling with, and what helps you manage?

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How To Wash Your Hands

I was browsing the health news reports to get an idea of a topic for this weekend’s post. Literally every post is about the coronavirus outbreak and its spread to numerous countries.

While this is very important, unfortunately I’ve already written about this topic. I have seen a number of posts this week on social media about proper hand washing, and decided this was a good time to review the right way to wash your hands.

Everyone from Mayo Clinic to the CDC has put out guidelines about how to wash hands correctly. I have included a video at the end but here are the steps:

  • Wet hands with warm water
  • Use regular soap. Antibacterial soap actually increases the risk of staph infections and is not recommended.
  • Lather the hands thoroughly and rub them together. Get between the fingers, the tips, and the thumb.
  • Continue to rub the hands for 20 seconds. This is the time it takes to sing the Happy Birthday song or the Yankee Doodle song through twice.
  • Rinse the hands thoroughly under warm water.
  • Turn off the tap with a paper towel, NOT your clean hands
  • Open the bathroom door with a paper towel, NOT your clean hands

Studies have shown over and over that good hand hygiene is critical in preventing infection. This is true not only in hospitals and doctors’ offices but in the general public as well. Especially with the growing concern about coronavirus infection, proper hand washing is a critical measure everyone can and should take to reduce their risk of illness.

QUESTION: Are you washing your hands correctly?

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Sudarshan Kriya Yoga For Health

So many of my patients suffer with anxiety and depression. What’s worse, it is estimated that 90% of visits to primary care doctors are related to stress. Stress makes pain and other physical symptoms worse and harder to control. It interferes with management of medical problems like diabetes, high blood pressure and heart disease.

I’ve known for a long time that yoga is helpful for stress management and for your physical health. But there is one specific yoga practice, taught and practiced right here in Cleveland (and around the world), that has proven health benefits. Sudarshan Kriya yoga.

Sudarshan Kriya yoga (SKY) was developed and is taught by Art Of Living International, a nonprofit group led by Sri Sri Ravi Shankar. I was privileged to participate in a training course recently and can tell you from personal experience that there are real benefits to this practice.

I wouldn’t necessarily recommend this practice to patients and readers based on my own experience. It turns out, though, that there have been over 30 scientific studies published on the health benefits of this practice. Let’s review some of the evidence.

Anxiety is one of the most common mental health problems I see. It is a chronic illness that colors a patient’s entire experience and significantly impacts their quality of life. Sudarshan Kriya yoga was shown to produce improvements in symptoms in over 70% of subjects and complete remissions in 41% of subjects in only 4 weeks of practice. That is comparable to the effectiveness of medication and psychotherapy.

An estimated 20% of American adults will suffer with depression, and it is one of the most common problems I see in the office. Most patients respond well to medication but some do not. SKY is as effective as imipramine (a third-line medication choice) for patients who don’t respond to more commonly used medications.

Post-traumatic stress disorder is a terrible consequence of traumatic life events seen in survivors of natural disasters, terrorist attacks and childhood trauma, and especially in combat veterans. It is very difficult to treat and leads sufferers, particularly veterans, to even contemplate suicide to escape their symptoms. Sudarshan Kriya yoga produced significant and sustained improvements in symptoms in veterans suffering from PTSD, suggesting it should be considered in all patients with this awful illness.

With the attention being paid to the opioid epidemic, it is encouraging to be able to offer an intervention that improves quality of life for opioid users in recovery. One study did demonstrate this effect. SKY also helps smokers quit using tobacco products.

Stress, anxiety, and depression all have physical effects on the body. Many adverse effects of stress have been documented and they contribute to many chronic illnesses. How does SKY impact these physical illnesses and improve health?

Stress causes changes in the lipid profile and in hematological parameters such as platelet count. Over time, these changes may contribute to the increase in heart risk known to be associated with high levels of chronic stress. Sudarshan Kriya yoga has been shown to improve these changes in as little as 3 weeks.

It is also known that stress causes changes in the cardiovascular system related to the autonomic “fight or flight” system. Over time, especially in patients with high blood pressure and diabetes, dysfunction in this system can contribute to increased risk of heart attack and stroke. SKY improves measures of cardiac autonomic function which may in the future be shown to decrease cardiovascular risk.

Diabetics in particular can benefit from the practice of Sudarshan Kriya yoga. Glucose tolerance (postprandial glucose) improved significantly in people practicing SKY and, as mentioned above, cardiac autonomic function improved as well.

Those who are living with chronic, life threatening diseases such as cancer know that stress and anxiety worsens all their physical symptoms. Yoga, including SKY, improves pain and stress even in those with advanced stage breast cancer.

We are not just physical beings. Our minds, emotions and spirits affect our bodies as much as the foods we eat and the exercise we perform. Sudarshan Kriya yoga is an effective way to improve our mental health and our physical wellbeing. If you suffer with anxiety, depression, PTSD, substance addiction, diabetes, heart disease or any other chronic illness please consider taking the Happiness Course with Art Of Living International. Click this link to find a course near you!

QUESTION: Do you practice yoga? Would you consider trying it?

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Wuhan Coronavirus

OK, everyone is talking about the Coronavirus infection that started in Wuhan, China and is spreading throughout the world. What do you need to know about it?

This infection was first reported in late 2019 in Wuhan, China. A number of the first cases were reported in people who had connections to a large seafood and animal market, but later cases seemed to clearly show person-to-person transmission.

The infection is now here in the United States, and not everyone who has tested positive for the virus has been to China. Clearly the virus can pass from person to person. As of Friday, 1/31, there have been seven cases in the United States.

Wuhan Coronavirus is a respiratory illness that causes fever, cough and shortness of breath. Serious cases can involve pneumonia. Symptoms can be mild to severe. There is no vaccine, although scientists are working to develop one, and as of now there is no widely available treatment. A combination of medications designed for influenza and HIV seems to be helpful though.

Right now the best way to stay safe from this virus is to avoid infection. Travel to China has been restricted by the State Department. People returning from the Wuhan region of China are being quarantined.

If you have been to China and are sick with a respiratory illness, please see the doctor right away and tell the doctor immediately that you were in China. Follow sensible precautions like washing hands, covering coughs and disinfecting surfaces in your home.

The Wuhan Coronavirus can be deadly. About 2% of cases in China have been fatal. Compared to influenza, which kills about 1 in 1000 people who catch it, this is much more dangerous but also much more rare. 360 people have died in China from Coronavirus, compared to over 34,000 people who died in the United States in the 2018-2019 flu season.

Be aware of Wuhan Coronavirus. Don’t travel to China until the State Department announces it is safe. If you have traveled and get sick, see the doctor and make sure they know your travel history. Take sensible precautions. And don’t panic.

QUESTION: Are you worried about Wuhan Coronavirus?

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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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