Dr. Grimshaw provides helpful tips and other useful information to his patients and many others. These Health Guides and Newsletters can all be found online now. Feel free to browse through them for tips toward a healthier life or other health information whenever you want. There is information on sleep trouble that you can read at three in the morning or diabetic information that you can read at two in the afternoon. Whenever you want, these guides will be here at your disposal.
How to Read Food Labels: There’s lots of complex information on the side panels of most packaged foods. A Registered Dietitian can give you personal guidance on topics such as a daily calorie "bank" to draw from. But the Nutrition Facts label can help you see how to fit each food into your own diet plan!
What’s on the Label?
Serving Size: similar products are supposed to have to same serving sizes, reflecting the amounts people actually eat.
Calories: many patients trying to manage their diabetes (or heart disease or arthritis) are also trying to bring their weight down. You need to always know the total calories you can have daily – and figure how each food draws down your calorie "bank account."
Calories from Fat: Many people are trying to prevent heart disease by limiting their fat intake. Fat calories should contribute no more than 25-25% of the total intake. And remember, fat has 2 & 1/4 times the calories by weight as carbohydrates or protein!
Percent Daily Value: This helps show how each food contributes to a sample diet. At the bottom of the label, the Percent Daily Value box gives you a comparison of 2,000 and 2,500 calorie diets, and how much the food has of fat, sodium carbs, cholesterol and saturated fat. The example on this page shows a nice, low total fat of 2% of a 2000 calorie diet, with 1 gram of fat per serving.
If you need help, ask! We can connect you with a Registered Dietitian to help you navigate the supermarket aisles with panache.
- Serving Size 3 oz cooked fish
- (84g/about 1 1/2 fillets)
- Servings per Container about 4
- Amount Per Serving Calories 100 Calories from fat 10 % Daily Value*
- Total Fat 1g 2%
- Saturated Fat 0g 0%
- Cholesterol 80 mg 27%
- Sodium 85 mg 4%
- Total Carbohydrate 0g
- Dietary Fiber 0g
- Sugars 0g
- Protein 21 g
- Vitamin A 0% * Vitamin C 0%
- Calcium 2% * Iron 6%
- *Percent Daily Values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs Calories 2,000 2,500
- Total Fat Less than 65g 80g Sat Fat Less Than 20g 25g
- Cholesterol Less Than 300mg
- Sodium Less Than 2,400mg
- Total Carbohydrate
- 300g 375g
- Dietary Fiber 25g 30g
Berkeley HeartLab: Our office is proud to offer “next generation” blood testing for helping prevent and treat heart disease. The Berkeley HeartLab offers tests developed by Drs. Ronald M. Krauss and H. Robert Superko at the famed Lawrence Orlando Berkeley National Laboratory at the University of California-Berkeley. These go beyond the usual “lipid panel.” Those tests are total cholesterol, triglycerides (2 ‘fat’ chemicals in the blood) and the “good” or high density lipoprotein (HDL), as well as the “lousy” or low density lipoprotein (LDL).
The Berkeley tests include the pattern of the LDL: small, dense dangerous pattern B, or less risky pattern A. They also help tell what trait you might have inherit-ed, which can help your brothers, sisters or children. At least 80% of heart and artery problems are inherited. If you’ve got one of these, there’s a 50% chance you’ll pass it to your kids.
Your child may have your chin and your spouse’s eyes -- you can see that. But you won’t know about their heart risk unless you get checked.
Who Needs These Tests? YOU Do If:
- You’ve had a heart attack, stroke, aneurysm or signs of clog-ged arteries in the heart (“angina”) or in the legs (“claudication”).
- Someone in your family has had a heart attack or angina.
- You’ve got diabetes or another sugar problem and your cholesterol picture is not perfect.
- You’ve got two or more risk factors for heart disease such as high blood pressure, smoking, inactivity, “high powered” type A personality, high triglycerides or low HDL.
What Will We Do With The Results? We hope to keep you from having a heart attack! Using these tests at Stanford, Dr. Superko’s group was able to reduce future heart events by 43% over 4 years! Now a study of patients who had heart attacks in Tyler, Texas shows that individualized therapy guided by these tests saves money: some $4120 per patient was saved in one year over standard care! That savings reflects better lives: less hospitalizations, less surgery, less angioplasty. Other studies have shown that you can “unclog” arteries with targeted therapy.
We’ve Launched an Intensive Effort to accomplish this. We can arrange for the studies with Berkeley. We will provide appropriate nutritional counseling (diets are different for different problems, and in some cases, a very low fat diet can make things worse!) with sophisticated computer support.
BHL Testing Requires Careful Preparation: a 12-14 hour fast is required, a questionnaire must be completed, and we have to know ahead of time in order to arrange for special handling in our office and FedEx.
How Much Will it Cost? The Advanced Cardiovascular panel is $375. Medicare covers some of this. Otherwise, please be prepared to pay for this in advance, as many insurances have not yet decided on coverage. We think you’re worth the investment! Our dietician’s and our services are covered under Medicare and most insurance.
Dr Alois Alzheimer described the disease which carries his name in 1906. It is now the most common cause of memory loss in the U.S.:
4 million have it now
14 million are expected to have it by 2050
1 in 10 people over 65 has it
half of those over 85 have it
US costs are estimated to be at least $100 billion yearly
average lifetime cost per patient is $174,000
What is Alzheimer’s? It is not yet clear what the cause or causes of AD are. Autopsy studies show dense "neurofibrillary tangles"and "senile plaques" in brain specimens. Beta-amyloid and tau proteins are strongly implicated, as are some nerve transmitter deficiencies. At least 4 genes are suspected.
Warning Signs Include:
- Memory loss at work
- Problems with familiar tasks such as forgetting you made a meal
- Problems with simple words
- Getting lost in your own neighborhood or home
- Poor judgement such as not dressing properly
- Abstract thinking issues such as inability to work numbers
- Misplacing things bizarrely such putting an iron in the freezer
- Unexplained mood swings
- Changes in personality
- Profound loss of initiative
How is Alzheimer’s Diagnosed? No one test (except brain biopsy!) is diagnostic. History & physical exam, a brief memory test and lab tests to rule out other diagnoses (such as low thyroid and vitamin B-12 deficiency) are done. MRI or CT scan of the brain may be needed to rule out multiple small strokes.
Mental Activity: A study by Dr. Robert Friedland and colleagues at Case Western Reserve in Cleveland found that the more you do (mentally), the more you can do. Those who were more active mentally in early and midlife had 1/4th the chance of AD.
Exercise reduced the risk of AD in senior women in 1 study by 13% for every extra mile walked daily.
Antioxidants: Vitamin E (2000 units daily) was shown to reduce the risk of AD in the Alzheimer Prevention Study; in the Rotterdam Study beta-carotene and vitamins C & E reduced AD, especially in smokers.
Alcohol: in a Boston study, 1-2 daily drinks led to less AD.
Low-fat Diet: Another Cleveland study showed high-fat diet increased AD 5-6 fold in susceptible patients.
Non-Specific Drug Treatment:
Diabetes: control of type 2 diabetes reduced dementia in a Dutch study.
Blood Pressure: control of blood pressure also reduced dementia in several studies.
Statins: anti-cholesterol drugs (lovastatin, etc). Reduce AD
Anti-inflammatories: Aspirin, ibuprofen and similar drugs have been associated with reduced AD in several observational studies.
Anti-Alzheimer Drugs: Tacrine (Cognex) was the first; little used now due to liver risks.
Donepezil (Aricept) is now the most used, working by increasing the neurotransmitter acetylcholine.
Rivastigmine (Exelon) is a similar drug, with perhaps a bit more improvement in memory, but with higher rates of stomach trouble here.
Galantamine (Reminyl) is the newest drug (derived from the daffodils), acting similarly, but with a 16% drop out rate due to side effects.
There are no head-to-head studies. On these drugs, avoid Ditropan, Levsin, Atrohist, Bentyl; they counter the effect.
Future Vaccine? Elan Pharmaceutical has a vaccine trial underway against one of the proteins in the amyloid plaques.
At this writing reports indicate a low, but not zero risk of this deadly ancient bacterial disease. Most patients have had the less dangerous skin infection, and have been exposed to spores sent in the mail. But anthrax lung disease in a NY Eye & Ear worker and in a 94 year old Connecticut woman is unexplained at this time, and preparation for additional patients is prudent.
What is Anthrax? It is a bacterial illness caused by exposure to the naturally occurring spores – either a skin pustule that turns black, or a respiratory illness that mimics influenza. There is also an intestinal form, which hasn’t been seen at this writing.
Who is at Risk? The highest risk appears to be in postal workers near government or major media offices. Next highest risk is in those who work in such offices, particularly those who open the mail.
What are the Symptoms? Cough, fever, chills and muscle aches start 3 days to 6 weeks after exposure to the spores. Patients are sick for about 2-3 days, then appear to be getting better for 1-2 days. Then they "crash" with severe damage to the lungs, "air hunger" and a death rate of 80%+.
What is the Treatment? Ciprofloxin (Cipro) is the only currently licensed antibiotic. Penicillin, doxycycline (Doryx, etc), Avelox and Tequin also work on the strains seen so far. Speed is of the essence in starting treatment!
What Can be Done?
First, get your flu shot! The best way to decide on anthrax vs. flu is to avoid all such symptoms, and since flu is so frequent, and the vaccine so effective, get it!
For serious respiratory illness, we’ll see you right away and assess your risk. We have the ability to test for anthrax and for flu. But the most important test is how you do! We’ll ask you to call us the following days, and we’ll carefully track your progress. We are convinced that the problems seen so far would largely have been avoided with follow-up. IF antibiotics are needed, it’ll be for 60 days.
Is Anthrax Contagious? NO!! It cannot be spread person to person.
Is There a Vaccine? Yes, but it’s not available for civilian use. And none has been made since 1998.
This would be a whole different level of problem. For one thing, it is highly contagious person to person. The attack rate is about 90% just by being in the same room! The disease was last seen in 1977. One of the final patients was in a German hospital; he was promptly isolated, but still infected 11 other people on 3 floors! There’s no known effective treatment - only an untested antiviral medicine, cidofovir (Vistide). Those who were vaccinated over 20 years ago may have immunity, but may NOT. There are some 12-15 million doses of vaccine in the country. They won’t be used unless definite cases are seen, and then they will go to military and public safety people first. If smallpox starts and you have a rash, DO NOT come in! We’ll send someone to you!
Botulism: the toxin of this spore forming germ can cause muscle paralysis, including breathing failure. But the germ is treatable with antibiotics, and there is an antitoxin.
Plague: is another treatable germ; but it CAN be spread from person to person. In the most serious form a pneumonia develops after 2-4 days. A vaccine is being developed.
Tularemia: is another treatable germ that causes a flu-like illness, then pneumonia. It can NOT be carried person to person. Untreated, 35% die, but treatment is generally effective.
Food - Amount - Calcium (mg) - Calories
Fruit and Fruit Products
Apricots canned in heavy syrup 1 cup 28 222
Dried, uncooked 1 cup 100 338
Avocados 1 med 26 378
Blackberries, raw 1 cup 46 84
Blueberries, raw 1 cup 21 90
Cantaloupes, raw, 1/2 melon 27 82
Cherries, canned 1 cup 37 105
Dates, pitted 1 cup 105 488
Grapefruit, pink 1/2 med 20 50
Grapefruit juice 1 cup 23 96
Grape juice (canned or bottled) 1 cup 28 167
Lime juice 1 cup 22 64
Oranges 1 med 54 71
Orange juice 1 cup 26 112
Papayas, raw 1 cup 36 73
Peaches, dried 1 cup 77 419
Pineapple, raw 1 cup 27 81
Pineapple juice 1 cup 37 138
Plums, canned 1 cup 36 114
Prunes, cooked 1 cup 60 253
Prune juice 1 cup 36 197
Raspberries, raw 1 cup 27 70
Rhubarb, cooked 1 cup 212 381
Strawberries, raw 1 cup 31 55
Tangerines 1 med 34 39
Watermelon 4" wedge 30 111
Barley 1 cup 32 698
Biscuits, homemade 1 biscuit 34 103
Bran flakes & raisins 1 cup 28 144
Bread 1 slice 23 74
Cake (from mix) 1 piece 55 308
Cupcakes (fr mix) 1 small 43 88
Cornmeal 1 cup 23 433
Farina, cooked 1 cup 147 105
Muffins (wh flour) 1 muffin 42 118
Oats 1 cup 44 132
Wheat flour 1 cake 27 62
Plain or buttermilk 1 cake 58 61
Butterscotch 4" sect 98 344
Custard 4" sect 125 280
Mince 4" sect 38 364
Pecan 4" sect 55 488
Pumpkin 4" sect 166 272
Pizza, cheese 5 1/2" 107 153
Rice, cooked 1 cup 21 223
Rolls: Hard 1 roll 24 156
Frank/hamburger 1 roll 30 119
Spaghetti & meatballs
Homemade 1 cup 124 332
Canned 1 cup 53 258
Waffles: enriched 1 waffle 85 209
From mix 1 waffle 179 206
Sugars and Sweets
Caramels 1 oz. 42 113
Chocolate, milk 1 oz. 65 147
Fudge 1 oz. 22 113
Molasses, blackstrap1 tbs 137 43
Sherbet 1 cup 31 259
Sugar (brown) 1 cup 187 821
Nuts and Beans
Almonds 1/2 cup 160 425
Pecans 1/2 cup 42 406
Tofu 3 1/2 oz. 128 72
Walnuts 1/2 cup 50 326
Milk, skim 1 cup 296 88
Milk, whole 1 cup 288 159
Butter 1/2 cup 23 813
Buttermilk 1 cup 296 88
Blue 1" cube 54 64
Camembert 1" wedge 40 114
Cheddar 1" cube 129 68
Cottage 12 oz. 320 360
Parmesan, grated 1 tbs 68 23
Swiss 1" cube 159 64
American 1" cube 122 65
half & half 1 tbs 16 20
Light 1 tbs 15 32
Sour 1 tbs 12 22
Custard, baked 1 cup 297 305
Ice cream 1 cup 194 257
Ice milk: soft-serve 1 cup 273 266
Margarine, stick 1/2 cup 23 816
Chocolate 1 cup 250 385
Vanilla 1 cup 298 283
whole milk 1 cup 272 152
Partially skimmed 1 cup 294 123
Meat, Poultry and Seafood
Beef, lean 2.5 oz. 10 153
Chicken breast, fried2.5 oz. 9 160
Eggs: whole 1 egg 27 82
Yolk 1 yolk 24 59
Scrambled 1 egg 51 111
Clams 3 oz. 53 65
Crabmeat, canned 3 oz. 38 91
Haddock, fried 3 oz. 34 141
Oysters, raw 1 cup 226 158
Salmon: canned pink3 oz. 167 120
Sardines: oil, drained 3 oz. 372 174
Shrimp, canned 3 oz. 98 99
Soups: Canned, prepared with water
Clam chowder 1 cup 34 81
Cream of chicken 1 cup 24 94
Cream mushroom 1 cup 41 134
Minestrone 1 cup 37 105
Tuna: in oil, drained 3 oz. 7 167
Asparagus, green 1 cup 37 36
Beans: Lima 1 cup 80 189
Red kidney 1 cup 74 218
Snap:yellow/green1 cup 72 31
Beets 1 cup 29 58
Broccoli, cooked 1 stalk 158 47
Brussel sprouts 1 cup 50 56
Raw 1 cup 39 20
Cooked 1 cup 64 29
Red, raw shredded1 cup 29 22
Carrots 1 cup 45 48
Cashew nuts 1 cup 53 785
Cauliflower, cooked 1 cup 25 28
Celery 1 cup 39 20
Collard greens 1 cup 289 51
Mustard greens 1 cup 193 32
Raw 1 onion 30 44
Cooked 1 cup 50 61
Parsnips, cooked 1 cup 70 102
Peanuts, roasted 1 cup 107 838
Peas, green 1 cup 44 114
Pumpkin, canned 1 cup 57 81
Sauerkraut, canned 1 cup 85 42
Spinach 1 cup 200 41
Squash, cooked 1 cup 55 129
Sweet potatoes 1 med 52 185
Tomatoes 1 med 24 40
Tomato catsup 1 cup 60 289
Turnips, cooked 1 cup 54 36
Turnip greens 1 cup 252 28
Sources: Calcium: Krause, MV, Mahan, IK Food, nutrition and diet therapy, WB Saunders Co 1979, p 828; Calories: Nutritive Value of American Foods US Dept Agriculture, 1975
by Geri Brewster, RD, MPH, CDN
Let me begin by explaining all the parameters:
Total cholesterol (TC): Originally this is all that was looked at and the goal was to keep it under 200, except people still had heart disease. So, the scientific community began to look at High Density Lipoprotein (HDL - the good cholesterol), and the ratio of total to good. A ratio of 4 or less is considered protective (25% or more of TC). But, people were still getting heart disease. So, they began to look at the Low Density Lipoprotein (LDL - the “bad” cholesterol) and came up with a breakdown: if there is no known heart disease and one or no risk factors it should not exceed 160. If there’s no known heart disease but two or more risk factors it should not exceed 130, and with known heart disease it should not exceed 100.
The risk factors: smoking, diabetes, hypertension, HDL less than 35, and family history of early onset heart disease (a cardiac event in males before 55 and in females before 65), being a man over 45 or being a woman over 55.
Because we could all live well and healthily into our 90s by preventing arteriosclerotic heart disease, I say we fine tune every parameter to our benefit:
- LDL is made up of 2 types: the smaller molecular pattern B type which is readily oxidized and adheres to the artery walls and the larger molecular pattern A which is more easily swept from the bloodstream by the HDL (there are a bunch of other remnants fIoating as well which is why the HDL and LDL added together do not equal the TC). Sophisticated testing is available to determine if you are pattern A or B, but it's generally not done unless you've had an event or unless you've got an aggressive internist. Anyway, most pattern B people are also triglyceride formers. Triglyceride levels should always be less than 200.
- Triglycerides generally represent excess fat and sugar calories that get converted to and stored as fat. In that conversion process they become triglyceride-rich particles which have a great affinity for adhering to the artery walls and speeding up the process of hardening them. Triglycerides are also an important ingredient in LDL particles which is why overweight people usually have high LDL’s and why weight loss usually results in decreasing LDL (unless routine daily exercise is part of the equation, bringing down the TC may result in bringing down both HDL and LDL and the ratio doesn't improve, so the risk remains high).
- Two additional tests to discuss with your internist:
- A homocysteine level. Homocysteine is a by-product of protein metabolism which makes the wall of the arteries stickier, easing the adherence of oxidized LDL and speeding up the process of hardening of the arteries. You want your homocysteine level to be less than 9.
- A Doppler of your carotid arteries. This non invasive test looks at the interior of the carotid arteries of the neck--the ones that, if blocked, lead to a stroke. If there is any plague deposited in these arteries, there is a 70% likelihood that the coronary arteries have developed plaque also.
The following supplement recommendations are well regarded by top cardiologists and internists and supported in the literature:
- Antioxidants to prevent the oxidation of the LDL cholesterol that you have: Vitamin E 400 IU, Vitamin C 500 mg timed release in the morning (do not take C with calcium, take calcium in the afternoon and before bed). If your homocysteine level comes back higher than 9, you'll need a prescription for 1 mg of folic acid. In the interim, 400 mcg (available over the counter) is fine along with 50 mg B 6 and 100 mcg of B 12. These nutrients decrease homocysteine, making the interior walls of the arteries Teflon like and more resistant to the adherence of oxidized LDL. No-flush or timed release niacin, 250 mg with food, helps convert pattern B to pattern A and is also available by prescription by the name of Niaspan in order to consume higher doses without the flush.
- Soluble fiber found primarily in oatbran and legumes (peas, beans and lentils). Daily oatmeal is OK, but doesn’t really make a big difference. I usually advise 500-1000 mg oatbran tablets with each meal. It binds with bile acids in the colon so you excrete them. This prevents their reabsorption by the body which then uses the bile to manufacture its own LDL cholesterol. So, you can dramatically cut down on what your body is making.
- Omega 3 fatty acids from fish oils, found supplementally in MAX EPA 1000 mg - take with food, or in fatty fish such as salmon, halibut, sardines, tuna steak, swordfish twice a week. Omega 3's are especially effective in preventing the damage from excess circulating triglycerides. They, like Vitamin E are also natural blood thinners. Omega 3's are also natural anti- inflammatories.
- Olive oil is rich in monounsaturates, a good fat, and red wine and red wine vinegar are also good for their natural antioxi-dant compounds.
- Benecol and TakeControl spreads are now available in supermarkets. These use a natural plant sterol to decrease LDL. Benecol also comes as a salad dressing. Three servings a day can decrease LDL by 14% they say--it*s pricey, about $8 for 2 weeks for 3 servings a day.
Stay away from saturated fats, partially hydrogenated vegetable oils (found in most commercial baked goods and convenience products), simple sugars and late day eating. Anything that is more than 30% fat calories is usually a no. However, nuts, which are a fat, do contain monounsaturates which are good along with a host of other great nutrients. So, 1 to 3 oz of nuts at 4 PM for 200-400 cal to take the edge off of overeating at dinner is OK.
Diabetes: the "Cliff Notes" Version
Distilled From Harvard’s 2001 Annual Joslin "Diabetes & Endocrinology, Critical Issues" meeting in Boston
OK, So You’ve Got Type 2 Diabetes – Deal With It!
1) Blood pressure: Many of our patients have heard the "quiz" – what’s the most important thing you can do to live better and longer with the disease? And you now know the answer: control your blood pressure!! Goal blood pressure for those with diabetes is 130/80 or less. This goal, from the National Kidney Foundation, is supported by a lot of data, according to Joslin kidney specialist Dr. Richard J. Solomon. At that blood pressure, annual loss of kidney function approaches that of non-diabetics. And the huge United Kingdom Prospective Diabetes Study (UKPDS) showed that achieving a blood pressure of 142/82 instead of 154/87 cut the heart attack and stroke rate by 44% over 9 years. Tighter sugar control also helped, but not nearly as much – those who got a "long-range" sugar Hemoglobin A-1C ("Glyco") test of 7.0% had a 16% lower rate than those who got 7.9%. And it can take several drugs to get to the goal – 3 drugs were used in the UKPDS and they still didn’t get everyone to the new goal of 130/80! Uncontrolled hypertensives lose 15 times the kidney function of normals annually. If your BP is 140/90, you’ll still have over 3X normal loss!!
Sadly, of 75,000 U.S. patients who go on to dialysis or kidney transplant every year, 75% are diabetic, hypertensive, or both!
2) Cholesterol :What’s the second most important thing you can do for better diabetic health? Right again, control your cholesterol!Goal LDL ("Lousy Darn Cholesterol" or low density lipo-protein) is 100 or less. And the goal "good" HDL is 45 or more. This is also the goal for people with known heart attack (myocardial infarction or MI) or other blood vessel disease. It turns out that diabetics have a higher risk of heart attack than non-diabetics who have already had an MI! So reports Lahey Clinic cardiologist Dr. Richard W. Nesto. In the East-West study, diabetics had a 20.2% heart attack risk over 7 years, compared to 18.8% in non-diabetics with previous MI. Even those with "prediabetes" or impaired glucose tolerance (some 20 million in the U.S.) are at risk. Diabetics have less warning symptoms of and poorer survival after MI. Lowering LDL and raising HDL can drop diabetic heart death rate by more than 50%
3) And, Yes, Sugar Control is Also Important! The UKPDS showed that better sugar control (lower hemoglobin A-1C) reduced all complications: heart attack, eye disease, and kidney damage. A level of 6% or less (which is what half of our type 2 patients achieve) reduced heart attacks and related events to normal in that study. And intensive therapy did decrease the heart attack rate 14%. Better sugar control also reduced kidney damage by as much as 25% in the UKPDS.
- Stop Smoking! That cuts heart events by 50-70%!
- Regular Exercisecan drop rates by 45%.
- A Healthy Weightmaintaining it reduces rates by 35-55%
- Mild to Moderate Alcoholintake, in those who already drink, can reduce event rates by 20-40%.
- Aspirin:650 mg daily reduced heart attacks 17% in a group of diabetics who had never had an MI (primary prevention) and 32% in another group who’d already had an event (secondary prevention); in that group stroke was reduced 27% and heart death 15%.
- And Don’t Forget Feet! Check them frequently (and we will, too!). Your feet help tell your overall vascular and nerve health.
What is Diabetes?
Diabetes mellitus is the increase in blood sugar that happens either because there’s too little insulin (type 1 diabetes) or because the body’s cells can’t use insulin properly (type 2). Insulin is made by beta cells in the Islets of Langerhans in the pancreas, deep within the abdomen.
Who Gets It?
Some 15.7 million people - 5.9% of us - have it in the U.S. It’s even more common in those over 65: 18.4%. You are more likely to get type 2 if: ‚
- you’re over 45
- there’s a family history of it
- you’re overweight
- you don’t exercise much
- you have cholesterol issues
- your heritage is African, Hispanic, Asia/Pacific Island or Native American
- you had gestational diabetes (increased sugar during pregnancy)
“Pre-Diabetic” Conditions include Impaired Glucose Tolerance, (IGT), found in 20 million Americans or 11% of us. They have the same heart and blood vessel risks that diabetics have. About 40-45% of those over 65 have IGT or type 2 diabetes! Impaired Fasting Glucose is when a fasting sugar is above 110, but less than the 126 which defines diabetes. Some will have IGT, some not (they “just have a high number”).
How Does It Hurt You?
- Diabetes kills 187,000 yearly
- 12-24,000 go blind annually
- 27,900 start dialysis annually
- 56,000 have an amputation
- heart attack & stroke are 2-4 times more likely: 77,000 yearly
- impotence can run 50-60%
Costs of Diabetes were estimated at $98 billion in 1997: $44.1 billion for treatment and $54 billion for disability and death.
What Do I Recommend on Checking Your Sugars?
- You should have a fasting (at least 8 hours and preferably 12) blood sugar at age 45 -- sooner if diabetes is in your family, or if your have any of these other risk factors. Venous blood processed in a good lab (our accuracy is 0.2 mg) is the best way to do it. If you’re high risk, you should get checked at least every 2-3 years.
- If your sugar is over 126 mg, this should be confirmed with a second test.
- If your sugar is between 110 and 126, I recommend a formal Glucose Tolerance Test (that’s the one with the over-sugared cola or orange drink) to see if you’re diabetic or Impaired Glucose Tolerance or “just a high number.”
Here’s How We’ll Help:
- Diet: with our dietician - we'll aim for at least an annual review of your diet.
- Blood Pressure should be 130/85 or less
- Sugar Checks you’ll be checking your blood yourself
- Urine Checks looking for early damage (“protein leak”): a level under 30 is ideal.
- Long-Range Sugar Check every 3-6 months with a hemoglobin A-1C (a protein in your red blood cells) under 6% Ideal under 7% Excellent under 8% Good under 9% Fair (but needs help) under 10% Suboptimal Over 10% Poor!
- Eyes: a yearly check with an eye doctor is needed
- Feet: checked regularly for sensation, blood flow and ulcers
- Lousy LDL Cholesterol should be under 100
- Smoking: if you do, we’ll help you stop!
Dr. Grimshaw won recognition in 1999, and again in 2001 from the American Diabetes Association and the National Committee for Quality Assurance. It means that we met goals for sugar and blood pressure control and education.
Checking Your Sugars:
Who Should? Anyone on a medicine (pills or insulin) that lowers blood sugar, and anyone who is having trouble controlling their sugar, even if only on diet.
How to do it: we suggest the Freestyle by Therasense. It’s easy to care for, “dry”and much less painful than most others. We suggest checking in the am day 1, 2 hours after breakfast day 2, 2 hrs after lunch day 3, 2 hrs after supper day 4.
The GlucoWatch is due to be approved soon by the FDA; you strap it to your wrist, and it tells your blood sugar with a remark-able degree of accuracy for 12 hours. The FDA and the manufacturer, Cygnus, say that decisions on insulin shots should still be double checked with a blood meter. The cost may be $300 for the hardware and $4 for each sensor pad (good for 12 hours); & it tells time!
- Diet: Still remains the cornerstone. We’ve come a long way from the “strict” diet developed by Dr. Eliot Joslin when he attended my father. You can have a lot of different foods, just “sensibly” -- in modest portions.
- Exercise: Again, extremely important. Most type 1 (insulin) and type 2 (non-insulin) patients do much better with regular exercise, especially after meals.
- Metformin (Glucophage) works by making your insulin work better for you, especially in your liver. It can’t be used by everyone, particularly if there are significant kidney or liver problems. Dose is 500- 2000 mg per day. The big advantage is no low blood sugars.
- Rosiglitazone (Avandia) makes your insulin work better in your muscles. It’s not for people with liver problems, and requires regular liver checks. It can be used 1st line or with other medications . It does not cause low blood sugars.
- Pioglitazone (Actos) is another in the Avandia class, and also can be combined with other agents or used 1st line. Again, it does not cause low sugars
Sulfonylureas: force the pancreas to secrete extra insulin and may normalize liver glucose production. They all work with metformin.
- Chlorpropamide (Diabinese) is the longest acting and oldest. We don’t use it much due to the risks of low blood sugar; it lasts 3 days.
- Tolazamide (Tolinase), also older, lasts about 18 hours.
- Glyburide (Glynase, Diabeta, Micronase) lasts 24 hours.
- Glipizide (Glucotrol): 12-18 hours.
- Glucovance is a combinationof metformin and glipizide and lasts about 12 hours.
- Glimepiride (Amaryl): lasts about 24 hours.
Meglitinides: also stimulate insulin release from the pancreas.
- Repaglinide (Prandin) is taken right before a meal (0-30 minutes); dose is 0.5-4mg 2-4 times daily. The drug can be combined with metformin.
- Neteglinide (Starlix) is similar to Prandin and can also be combined with metformin
Glucosidase Inhibitors: These work by inhibiting sugar absorption. Side effects are bloating, gas and diarrhea from the non-digested food.
- Acarbose (Precose) is taken at 1st bite.
- Miglitol (Glyset) is similar.
Insulins: were originally of animal origin; now most in use are made by recombinant DNA methods.
- Insulin Glargine (Lantus) provides essentially 24 hour "peakless" insulin levels.
- Insulin Aspart (NovoLog) is the fastest “bolus” insulin to date, with a peak at 20 minutes and a duration of 3 hours..
- Lispro (Humalog) has an onset of action in 15 minutes, and a peak at 30-90 minutes, lasting 5 hours.
- Regular has onset at 1/2-1 hr, peaks at 2-3 hrs, lasts 4-6 hrs.
- NPH has onset at 2-4 hrs, peak at 4-10 hrs, lasts 14-18 hrs.
- Lente has onset at 3-4 hrs, peaks at 4-12 hrs, lasts 16-20 hrs.
- Ultralente has onset at 6-10 hrs, no peak and lasts 20-30 hrs.
Inhaled insulin will mimic Aspart, peak in 60 minutes, with an effect like lispro.
Carbohydrates: The Good, The Bad, and The Ugly
“But I thought all carbohydrates were good,” is something we hear a lot. The Ornish, the Pritikin and other diets have pushed the idea that very low fat (and high carb) diets are the answer to heart disease and diabetes. Unfortunately, ‘taint so!
The Problems: non-fat or low-fat foods, especially snacks, use simple sugars instead of fat for flavor. And these sugars are Bad! They
- promote tooth decay
- cause blood sugar “spikes”
- raise insulin levels (especially in type 2 diabetes or Impaired Glucose Tolerance)
- raise triglycerides (which are so toxic to the linings of your blood vessels that they can be paralyzed for 4 hours after such a meal).
The Insulin Issue: Insulin brings sugar down in the blood by helping cells (particularly muscle and liver) bring sugar inside, to be stored as glycogen. If your cells have enough glycogen, the extra sugar gets stored as fat. Excess insulin can:
- promote the creation of toxic trigylcerides
- inhibit the burning of body fat
- inhibit the use of fatty acids for energy
- inhibits the release of growth hormone (GH). GH is essential to muscle growth and renewal. GH is released in large amounts after you exercise and right as you fall asleep. Eating a simple sugar snack after exercise or within a few hours of sleep will abort the GH release
And so you ultimately store more body fat, have less stamina and decreased metabolism and increased weight gain when you eat foods high in simple sugars!
Enter Atkins and Variants:
The above is the basis for the high protein, low carbohydrate diets of Dr. Robert Atkins, our old friend Dr. Joseph Hickey, and others. If you don’t eat sugar, you don’t get the insulin spike, the triglyceride release, and the growth hormone response is normal. In essence, your body thinks it’s starving, and you burn stored fat! Readers of these pages know that there’s been little long-term testing of the Atkins approach. But short term trials of up to 18 months have shown no problems. Many physicians - including some (but not all) cardiologists - are quite leery.
Can We Finesse This? For selected patients, we use a modified carbohydrate restricted diet. This is high in:
- lean animal protein such as chicken
- fish rich with omega 3 fats
- low carb vegetables
- egg white
Talk With Us! We’ll tailor your diet to YOUR needs, based on blood pressure, cholesterol and sugar control as well as heart and vessel risks, body mass and your own experiences. We could try to “tell you” what to do (which never works). Instead, we’ll ask you what you’ve done, what you’re doing, and what you hope to do. This works!
The Glycemic Index (GI) is a measure of the rate at which carbohydrates are converted into blood glucose. Obviously, from what we’ve been discussing, foods that cause a rapid rise in blood sugar - a high glycemic index - will worsen diabetic control and raise triglycerides (another way besides cholesterol that you carry fat in your blood). An index under 100 is considered good. Generally, the higher the fiber, the lower the GI.
Some foods with good GI’s:
- whole grain bread
- dried peas
- lentils and beans
- high protein pasta (Barilla)
- sweet potato
- plain yogurt
Foods with bad GI’s:
- white bread
- white pretzels
- white rice
- corn flakes
- Rice Krispies
- fruit juice
Basic Pointers For Controlling Blood Sugar:
- Avoid simple sugars such as candy, cookies, cakes, pudding, Jello, ice cream and fruit juice. Excess “quick” white flour foods such as noodles, pasta, potatoes, rice and white bread bring higher sugars.
- Increase fiber at meals such as whole wheat bread, brown rice, vegetable and beans.
- Have whole fruits (rather than juice) with meals.
- Equally distribute calories with 3 meals and 1-2 snacks per day. This avoids large blood sugar rises
- Include protein, complex carbohydrates and “good fats” at all meals. Olive or canola oil are ok. This again decreases the rise of sugar in the blood with meals.
- Combine carbohydrates and protein (or use complex carbs) for snacks. Skim milk works fine.
- Check your blood sugar frequently to see what happened from your last meal and to help figure what to eat next.
- Don’t eat 2-3 hours before bedtime unless your bedtime blood sugar is in the 80-120 range or if you’re on insulin or pills that drop your sugar (not Glucophage or Actos or Avandia).
Travelling With Insulin?
If going across 6 or more time zones:
- take usual dose on the day of departure
- 18 hours after departure, take 1/3 of dose + snack if sugar over 240
- 1st day at destination, take usual dose
- take usual AM and PM doses on day of departure
- 18 hours after departure, take 1/3 AM dose + snack if sugar over 240
- take usual dose on day of departure
- 1st morning at destination, take 2/3 usual dose
- 10 hours after AM dose, take 1/3 AM dose if sugar > 240
- 2nd day take usual dose
- take usual doses on day of departure
- 1st morning take 2/3 usual AM dose if sugar over 240
- 10 hours after AM dose, take usual PM dose + 1/3 AM dose
Source: The Diabetic Traveler PO Box 8223 RW Stamford, CN 06905. Send SASE for more info.
Joslin Diabetes Center, Boston, Mass.
Provided by Robert S. Grimshaw, Jr. M.D.
ASPECTS OF FOOT CARE
How often do you tell someone that you're going to jump into a project "feet first?" When was the last time you thought about how to "put your best foot forward?" How frequently have you told someone about the "fancy footwork" you had to perform because you "put your foot in your mouth?" To use another popular American phrase, they can be your "Achille's heel." Why? Because diabetes can cause the arteries in your legs and feet to become hardened and clogged, preventing blood from circulating properly. It can also affect the nerves in your feet, causing a loss of sensation. Without adequate feeling or circulation in your feet, even minor cuts and scratches, callouses, corns and toenail injuries can become serious problems. To protect yourself from these kinds of problems you need to carry out a daily foot care program that includes: washing and examining your feet each day; applying moisturizing creams to dry skin; filing toenails regularly; treating cuts and scratches promptly; taking care of corns and callouses; managing athlete's foot promptly; attending to warts; and, selecting footwear carefully. Perhaps feet are such a useful part of the American language because they're such an important part of our anatomy. But for people with diabetes, feet can also pose special challenges.
NERVE DAMAGE AND FOOT PROBLEMS
The nerves are your body's communication system, carrying information back and forth between the brain and other body parts. Some nerves, called sensory nerves, carry messages of pain, touch or temperature up to the brain. Other nerves, called motor nerves, carry instructions for movement from the brain down to the muscles in your legs, feet and hands. One of the purposes of this communication system is to protect you. Let's suppose again that you cut the bottom of a foot on a piece of glass while walking on the beach. Sensory nerves would immediately send a message of pain to your brain. Your brain would then send a quick message via the motor nerves to the muscles in the appropriate leg, telling you to pick your foot up off the sand. Almost before you were aware of what was happening, your brain would have prescribed the first step in treating the injury: "Stop walking on your cut foot!" Diabetic neuropathy is nerve damage believed to be caused by chronic high blood sugars. If neuropathy affects your sensory nerves, you may suffer a loss of feeling in parts of your body. Frequently, the feet are affected. As a result, a cut or wound on the bottom of your foot will not hurt and may go unnoticed. You may continue walking on the injury, causing additional damage with every step, and preventing the wound from healing. Diabetic neuropathy can also affect the motor nerves, though less frequently than the sensory nerves. The muscles in the feet and legs may be involved. In severe cases, some of the muscles may become weak, which can make walking difficult.
PREVENTING NERVE DAMAGE
Why does diabetic neuropathy occur? Scientists and clinicians currently believe that the nerves are damaged by the high levels of glucose in the blood. The nerves are constructed like electric wires. The nerve, itself, is like the metal part of a wire. Other cells surround it, just as insulation covers a wire. These cells are called Schwann cells. In people with diabetes, excess glucose gets into the Schwann cells and is changed into sorbitol. (The sorbitol produced in the Schwann cells is unrelated to the sweetener of the same name found in many dietetic foods.) It is believed that sorbitol causes the cells to swell, irritating the nerve and eventually destroying it. Because chronic high blood sugars are believed to be the root cause of nerve damage in diabetic neuropathy, the most important thing you can do to try and prevent this condition from developing is keep blood sugars within normal ranges through good diabetes management. Even people with generally good diabetes control can develop neuropathy, however, so it is important to keep an eye out for signs of trouble.
SIGNS OF DIABETIC NEUROPATHY
Numerous symptoms may occur continuously or irregularly when diabetic neuropathy affects your feet and legs. You may lose sensation and your feet may feel numb. At other times, you may feel shooting pains, pricking, tingling and/or burning on the skin of your feet and legs. These pains and sensations can be mild, or so severe that they can be almost unbearable. Sometimes both sets of symptoms are present.
FOOT CARE WITH NEUROPATHY
In and of itself, diabetic neuropathy is not dangerous. The danger lies in being unaware that you have lost feeling in your feet, and allowing a foot injury to be neglected as a result. If you have neuropathy you need to protect yourself against this risk. Since the automatic alarm system in the foot. is not functioning, replace it with a manual one--good foot care that includes regular foot inspections! A practical way to set up a manual alarm system is to change shoes and socks every three to four hours. There are three advantages to doing this. --If you have limited or no sensation in your feet, this gives you frequent opportunities to look for any problems which may occur. If you find a foot injury, it can be treated immediately. --By changing your shoes several times a day, you can shift the pressure points on your feet that the shoes cause. --Changing shoes and socks every three or four hours can help to eliminate damage to the skin and reduce the risk of infection and sores which the friction of continually worn shoes-can cause. (All shoes begin to allow the foot to slide parallel to the sole of the shoe after three to four hours of continuous use. This increases friction which may cause blistering and skin breakdown.)
THE MUSCULOSKELETAL SYSTEM AND FOOT PROBLEMS
The musculoskeletal system includes the bones and joints and the muscles, tendons and ligaments that connect muscle to bone or bone to bone. The system gives form and shape to your bone and enables you to move around. Any problem in the structure of the musculoskeletal system-such as a birth deformity--may disrupt the smooth-gliding joint actions, exert abnormal forces on various parts of the feet and lead to further changes in foot structure and shape.
SIGNS OF PROBLEMS
Some of the more frequent changes which occur are hammertoes, bunions and metatarsal deformities. A hammertoe is a condition in which the toe is contracted (drawn together) at one or more joints. A bunion is a deformity in which the big toe has moved laterally toward the other toes and the first joint of the toe bulges outward. A metatarsal deformity is a problem in one of the five large metatarsal bones behind the toes which make up the center of the foot. Common metatarsal deformities such as flat feet and high arches cause pain and discomfort in and around the ball of the foot. They may also cause heel spurs. PREVENTING FURTHER FOOT PROBLEMS Walking on deformed feet or trying to wear shoes which are designed for normally shaped feet may be painful and can lead to further foot damage. If you have diabetic neuropathy, you may not feel the pain, and be unaware of additional damage. If you have foot deformities along with poor circulation and/or loss of sensation, seek professional foot care on a regular basis. Most musculoskeletal conditions can be managed without surgery. Wearing appropriate shoes, taking care of your feet each day, and getting regular professional care, will in most cases enable you to do all you like doing without problems. Surgery should be used for musculoskeletal problems only if the pain is disabling or further damage is occurring.
CHARCOT FOOT - A SPECIAL PROBLEM
Charcot foot is musculoskeletal condition which affects approximately one of every 700 people who have diabetes. It is usually limited to people who have moderate to severe loss of feeling in their feet. Charcot foot is more common among people who are overweight, but can occur in thin people. No one is quite sure how Charcot foot begins. However, it is thought to be caused by either an incidental trauma or a misstep or twist of the foot which injures some of the ligaments that support the arch or the foot. Once the ligaments have been damaged, the bones begin grinding against one another and the arch may collapse. The damage often goes unnoticed because the person has already lost feeling in their foot. With the collapse of the bones in the arch, the weight bearing is distributed differently along the sole of the foot, causing irritation and blistering, which may lead to sores and infection. If your foot swells without explanation and is warm to the touch with no apparent break in the skin, there is a good possibility you have Charcot foot. When these symptoms occur, be sure your physician or podiatrist examines your foot. Rest is the primary treatment for Charcot foot. Depending on the severity of the damage, no weight should be placed on your foot for 8-16 weeks. If both feet are affected, you may not be able to walk at all until the damage heals. Permanent foot deformities may be avoided if the condition is diagnosed and treated early. If a significant permanent deformity does occur, you will need special molded shoes to protect your foot.
YOUR SKIN AND FOOT PROBLEMS
The skin is your body's barrier against infection, so potential and actual skin injuries need immediate attention. This is especially important if you have diabetes because poor circulation may have decreased your body's infection-fighting and healing capacity. Small wounds that lead to infections and larger non-healing wounds can eventually result in the loss of a part or all of a foot.
PREVENTING SKIN PROBLEMS
A system of regular foot care will help you prevent many of the minor skin problems that, if unattended, can lead to major problems.
WASHING YOUR FEET
To protect your skin, wash your feet each day and check yourskin for injuries. Wash your feet in warm, soapy water. Don't soak your feet - that will soften your skin and make it more susceptible to infection. Use a mild hand soap and don't use HOT water. Test the water temperature with your wrist so you don't scald your feet if you have neuropathy and have lost sensation in your feet. Rinse your feet well after washing and dry them carefully, especially between the toes. After you have washed and dried your feet, examine them closely in a good light. If you cannot bend over to see the bottom of your feet; place a hand mirror on the floor and hold each foot, in turn, over it so that you can see the reflection in the mirror. If you have poor eyesight, ask someone to examine your feet for you. Keep an eye out for the common problems that often threaten the protective function of your skin. These include dry skin, toenail injuries, cuts and scratches, callouses and corns, dermatitis (athlete's foot), and warts. Descriptions of these problems and how to care for them appear below.
Dry skin may lead to cracks which bleed and become infected. The moisture content of a person's skin depends on heredity and environmental factors. Some people have skin that rarely needs moisturizers. others need to use creams several times a day to prevent the skin from drying. Creams such as Nivea, Eucerin, or Alpha-Keri help restore moisture to the skin. Creams are better than lotions because they hold moisture in the skin for a longer period of time. Apply cream starting at the heel and work towards your toes. This will help you avoid leaving excess amounts of cream between the toes which can lead to a wearing away of the skin and possible infection. Dry skin around the edges of your heels is especially prone to cracking. Sometimes dry heels are treated by applying a liberal amount of cream to the dry areas before going to bed, covering the area with a piece of clear plastic wrap and wearing a sock over the wrap during the night. This procedure can be repeated two or three times a week, depending on the degree of dryness. If severe dryness persists, consult your podiatrist or a dermatologist. If your feet perspire, use talcum, baby powder or mild foot powder to absorb the moisture. Be sure the powder doesn't collect between your toes.
Most people with diabetes can care for their own toenails. However, you should probably have someone else care for your nails if you have poor circulation, have lost sensation in your feet, have extremely poor eyesight or have severe arthritis in your hands and back. Ask a family member or friend to help you or have regular appointments with a podiatrists. If you, a family member or a friend care for your toenails, file them with a diamond-type file (Emery board). A scissors orclippers should not be used since any instrument which will cut your nails could also cut your skin. File nails to the ends of your toes, but no shorter. Shape them according to the contours of your toes and the toes next to them. If abnormal toenail growth leads to ingrown toenails and infections, seek help from a podiatrist. An infected ingrown toenail can become a serious problem if not treated appropriately. Often it requires removal of a portion of the nail, drainage of the infection, antibiotics and bandaging with frequent dressing changes until healed. Fungal infections which lead to the discoloration and thickening of toenails should also be treated by a podiatrist. Treatment usually involves regular trimming and filing in order to keep the nails as thin as possible. Sometimes surgery is necessary to remove the nail in order to prevent continuing pain and infections. over-the-counter remedies for these fungal infections are usually not effective. There are effective oral medications, but the side effects do not warrant their use unless the fungal infection has spread over large portions of your body. They should be used only in consultation with your podiatrist or physician.
CUTS AND SCRATCHES
If you have a cut or scratch on your foot, wash the affected area with warm water and soap promptly. Do NOT SOAK. Apply a mild antiseptic such as ST/37, Bactine, or Johnson's First Aid Cream. Never use strong antiseptics such as iodine, Betadine (unless diluted according to the instructions of your physician) , Mercurochrome, boric acid, Epsom salts, creosol or carbolic acid. Cover the affected area with a dry sterile dressing. Secure the dressing with paper tape or a Telfa bandage.
DO NOT USE ADHESIVE TAPE, INCLUDING BAND-AIDS, ON YOUR SKIN.
Do not apply heat treatments such as a hot water bottle or heating pad to the cut or scratch. Stay off your feet as much as possible and call your physician if the affected areas do not improve within 24-30 hours. If redness, swelling, increased warmth or a yellowish drainage occurs, contact your physician immediately. Do not assume the condition is improved just because there is no pain.
CALLOUSES AND CORNS
Callouses and corns are caused by friction on the foot from the sole or toebox of a shoe. They usually occur because of faulty foot mechanics or because deformities such as bunions and hammertoes have caused parts of your foot to rub against the shoe. The thickened skin characteristic of callouses and corns can be painful for people with normal sensation in the feet. The pain can be relieved by thinning the callous or corn, wearing shoes which leave room for crooked toes, and using toe pads to minimize friction. If you have lost feeling in your feet, you may not notice any pain from callouses and corns. If you neglect them, however, they may blister, break and become infected. Further neglect may lead to sores which can quickly affect the bone. Blisters should be treated by immediately removing the cause of the friction and applying antiseptics. Avoid walking when you have blisters on the bottom of your feet. open sores require strict bed rest, antibiotics, dressing changes and sometimes hospitalization. Sores should never be soaked.
DERMATITIS (ATHLETE'S FOOT)
Dermatitis is a skin disease which reduces the skin's ability to provide a barrier against bacteria and to fight infection. Any dermatitis condition on the feet needs to be identified, treated and cured in order to prevent a breakdown of the skin. One of the more common forms of dermatitis is athlete's foot, which causes the skin between the toes to redden. Blisters may form, accompanied by fluid drainage and painful itching. Over-thecounter antifungal agents such as Tinactin and Desinex are usually sufficient to heal the condition. If these remedies don't help after seven to ten days, consult a dermatologist or podiatrist. A stronger medication such Halotex, Lotrimin or Loprox may be needed. You will need a prescription for these drugs.
Warts are caused by a virus which has a tendency to grow in the skin. Plantar warts occur on the plantar or bottom surface of the foot. You may have difficulty distinguishing between a wart and thick callous. Ask your physician or podiatrist if you have a growth and are not certain whether it is a wart or callous. Warts will usually disappear if left alone. For this reason, and since many of the methods used to remove warts are worse than the condition itself, it is best not to treat warts unless they begin to spread or become painful to walk on. None of the methods used to treat warts are 100 percent effective. The most successful methods are surgical removal and caustic acid therapy, but they are only 80 to 90 percent effective. Sometimes several methods must be used before warts can be successfully and permanently removed.
SHOES AND SLIPPERS
Wearing sturdy, appropriate footwear is another important way to protect the skin covering your feet from injury. Most of the surfaces you walk on, such as concrete and asphalt, are hard. Unlike walking in the sand, where the foot sinks into the surface and the ground comes up to meet it, a foot walking on a hard surface tends to collapse down on to the surface. The best shoes for use on hard surfaces are those that are soft and supportive. They provide an interface between the foot and the walking surface. Athletic shoes with soft uppers, cushioned soles and firm counters around the heel provide the necessary support. However, all shoes begin to lose their cushioning and supportive capability after 4-5 hours of continuous wear. For this reason, it is best to change shoes in the middle of the day to help maintain maximum cushioning and support. Although they may be the height of fashion, do not wear sandals, clogs or flipflops. Avoid pointed shoes which squeeze the toes together. Break new shoes in gradually. This will prevent blisters from forming. When you wear slippers around your home, make certain they have sturdy toes in order to prevent stubbing your toes. While the temptation may be strong, do not go barefoot at the beach or anywhere else for that matter. You will need specially molded shoes with extra room in the toebox if your feet are significantly deformed. Your podiatrist or physician will advise you about the kind of shoes you need.
SOCKS AND STOCKINGS
Cotton and wool socks or stockings, or hosiery made from combining cotton and wool along with synthetics are best if you have diabetes. They provide some additional degree of cushioning and also help to prevent friction between the shoes and prominent bony protrusions on the feet. Wear a clean pair each day. Socks and stockings should be correct size and free of seams and darns. You should avoid wearing socks or stockings with constricting tops that might further slow circulation. Constricting garters and girdles are a no-no too. If your feet sweat, change your socks several times a day.
A LAST WORD
Foot care takes a little more time and attention if you have diabetes than if you don't. But like everything about having this condition, the extra attention now is well worth the long-term return. Just because you have diabetes doesn't mean you can't do all the things you want to do. And healthy feet will take you wherever you want to go--up a mountain, across a continent . . . or just around the corner.
When it comes to herbal supplements, what are patients taking? Here is a review of some of the most popular ones, from the annual meeting of the American College of Physicians. I’ve tried to “weed through” the data – note that most studies are short term, with few patients. And watch out! Problems with purity and potency abound – especially with “quick buck” artists.
St. John's Wort:
Also known as Hypericum perforatum, it has a 2000 year history of use for depression. The German Commission E (one of the most complete reviews of supplements) gave it early support for “depressive moods, anxiety and/or nervous unrest.” In a review of 17 double-blind randomized placebo controlled trials (the best studies that can be done) with 1168 patients, 56% of those on SJW improved versus 25% on placebo. In a 6 week trial, 400 mg twice a day worked about as well as 20 mg Prozac. Side effects include dry mouth, stomach upset, restlessness and increased sun sensitivity, but less than 1% of patients dropped out. There can be interactions with drugs for depression, contraception, epilepsy and AIDS.
Used to try to improve brain function, particularly memory. It comes from a 200 million year old species of trees, and is the top selling herbal therapy in the US and Germany. Most studies to date have been poorly done; of 56 studies only 4 could be used for meta-analysis in a review in Archives of Neurology. With 120-240 mg/day for 3-6 months there was modest improvement in some measures of thinking. Side effects are mostly uncommon and mild: headache, rash, and stomach upset. There are occasional reports of spontaneous bleeding, such as in the eye or brain.
Kava: (Piper methysticum)
Called the “intoxicating pepper” and first reported in English by Captain James Cook in1768, it’s used for anxiety in the Kava ceremony in the South Pacific. The active ingredient in kavapyrones. In 2 double-blind controlled trials (58 patients for 4 weeks and 101 for 25 weeks) using 100 mg (70% kavapyrones) 3x/day, there was improvement in anxiety scores. Side effects include low weight and skin disorder from long term use, involuntary muscle movements and coma when combined with Xanax. Watch out for the dose! The percentage of kavalactone is important. Commission E recommends 60-120 mg kavalactone per day.
Valerian: (Valeriana officinalis)
This root is used for insomnia. In a study of 121 patients, valerian 600 mg nightly was compared to placebo for 28 days, with continuing improvement. There is one report of severe withdrawal after long-term high dose use, and it is metabolized by the liver with occasional toxicity (we have seen this).
Ginseng: (Panax ginseng)
Used as a general tonic. It is thought to have effects on nerves involved in serotonin and GABA. Studies have had mixed results; commercial preparations vary widely in content and purity, and in some no ginseng was found at all. Side effects include jitteriness, diarrhea, hypertension, and insomnia.
Continuing our series on popular supplements, from the American College of Physicians meeting and other sources. Remember, purity and potency are not guaranteed under American law because these are considered foods. I don’t recommend any supplements without careful thought and consultation.
Saw Palmetto: (Serenoa repens)
The berry of the scrubby palm found from Texas to Florida. Its main use is for benign prostate enlargement, in a dose of 160 mg twice daily. Evidence of effectiveness is fair with open label (patients and doctors knew who was getting what) studies showing reduction in urinary symptoms for up to 3 years. Side effects include rare stomach upset and less impotence than finasteride (Proscar). It appears to work by much the same mechanism as that drug: inhibiting the conversion of testosterone to the 5-alpha dihydrotestosterone metabolite. Two cautions: 1) some people use it instead of thyroid hormone replacement (which can make them very sick if they’re hypothyroid); and 2) please get a prostate check (including PSA) BEFORE taking it (so we don’t miss a chance to catch early prostate cancer).
Garlic: (Allium sativum)
Garlic in doses of 600-900 mg extract (1800-2700 mg raw garlic) has been touted for blood pressure, clot inhibition and pain relief, and was even used as an antibiotic by the Soviet Army during WWII when penicillin ran out. But the best evidence of effect is in reducing cholesterol (9-12% drop in total cholesterol in several studies). Side effects are few, but include possible bleeding.
Ginger: (Zingiber officinale)
Frequently used for nausea; it’s also used for motion sickness and flu symptoms. The dosage is 940 mg up to 3 times a day; studies have shown modest effects; drugs are more effective. Ginger, however, has few side effects, mostly stomach upset.
Feverfew: (Tanacetum parthenium)
Used for migraine. The usual dose is 1 dried leaf. It appears to inhibit the release of the neurotransmitter serotonin by platelets. A 1988 Lancet study showed a 24% reduction in migraines, when feverfew was used for prevention. Side effects are few, including mouth sores if the leaf is chewed. Locally, New York Medical College neuro-ophthalmologist Dr. Scott Forman has tried it for ophthalmic migraine (which affects vision, with no usual headache). And, he told me recently, it's good for many types of migraine.
Caution: garlic, ginger and feverfew can all increase the effect of the blood thinner Coumadin and should be avoided by Coumadin patients. They also should not be used for 2 weeks before any elective surgery.
Echinacea: (Echinacea purpurea, E. Pallida, E. angustifolia)
Used for cold and flu symptoms. Dose is up to 9 300-400 mg capsules a day. Evidence of effectiveness is weak, partially because of trouble making a reliable extract and the “bite” that it has, which makes placebo trials difficult. Side effects include allergic reactions (especially in those known to be allergic to ragweed or daisies), at least one death due to a lupus flare, and possible reactions in those with HIV, multiple sclerosis and tuberculosis.
Goldenseal: (Hydrastis canadensis)
Root and rhizome is used for diarrhea and upper respiratory infections. Dose is up to six 500-600 mg capsules. Large doses can cause skin ulceration, uterine contractions, stomach upset, hypertension and seizures. Clinical evidence of effect is scant.
Dong Quai: (Angelica senensis)
Used for sleep, a laxative and as an estrogen supplement. The dose is 1.5 grams 3 times a day. There are few adverse effects and little evidence of any beneficial effect.
Continuing our series on popular supplements, from the American College of Physicians meeting and other sources. Remember, purity and potency are not guaranteed under American law because they’re considered foods. I don’t recommend any supplements without careful thought and consultation; a good way to think of this is “if it has an effect, it will have a side effect.”
Glucosamine is the most popular supplement for osteoarthritis. As readers of these pages are aware, a well-designed Belgian study reported in early 2000 showed slowing of structural damage to the knee. Dose is 1500 mg per day. Side effects are few, but it might worsen blood sugars in diabetics or prediabetics. Several weeks may be required to show an effect.
Chondroitin is frequently used in combination with glucosamine. The number of studies in humans is very small, but there appears to be a modest benefit in osteoarthritis at 4-6 months. Both “nutriceuticals” act in different ways to enhance production of cartilage matrix by the chondrocytes that provide the joint lining. Studies of one agent against the other or against the combination haven’t been done. And it’s hard to make chondroitin: 6/13 products studied flunked quality testing.
DHEA: (dihydroepiandrosterone) is being used to improve sexual function, and also for preserving thinking, improving strength and slowing aging. DHEA is harvested from animal adrenal glands and is in the same group as testosterone. Evidence for erectile function comes from the University of Vienna, with improvement in a 40 patient trial for 6 months. The dose was 50 mg per day. Studies of DHEA in depression, osteoporosis, strength, lupus, and weight loss have shown intriguing trends, but all had small numbers of participants (generally less than 10 in the treatment arms). Side effects include acne, irritability, increased appetite, drop in “good” HDL cholesterol, prostate enlargement and liver toxicity (much as oral testosterone). I could find no long term safety studies.
SAM-e: (S-adenosyl-methionine) - pronounced “Sammy” - is being touted for depression, arthritis and liver disorders. SAM-e is found through-out the body, including the brain and spinal cord. A review of 20 studies (giving it by vein) show improvement in mood and symptom improvement at least as frequent as with older (tricyclic) antidepressants. There’s little data on oral SAM-e. For some liver conditions, it may be superior to placebo; for arthritis, the data is scant. It can cause thirst, salivation, head-ache, nausea, diarrhea and urinary frequency. It changes the metabolism of 3 important neurotransmitters: serotonin, norepinephrine and dopamine. Drug interactions are to be expected, but haven’t been studied. And, it’s very hard again to make it: chemical stability of the oral form has been a problem and on testing some pills had no detectable SAM-e in them.
Selenium: this antioxidant has been suggested for preventing prostate cancer and other cancers, heart disease and sun damage to skin. The evidence on cancer comes from a study at the University of Arizona. Dr. Larry Clark found that patients taking 200 micrograms daily selenium had 63% less prostate cancer, 58% less colorectal cancer and 45% less lung cancer. There were some 1300 patients in the study published in 1996 in the Journal of the American Medical Association. That study is yet to be confirmed by similar one. Other studies have shown that areas of the country with low selenium in the soil (such as the Pacific Northwest and some parts of the East Coast) have higher rates of such cancers. We should point out that a blue ribbon panel of the Institute of Medicine recently set the recommended level at 55 mcg per day, with the upper limit of 400 mcg per day. Those taking too much can have brittle nails and hair loss. Sources of selenium include yeast, whole grains, fish, meats and nuts.
MSM: or methylsulfonylmethane, has been recommended for arthritis, muscle pains, asthma and headaches, as well as emphysema, cataracts, allergies depression and even constipation. It is expensive, and is very similar to an industrial solvent called dimethyl sulfoxide (DMSO). The theory of action of this supplement is that the body uses sulfur (which is in MSM) for cell oxygenation and cartilage and collagen manufacture. There are no long term studies and few if any published scientific studies. It is difficult to imagine anything that would have as many benefits as claimed for this one. Bottom line: unproven.
Forever Female -- The Case For Estrogen:
A striking case can be made for the use of hormonal replacement therapy in post-menopausal women:
Quality of Life--You Live Better:
a) You don't get (as) fat -- and if you do gain weight, you put it on your hips and buttocks (pear shape), not the more dangerous area of the waist (apple shape).
b) Your skin looks younger with less wrinkles are more moisture.
c) You remain stronger (bone, muscle, cartilage).
d) You have less joint aches (arthralgias)
e) You get less urinary infections.
f) You have less vaginal dryness.
g) You have less pain on intercourse.
h) You think more clearly -- there is early evidence that the incidence of Alzheimer's disease is reduced in women on estrogen.
i) You feel more energy, less fatigue, sleep better, have less head-aches, palpitations and flushes.
j) You keep more of your teeth.
Quantity of Life --You Live Longer:
a) Decreased heart disease. The rate of coronary disease goes down 50%. This compares with a relative risk of menopause of 317%! And recent additional data shows women who’ve had bypass surgery are more likely to survive on estrogen -- 98.8% vs 82% for nonusers after 5 years.
b) Decreased stroke. The stroke rate on estrogen is 31% less, and death rate from stroke 63% less.
c) Decreased diabetes. In one analysis, risk dropped by 32%.
d) Increased bone strength, decreased fracture risk. As we have noted in these pages before, one million post-menopausal women will break a bone this year. 300,000 will break a hip. 100,000 will wind up in a nursing home, and 60,000 will die. Vertebral compression fractures, which lead to substantial loss in height, will occur in nearly one woman in four after menopause.
e) Decreased risk of hypertension.
f) Decreased risk of colon cancer.
g) Decreased risk of ovarian cancer (by 37% in one 1994 study).
h) Decreased risk of blocked arteries to the legs. (Peripheral vascular disease.)
On balance, a study in the Journal of the AMA says, women gain between 4 and 41 months of life with estrogen.
What's the Downside?
As always, there is no perfect pill.
a) Uterine cancer. This risk occurs only with the use of estrogen only in women who still have a uterus. It has now been eliminated by use of progestins either simultaneously or in a cycle that mimics a normal period.
b) Breast cancer. This remains quite controversial, but there is substantial evidence of a small, but measurable, rise in breast cancer in women on estrogen. This makes biologic sense, since a large number of breast cancers are dependent on estrogen for growth. But it's a small effect -- a relative risk between 15 and 74% higher. This compare with a 100% increase with obesity, a 100% increase with never having had children, a 200% increase with a high fat diet, and 500% increase with excess alcohol! And analysis of 122,000 women in Boston’s Nurses’ Health Study showed that only women who drank had the increased breast cancer risk.
Forms of Estrogen Include: pills (Premarin, others), combinations (PremPro), patches (Climera, Alora, Estraderm) and creams. The data on pills is better than that for patches and creams.
Sources: Sandra Raff, M.D., director of endocrinology at New Britain (Conn) Hospital, JAMA, others.
What Is It?
Poorly understood by just about everyone, it is a chronic condition of widespread pain. The "Fibro" means fibrous tissues such as tendons and ligaments. "My" means muscle, and "algia" means pain. Pain (not just tenderness) is found on pressing at least 11 of 18 specific points (see diagram). FM patients usually have problems sleeping and fatigue. Often the same people have morning stiffness, irritable bowel syndrome and can be anxious. Occasionally it’s been called the "irritable everything"syndrome. The urge to urinate is frequent, as is numbness, dry skin, temperature sensitivity, chest pain, headache, fainting, and trouble with balance. Some report "spaciness" and difficulty concentrating: "fibro-fog."
Who Gets It?
Fibromyalgia is thought to affect 3-8 million people in the U.S. Most (80%) are women Family clusters have been reported, suggesting a genetic factor.
What Causes It?
The cause is not known. Theories abound: altered serotonin (a brain nerve transmitter) levels, immune or endocrine abnormalities (such as thyroid disorder), stress, trauma or a virus (no evidence so far). There is also a proposal that salicylate food preservatives are responsible.
What Is The Evidence?
A chemical nerve transmitter, Substance P (involved in pain) is elevated 3-fold in FM patients. There is also SPECT (brain) scan evidence of changes in regional brain blood flow in FM patients.
Lab Tests are mainly used to exclude other problems - there is no definitive "test" for FM. It is important to check for Lyme disease, systemic lupus, rheumatoid arthritis, low thyroid and some forms of viral hepatitis.
How Is It Treated?
Treatment is quite varied:
Physical Maneuvers: These include massage, ultrasound, hot/cold packs (warm-up/cool-down), myofascial release, postural training, aerobic exercise, stretching, relaxation therapy and occupational therapy (to adjust job-related tasks that contribute to pain such as repetitive motions).
Acupuncture: has been reviewed at the National Institutes of Health and a Consensus Panel found that FM is one of the conditions most successfully treated with acupuncture. The mechanism is not clear; there is fair evidence that the needles induce the release of the body’s own version of morphine.
Medication: is often quite helpful, especially in patients with sleep disorders. The 2 best studied are amitriptyline (Elavil, others) and cyclobenzaprine (Flexeril). Elavil is an antidepressant that works on the serotonin disorder. Adding fluoxetine (Prozac) is more effective than either drug alone. Flexeril works best at night. Other drugs tested include Zoloft, Paxil, aspirin and other anti-inflammatories (such as Naprosyn, Vioxx, Celebrex etc), and the non-narcotic pain killer, tramadol (Ultram).
The "Silent Disability"
Hearing loss, "is the number one disability among the elderly," according to Dr. David Nielsen, executive VP of the American Academy of Otolaryngology. People with it, he says, "just muddle through, struggling with communication." We hear about it when another family member complains about "being ignored" or about the TV volume being too loud. And all too often patients with hearing loss are thought to be losing memory and "going Alzheimer’s" or to be depressed. In a year 2000 survey by the National Council on the Aging, those with untreated hearing loss and their families reported more sadness, depression, worry, anxiety and paranoia.
The numbers are staggering: 20-26 million in the U.S.
Causes of Hearing Loss:
- Noise - loud noise over time can cause significant hearing loss, beginning in the higher frequency ranges. This is a significant worry in fans of loud music who come back from concerts saying their ears are "ringing." This means hearing is being damaged.
- Wax - build up can easily be relieved by us or an ENT consultant
- Medications - some 200 drugs are known to damage the inner ear. Among the most frequent are those used for cancer treatment or serious infections; the damage may be permanent. High dose aspirin, quinine and certain "water pills" (such as Lasix/furosemide) can cause temporary damage. More rarely prednisone-type medication, certain anesthetics and some mood-altering drugs can affect hearing. Typically, high frequencies are lost first.
- Otosclerosis is basically arthritis of the middle ear bones
- Meniere’s disease affects the inner ear with deafness & vertigo
- Acoustic neuroma is a tumor affecting the nerve of hearing and balance
- Autoimmune inner ear disease results from an attack by the body’s immune system
- Aging is also a factor
What Can Be Done?
- Limit Noise
- Clean out wax
- Don’t smoke!
- Regular hearing checks (which we’ll be glad to do!)
- We’ll get you help: Ear, Nose and Throat and audiology consultations.
- Hearing aids: 4 styles:
- 1) over the ear (biggest)
- 2) in the ear
- 3) in the canal
- 4) completely in the canal (smallest)
- Each comes analog (basically an amplifier, and less expensive) or digital (computerized to bring out speech, and more expensive).
- You have 45 days after purchase to return hearing aids in NY State Aids take time to get used to – often 6-12 months. They do not return the wearer to his or her youth. But they do improve the quality of life. Patients are safer, and they may even help prevent or slow down dementia.
The Future? Surgically implantable aids have been approved by the FDA and cochlear implants (in effect, bionic ears) are in study.
In the next hour, 170 Americans will have a heart attack; 70 will die. That’s one heart attack every 20 seconds, and one heart death every 51 seconds. There are 1.5 million heart attacks each year: total cost $60 billion. How do you avoid this?
Early Detection: We’re getting closer to being able to find who’s going to get heart disease, and much earlier — before their heart attack or stroke. And we can treat earlier, and more effectively.
- Genetic Testing: many of you have had advanced cardio-vascular testing through our office from the Berkeley HeartLab. These tests can help you, your brothers, sisters, children, and even parents know what their heart risks are and what to do about them. The tests are drawn in our office by special arrangement.
- High Frequency Carotid Ultrasound: A study by Dr. Howard Hudis and colleagues at the University of Southern California (in the Feb 15, 1998 Annals of Internal Medicine) showed this painless, inexpensive study of the arteries in the neck could pick up people with early heart disease. And frankly, if there’s disease in the arteries to the brain, treating helps prevent strokes at least, as well as heart attack! This is available nearby in New York with NYU cardiologist, Dr. Michael Schloss.
- Cholesterol Screening: A massive study of 6600 people in Texas concludes we should treat many more people than we have been under the guidelines of the National Cholesterol Education Program (NCEP). The Air Force Texas Coronary Atherosclerosis Prevention Study (AFCAPS/ TexCAPS) looked at men over 45 and women over 55 who had no known heart disease and low or normal “good” high density (HDL) cholesterols. The “lousy” or LDL cholesterols were 130-190. Treatment was with lovasta-tin (Mevacor). Those who were treated had 36% less risk of a first heart attack, angina or sudden death. Women did particularly well, with 54% reduction in first events. This study confirms an-other one done with pravastatin (Pravachol) in Scotland. Of great interest, the average LDL in the AFCAPS/TexCAPS trial was 150, below the NCEP’s sug-gested treatment threshold of 160.
Could Germs Help Cause Heart Disease? Enticing reports that Chlamydia pneumon-iae might be involved in atherosc-lerosis are about to be tested. A recent small study showed that giving the antibiotic Zithromax for the common germ reduced the rate of second heart attack 5-fold in 18 months! Is this voodoo? Well, we now cure ulcers with antibiotics...
The Endothelium: Where the Action Is: Imagine the lining of your arteries: the largest organ in your body: 1800 grams, and if spread out, enough to cover 6 football fields!
Preventing Heart Attacks and Strokes:
Diet: A “Healthy Heart” diet should approach the diet eaten in the Greek islands. This Mediterran-ean diet was used in the “Lyon” study and cut the rate of heart attack and other cardiac events by 76% in a 27 month period in a group of patients with known heart disease. In simple terms, the diet means:
- twice the seafood
- 66% more fresh veggies
- 10% more fruit
- 2-4 times the whole grains and beans
- 4 times the olive oil
- 45% less red meat
- 16% less eggs
- 50% less whole milk and dairy products
- 50% less non-olive oils
Sadly, the top 6 sources of calories in the usual American diet are: Whole milk, cola, margarine, white bread, rolls (ready to eat) and sugar.
Vigorous physical activity can markedly decrease the risk of heart attack. According to Dr. Robert Vogel, Chairman of Cardiology at the University of Maryland, 30 minutes at 75% of your maximum heart rate 1-2 times per week lowers your risk 80%. Doing it 5 or more times a week lowers your risk 50-fold! And in the Northern Manhattan Stroke Study, a walk a day reduced the risk of stroke by 62%.
Homocysteine can lead to athero-sclerosis, and can be brought down by folic acid, B-6 and B-12. It is estimated that 1 mg. folate daily could reduce strokes by 10% and heart attacks by 15% in the U.S. Vitamin A in veggies is good, but beta-carotene in pills has lead to an increased risk of lung cancer in current and former smokers. Vitamin E 400U daily was shown to reduce the risk of 2nd heart attack 77% in the Cambridge CHAOS study. In a small study, Dr. Vogel’s group has shown vitamin E plus 1000 mg vitamin C block the paralyzing effect that fatty meals have on arteries.
We now have proof that “statin” drugs (such as Baycol, Lescol, Lipitor, Mevacor, Pravachol, and Zocor) can decrease the risk of heart attack and stroke in men and women, even if they’ve never had symptoms. There are exciting possibilities that these drugs attack the cause of most heart attacks -- the oxidized LDL causing a ruptured arterial plaque. Pravachol also seems to lower platelet counts and stabilizes fibrinogen, elements involved in plaque rupture.
Niacin (Niaspan, etc) is very useful in those with dangerous LDL pattern B or elevated Lp(a) (risk factors we can check on with Berkeley HeartLab)
Estrogen and similar drugs such as raloxifene (Evista) may help. Several trials are under way studying if medications may be more effective than angioplasty or even bypass surgery — and early indications are that they are!
And Again, Aspirin:
Still one of the most effective drugs ever, 325 mg. of aspirin prevented 39% of heart attacks in a study of 22,000 U.S. physicians. And there is evidence 81 mg. should be enough. It’s also useful for preventing second heart attacks (32%) as well as strokes (27%) and total blood vessel disease related death (25%).
Our office is frequently asked if there are “any risks” in taking herbs that are available over the counter in health food stores or supermarkets. The brief answer is “if there are effects, there will be side effects.”
|Common name||Botanical name||Purported Use||Toxicity|
|Aloe General tonic||Aloe vera||Wound healing
|Darrhea / vomiting|
|Black cohosh||Cimicifuga racemosa||Premenstrual syndrome
Slow heart rate
|Comfrey||Symphytum officinale||Blood purifier
|Echinacea||Echinacea E. purpurea||Immune system booster||Shakes, jitters
|Kava kava||Piper methysticum||Sedative||Skin irritation
Shortness of breath
|Ma huang||Ephedra sinica||Stimulant
Rapid heart beat
|Pau d'Arco||Tabebuia impetiginosa
Immune system booster
|Valerian||Valeriana officinalis||Sedative||Involuntary muscle reactions
Source: March 1997 Internal Medicine News
"Doc, I’ve got this COUGH..."
Cough is one of the most common complaints we hear. In fact, it’s estimated to account for 4% of adult visits to doctors, of 25 million visits a year. The annual cost of treating cough in the U.S. is estimated to exceed $1 billion!
Acute Vs. Chronic Cough:
Acute cough is any cough that lasts less than 3 weeks. It’s usually caused by a viral illness, such as a cold. Lots of other things can be responsible:
- (post-nasal drip)
- acute bronchitis
- (whooping cough)
- congestive heart failure (see April 2001 newsletter)
- pulmonary embolus (a clot that travels to lung arteries)
Chronic cough lasts 3 weeks or more. Major causes include:
- post-nasal drip (40-50%)
- asthma (25-30%)
- GERD (GastroEsophageal Reflux Disease - or heartburn (20-25%))
And there are less frequent causes:
- chronic bronchitis
- bronchiectasis(thinning and consolidation of air sacs such as from cystic fibrosis or smoking)
- post-infectious cough (such as the one that lingers from whooping ("100 day") cough, more common now due to waning immunity from the childhood vaccine)
- lung & other cancers
- medications (such as angio-tensin converting enzyme inhibitors (ACEI’s): captopril (Capoten), enalopril (Vasotec) and others.)
Post-Nasal Drip is far and away the most common cause of cough. There are 3 major issues:
- Allergic drip: profuse watery discharge can be seen with seasonal (acute) allergy - and can lead to "choke cough" when lying down. It can also be seen with perennial allergy - which is frequently obscure because there’s no itch, sneeze or runny nose.
- Non-allergic drip can come from chronic extra blood flow in the nose and sinuses; these patients also are more likely to have upper airway and bronchial spasm.
- Chronic sinusitis will also cause cough: such patients will have excess sputum with their cough.
Rare causes include:
Chronic Interstitial Lung Diseases which are often tough to diagnose.
Habit (nervous) cough
Asthma is frequently due to allergy, and is often triggered by mouth breathing (which is seen in those who can’t nose breathe). Cough can be the only symptom (cough variant or "hidden" asthma). Post-nasal drip can trigger asthma; but some patients seem susceptible to both.
GERD (Heartburn) is due to acid "leaking" up form the stomach, which is protected from it, into the esophagus, which is not. 10-20% of GERD patients have respiratory symptoms including cough. These occur due to a nerve reflex from the esophagus to the airway or due to "microaspiration" of acid into the lung. Most patients with GERD cough do not have heartburn symptoms!
Diagnosis and Treatment are directed at the cause (or causes!) of the cough, sometimes treating the major causes simultaneously: sprays and antihistamines (and perhaps antibiotics) for the nose, inhalers and other drugs for asthma, allergy avoidance (or allergy shots), and acid blockers for the GERD. If therapy is unsuccessful, other tests, such as X-rays and CT scans, are done.
COUGH HISTORY QUESTIONNAIRE
If you have been experiencing a persistent nagging cough, it is a good idea to speak with us about it. This questionnaire is designed to help find the cause of your cough. Please take a few minutes to complete it prior to seeing Dr. Grimshaw.
1. How long have you had your cough?
- Less than 1 week
- 1-2 weeks
- 2-4 weeks
- Over 4 weeks
2. How many times a day do you cough?
- Over 20 times
3. Is your cough productive? In other words, do you bring up mucus or phlegm (a thick, slimy substance)?
4. Do you sometimes wheeze or feel that your chest is tight?
If yes," when do you usually have this feeling?
- At night
- After/during exercise
- Early morning
Other (please specify)___________________________________________
5. Is your cough seasonal?
If "yes," which season is the worst?
6. Have you had a cough like this before? If "yes," how long did it last?
- Weeks (how many?)____________
- Months (how many?)___________
7. Do you smoke?
8. Do you live with anyone who smokes?
9. Do you have pets
If so, what kind?__________________________________________________
10. Do you have any allergies?
If "yes," please list things to which you are allergic:
11.Do any specific substances, such as perfume, make you cough?
If "yes," please provide examples:
12.Is there one area where your cough is the worst?
If "yes," please say where:
13.Do you have "heartburn" or "indigestion?"
If "yes," when is this most common?
- After meals
- No special time
14.Are you taking any medications (prescription or over-the-counter)?
If "yes," please write them down:
Quick: what has
- 26 bones
- 33 joints
- 20 muscles
- 150 ligaments
- 250,000 sweat glands that release a cup of moisture a day
- daily endures the cumulative force of hundreds of tons
- trudges about 115,000 miles in a lifetime?
You’re right – your foot! Our feet are important to all of us, but are especially at risk in those with poor blood flow or diabetes. Of some 16 million diabetics, 15% will be hospitalized for foot problems. The reasons:
- Poor Sensation: Neuropathy (due to diabetes or other causes) leads to injuries because you don’t know you’ve been hurt, can cause toes to curl up and other deformities.
- Poor Circulation: Lessened arterial blood flow means that feet can’t fight infection and injuries are slow to heal. If you’re getting pain in your calves on walking, we should check your blood flow – there’s a lot we can (and should) do!
From callus to ulcer - what you don't want
What WE’LL Do:
At your physical, we’ll ask about your feet; alert us to any issues
We’ll check your feet for sensation, pulses and ulcers
If you’re diabetic:
Get our foot guide
We’ll check your feet more often
We’ll discuss a podiatrist (foot specialist)For more see the "Diabetic Foot Guide" in the Our Guide section. Other resources are the American Diabetic Association (diabetes.org) and the Joslin Clinic (Joslin.org).
What YOU Should Do:
- Wash every day, and dry carefully between toes
- Check daily for cuts sores, calluses & blisters
- Test the water first - don’t make the temp too hot
- CHANGE YOUR SHOES 2-3 times during the day – they lose resilience
- Wear socks if cold, and choose them carefully: well padded, ½" longer than your longest toe
- Don’t use hot water bottles, heating pads or electric blankets (you can be burned)
- No garters! (they cut off blood flow)
- Cut toenails straight
- Don’t rip hangnails
- Wear comfortable, flat shoes that fit, and break them in slowly
- Buy shoes at the END of the day, when your feet are swollen (if they’re comfortable then, they’ll likely be so all day!)
- Check shoes daily for pebbles, tears, etc
- Never walk barefoot!
- Keep your feet dry by dusting with non-medicated powder If your feet are too dry and the skin is cracking, moisten with Nivea, Eucerin or Alpha-Keri (NO PERFUMES!)
- If you’re diabetic, control your sugar
- DON’T SMOKE!!!
- If you lose sensation, tell us!
- See us at the FIRST sign of infection or inflammation.
As you can see from the map, Lyme disease is found primarily in the Northeast. In fact, the 6 northern towns of Westchester County are a major hot-bed of Lyme. Lyme was first described in the town of Old Lyme Connecticut after Dr. Allan Steere was put on the trail by a local artist, Polly Murray, who had found that many area residents, including a large number of children had been diagnosed with "juvenile rheumatoid arthritis." Steere and his Yale group were able to trace the disease to the "deer" tick Ixodes scapularis, and a germ in it, Borrelia burgdorferi. There have been over 161,000 cases reported in the US; 2,580 this year so far.
Tick Life: No deer, no Lyme is the bottom line. Although other animals, specifically white-footed mice, are important in the tick life cycle, the disease is where the deer are. On Grand Island, a peninsula off Cape Cod, all the deer were "harvested" – and no more Lyme occurred!
Symptoms: Early Disease: flu-like headache, fever, muscle aches, fatigue and the famous "bulls-eye rash." Disseminated Disease: nerve problems, such as facial droop (Bell’s palsy), arthritis (usually a few red, hot joints) and slow heart beat (heart block). Memory issues and trouble working with numbers have also been reported. According to the Centers for Disease Control, "Lyme disease is rarely, if ever, fatal."
Diagnosis: Early Lyme is diagnosed from the rash. Blood tests are not helpful at this stage. In disseminated Lyme, the diagnosis is made by history and physical exam, supported by lab tests. The main blood tests are a screening ELISA and a more specific "Western Blot". Unless antibiotics have been given, the tests, in my experience, are very good, especially for Lyme arthritis.
Treatment: Early Lyme is treated with 21 days of antibiotics. Doxycycline (Doryx, Vibratabs) is preferred, because it penetrates the joints, the central nervous system and covers for a frequent co-infection, Ehrlichiosis (see below). Stay out of the sun (due to rash)!
Disseminated Lyme treatment has become controversial. First therapy is 30 days of oral antibiotics, doxycycline again preferred. Studies have shown that this works as well as intravenous (IV) drugs, such as Rocephin (ceftriaxone). It’s good to remember that improvement can continue for up to 6 months, "coasting" after therapy is finished. IV meds are used if oral treatment fails. Unfortunately, there is a subset of patients who don’t get better, no matter what. A recent study showed no improvement with long-term antibiotics. But it’s been faulted for only using 1 month of IV meds and 2 months of oral therapy.
More data is needed!
Prevention: stopping ticks from biting is the best way – no bite, no Lyme. Long sleeves and long pants help. Picking the ticks off also helps: they have to feed for at least 36 hrs to infect you.
Antibiotics for Tick Bite? A report from NY Medical College shows Lyme can often be aborted by giving one dose of 200 mg doxycycline, if you’ve got a blood-engorged deer tick.
LYMERix Vaccine generated some controversy, but in March 2002 it was withdrawn from the market by the manufacturer, GlaxoSmithKline. The official reason was lack of demand.
- You can get Lyme again.
- Ticks walking on you haven't infected you.
- Testing ticks is NOT helpful
- DON'T LIVE IN "TICK FEAR!!"
Here's how to remove ticks:
Don’t Forget Ehrlichiosis:
In our area, ½ adult deer ticks carry Lyme; ½ also carry the germ that causes Ehrlichiosis; 1/4 carry both! Of the young nymphs, the figures are 1/4 for each and 1/8 for both.
Symptoms: a flu-like complex of headache, fever, fatigue and muscle aches comes 5-10 days after the bite. If you get these, get in right away! Ehrlichiosis can cause serious pneumonia and can be fatal.
Diagnosis is made from history and exam, supported by a blood count and liver tests. The best test is response to treatment; a specific blood test is expensive and slow.
Treatment is with doxycycline for a week; other drugs are available.
Babesiosis can also be carried by the deer tick, but hasn’t been reported in our area - yet. Patients with both Babesiosis and Lyme have been seen in Nantucket and treatment is complex and difficult.
A New Lyme-like Germ was reported in May by Dr. Durland Fish at Yale. They don’t know yet if it causes human disease.
Could it be the reason some patients do poorly?
Recipe for hypertonic saline (saltwater) for home or office irrigation:
- To 1 (quart) of warm distilled water, add:
- 2 -3 heaping teaspoons of sea salt and
- 1 teaspoon of Arm & Hammer baking soda.
The nose should be irrigated 2 - 3 times per day with a bulb syringe, large medical syringe (or a turkey baster!) or water pik with irrigator tip. Stand over a sink and squirt the saltwater into the nose in such a fashion that you are able to spit some of the saline out of your mouth.
Aim the stream of saline as though you are trying to squirt the back of your head, NOT the top of your head. It is acceptable to breath the saltwater directly into your nose.
Warm saltwater is preferred, as it is much more comfortable. The amount of salt added will depend on your tolerance. However, the more salt that is added the greater the decongestant effect. The bicarbonate is a buffer which makes the saltwater less irritating.
The benefits of hypertonic saline irrigation are three-fold:
- It is a solvent. It cleans mucus, crusts and other debris from the nasal passages.
- It decongests the nose. Because of the high salt concentration, fluid is pulled out of the membrane. This shrinks the membrane, which improves nasal air flow and opens sinus passages.
- It improves nasal drainage. Studies have shown that saltwater cleaning of the nasal membranes improves ciliary beating so that normal mucus is transported better from the sinuses through the nose and into the throat.
If you are also using a nasal steroid, such as Beconase, Vancenase or Nasacort, you should always cleanse the nose first with the saltwater before utilizing the nasal steroid. The nasal steroid is most effective when sprayed onto clean nasal membranes, and it reaches deeper into the nose after cleansing and decongesting.
Provided by Robert S. Grimshaw, Jr. M.D. from recipe by Timothy Siglock, M.D.
"The Fifty-Year Itch"
According to Dr. Laurie Polis, Mt. Sinai & Beth Israel dermatologist, "it’s almost as if when someone turns 50, their skin is likely to become much itchier." She calls this, "the 50-year itch."
Why does this occur?
- Thinning of the epidermis (the top layer of the skin) with age
- Change in skin oil production
- Hormonal change
Together, these changes cause itching and burning; if you scratch too hard, damage occurs, and an "itch/injury" cycle begins.
The Skin From MH Swartz, Textbook of Physical Diagnosis,1998 p 93 WB Saunders Co.
Older skin is more sensitive to irritants:
- fabrics, such as wool
- detergents & bleaches
And other factors irritate the skin:
- low humidity (relative humidity indoors in the winter can be close to zero percent when it’s below freezing outside, since the same air at 70o indoors can hold so much more water. It’s as if you’re in the dessert: skin then has to give up its own water to the very dry indoor air)
- low-fat diets sometimes also decrease skin moisture
- some medications also lower skin moisture
- Use cotton or a synthetic against your skin instead of wool
- No fragrance soaps or detergents (there are cleansers such as Aveeno for sensitive skin)
- Bathe in tepid or lukewarm water only - NO HOT SHOWERS OR BATHS!!
- Regularly bathe odor-bearing regions only - daily bathing dries out the skin
- Rinse completely after bathing to remove all soap or detergent
- Pat lightly to dry off –don’t rub!!
- After bathing, immediately apply a moisturizing cream (such as Nivea, Eucerin or Alpha-Keri)
- Topical anti-itch creams (such as Lanacane, others) can sometimes help
If There’s No Relief, We May Be Able to Help: Some medical conditions can cause itch, including certain liver disorders (such as hepatitis C), both low (hypo) and high (hyper) thyroid problems, kidney failure, iron deficiency or iron overload, nerve irritations, allergy, drug reactions, and (fortunately quite rarely) a few malignancies such as lymphoma and multiple myeloma.
And skin lesions that keep itching should get checked with a skin specialist (dermatologist).
Some 30% of older Americans who live in their communities fall every year, as do more than half of nursing home residents. Falls are the 6th leading cause of death in the elderly, killing some 10,000 a year. And they cost some $13 billion a year. So reports Mt. Sinai’s Dr Helen Edelberg. In fact, falls cause about 40% of all nursing home admissions.
Why do people fall? Only 10% of falls occur due to a single event; most occur due to multiple factors:
- muscle weakness
- foot disorders
- vision loss
- balance loss
- medication effects
- Parkinson’s disease
- other nerve disorders
- acute illness
Home Issues Are Important, Too:
- Stairs - 10% of falls occur on stairs, usually the last step
- Slippery floors
- Beds too high or too low Trip risks: cords, etc. Inadequate lighting
What Can Be Done?
- Eliminate clutter, especially on the floor
- Floors should be smooth, not slippery
- Carpets & rugs should be tacked or have skidproof backing NO THROW RUGS!!
- Stairs should be well lit and have handrails on both sides. Fluorescent tape on the edges of the top and bottom steps can help.
- Grab bars should be beside tubs, showers and toilets (there’s no ‘good’ place to fall in the bathroom!)
- Tub seats and hand-held shower heads help also
- Place rubber mats or non-skid strips in tubs and showers
- Furniture should be out of the flow of traffic in the house, stable and without sharp corners
- Improve lighting - add ceiling fixtures, use sound/motion activated lamps, increase wattage
- Use night lights
- Keep a flashlight at the bed
- Don’t use step stools, or if you must, make it sturdy with a handrail and wide steps
- Carpeting and curtains can minimize echoes and sharp noises
- Avoid shiny surfaces/glare
- Colors: yellow, orange & red are easiest for people with poor vision; contrasts help for doorways, stairs and walls
- Use a portable phone
- Get a "Lifeline" button-type emergency call service OR arrange for daily contact with a friend or family member.
- In rain/snow/ice, use a cane or a walker
- Wear warm boots with rubber soles
- Carry salt or kitty litter in your pocket or car in icy weather
- Stay away from slippery floors in public buildings.
3) Exercise Helps!
- Balance and gait training help. So does walking (improves endurance) and Tai Chi meditative movements. In an Australian study, group exercise was the single most important intervention in a fall prevention effort. When combined with home hazard reduction and vision improvement, falls dropped 14% annually.
For Vomiting & Diarrhea:
Every season has its risks of food poisoning and stomach viruses. In broad strokes, there are 2 types of food poisoning: 1) where you eat the toxin that has been made by germs incubating in a food and 2) where you eat the germs themselves. This guide is for viruses and for the first - not the second type of food poisoning!
Before we go further, this guide presumes that:
- You don’t have a temperature over 100 F.
- The vomiting stops.
- There’s no blood in your stool
For any of those conditions, call!!
The progressive diet is designed to keep your fluid levels up and to let your stomach and bowel “rest.” We’re aiming for at least 600 calories of intake a day also. That’s based on work by Dr. George Blackburn at Harvard with burn patients. 600 calories a day prevents muscle breakdown.
Start with step 1 and go up as you feel up to it - usually meal by meal (sometimes day be day). At each level, you can use all the foods from the previous level also.
1) Clear Liquids: This means anything you can see through plus ice chips, Jello and sorbets. Included are:
- Clear sodas: “ginger ale” (which of course has no ginger), 7-Up, Sprite and decaf colas.
- Clear juices are allowed: cranberry, white grape and apple (though this may cause increased diarrhea in some).
- Jello is fine, but make it the regular, not the diet - you need the sugar!
- Broth is very useful, be-cause a cup of one of the dried packets or one cube of bouillon gives you 3 grams of salt, and with vomiting or diarrhea, you are salt de-pleted. 3 cups is the same as getting one large IV bottle!
- Italian ices and sorbets are also allowed.
- Apple Sauce/apples
- Tea (decaf) with sugar
3) Soft Diet - No Milk
- Scrambled Egg
- White bread toast with margarine or jelly
- Boiled, broiled or baked chicken or turkey (bland)
- Rice, pasta, egg noodles (prepared in chicken broth)
- Cream of rice or wheat, no milk
- white potato with margarine
3) Regular Diet, No Milk Such as:
- Lean hamburger
- Cooked, non-greasy veggies
4) Regular: once you’ve had no diarrhea for 48-72 hours, gradually add milk products back in.
Diabetics: Special Considerations:
If you’re on oral agents, just hold them until you’re keeping down solid foods. You SHOULD check your sugars in the morning and 2 hours after meals during this period, and call if they’re over 250.
If you’re taking insulin, cut your “baseline” dose (usually NPH) to 50-75%, and again check your sugars 4 times a day as above. If you’re on lispro (Humalog) or regular before meals, hold those until you’re eating. You should get some calories in during the “clear” period - a little Jello or sorbet should be ok. Cover high sugars with regular or lispro.
(Prepared with the help of Geri Brewster RD MPH CDN)
Restless leg syndrome is a feeling of deep discomfort at rest. Patients will describe the feelings as creeping, crawling, itching, tingling, burning, pulling and jitters. 80% report the involuntary movements. While the cause is not known, abstaining from smoking, alcohol and caffeine usually helps. We should make sure there’s no drop in iron, folate or vitamin B-12, and check for medication effects, thyroid and kidney disease. Therapies include stretching, Sinemet, Klonopin, and Neurontin. Occasionally, quinine can be helpful – but really only for leg cramps, not for true Restless Legs.
To stretch, lean against a wall, placing your feet about a yard from the base of the wall while on the balls of your feet, then slowly come down onto your heels, with your knees locked. Do this for about 30 seconds. This will stretch the muscles in the back of your legs.
Sinemet, Klonopin and Neurontin are prescription items. From the Mayo Clinic Proceedings, Dr. Siong-Chi Lin and colleagues report that the anti-Parkinson drug pramipexole (Mirapex) may be very useful. They started with 1/2 of a 0.25 mg pill nightly 2 hours before bedtime. Only 1 of their 16 patients couldn’t take the drug. Most noted less leg restlessness including involuntary “jumping” and better sleep. The main side effect was fatigue or stiffness. The pills cost about $1 each.
For quinine, the easiest source is Schweppe’s Tonic Water - one glass at bedtime. Other sources can include the prescription Quinam tablets at bedtime.
Insomnia is one of the most frequent complaints we hear. In fact, most Americans sleep too little: the average adult sleeps just under 7 hours during the work week, according to a 2000 survey by the National Sleep Foundation. The recommended amount of sleep is 8 hours. One in 3 sleeps 6.5 hours or less.
Drowsy driving is estimated to cause 100,000 crashes annually. Not surprisingly, 62% have trouble sleeping a few nights a week. 43% say that daytime sleepiness interferes with their activities a few days a month. Some of these problems will come from diseases: heartburn (gastroesophageal reflux disease) wakes up many. People with lung disease, heart failure, arthritis and certain neurological conditions including strokes commonly have trouble sleeping. By far the most common is use of some medications, caffeine and rebound from alcohol.
So what can be done? From Dr. Joseph Kwentus writing in the Clinical Geriatrics, some thoughts on sleep hygiene:
Dr. Kwentus’ Sleep Hygiene Guide:
- Don’t go to bed until sleepy
- Do your bedtime rituals of washing up, brushing your teeth etc at the same time every night • Get up at same time every day
- DON”T NAP!!
- Exercise daily, early in the day
- Don’t use your bedroom except for sleep and romance
- Don’t ruminate about problems at bedtime - do it in the morning
- Avoid heavy meals at bedtime • STOP SMOKING! (At first your sleep will be worse, then better)
- Drink coffee, tea, chocolate, colas or other caffeinated beverages only in the morning and in limited amounts
- No alcohol 4 hours before bed
- Take diuretics earlier in the day
- Waking up with pain? Tell us!
- Empty your bladder before bed
- Limit night light, noise and temp
- Get a comfortable mattress
- Wear comfortable bedclothes
- DON”T WATCH THE CLOCK!
- Try reading or music at bedtime
- Get some sun (or bright light) during the day.
- Don’t exercise 2 hrs or less before bedtime
- Ask us about any medicines (or supplements such as ephedra) that might be keeping you up, including decongestants, and asthma inhalers.
When All Else Fails: we have medications which can help:
- Antihistamines such as diphenhydramine (Benadryl, etc) - but tolerance develops after 1-2 weeks, some men have trouble urinating and some feel a daytime “hangover”.
- Valerian is an herb which is sometimes helpful, 200-1000 mg ½-1 hr before bed; it’s unregulated.
- Melatonin 0.3-1 mg 2 hrs before bed may help, particularly seniors; it’s also unregulated by FDA.
- Antidepressants such as Elavil, Sinequan, Desyrel, Remeron or Serzone can be helpful, even for long periods. Side effects include dry mouth, constipation, etc.
- Benzodiazepines such as Sonata, Ambien, or Restoril can help for 4 weeks or less. Side effects include early morning awakening, short-term amnesia and rebound insomnia if withdrawn abruptly.
Irritation of the inner ear, called “benign positional (or paroxysmal) vertigo” - BPV - or labyrinthitis is one of the most common emergencies we see. Nationally, this affects about 160,000 people annually.
It frequently follows an upper respiratory infection, though it can occur with no preceding illness. Often, there is no warning. Patients feel as if they’re spinning, or as if the room they’re in is spinning. And frequently they’re quite nauseated, enough to vomit. The cause of BPV is free-moving particles in the fluid (endolymph) in one of the 3 semicircular canals that make up the organ of balance, the inner ear or labyrinth.
Treatment can be with antihistamines such as Antivert (meclizine), a patch behind the ear (Transderm Scop) and physical maneuvers. Sometimes (very rarely) surgery is recommended.
We use Cawthorne exercises in the office and a series of movements called a modified Epley maneuver or “Canalith Repositioning Procedure”. The idea of both physical maneuvers is to move the loose particles from the posterior canal where they’re causing trouble back into the sump or utricle, where they don’t. A recent study at the Mayo clinic showed that ½ of patients will respond to the Epley maneuver alone; those treated with a sham procedure had a response of only 19%. It should be noted that usually 1/3 of patients have episodes of vertigo for more than 1 month after their first visit.
Patients can use a cervical collar and should sleep sitting up for the 1st 2 nights. They should not sleep on the symptomatic side for an additional five days and should avoid excess head turning for 1 week after the initial visit.
In another study, patients were taught how to do the Epley themselves, and did it 3 times daily until they got relief for 24 hours. There was a 64% response in a week.
For more: www.charite.de/ch/neuro/vertigo.html
What is Allergy?
In 1902, two French Scientists injected dogs with an extract of the sea anemone. Nothing happened. When they repeated the injections a week later, the dogs developed severe reactions to the extract – becoming "sensitized". That was the start of our understanding of the allergic response. Antibodies are formed against antigens, or allergens - the proteins we know as mold, pollens, house dust mites, animal danders and foods. The antibodies involved in allergy are usually a special class called IgE - Immunoglobulin E. These chemicals act as the "key" to open a "lock" in the surface of special immune cells, called mast cells. These cells contain granules of various inflammation proteins, including histamine, that cause the symptoms of runny nose, watery eyes, itching and sneezing.
What Can You Do?
First, you can avoid the allergens! That means avoiding feather pillows, carpets or rugs (which hold dust mites), keeping animals out of bedrooms and staying away from suspect foods and allergy triggers.
Second, allergy shots can help! They induce a different antibody class, IgG in the blood. As this antibody, circulates, it "scoops up" the allergen before the IgE "sees it." So, no binding, no harm, no foul.
Third, antihistamines help. The newer ones (Allegra, Claritin, Clarinex, Zyrtec) have less side effects than older drugs. And there are topical agents such as Patanol, Livostin (for the eye) and Astelin (for the nose).
Fourth, anti-inflammatories help. These include cromolyn (Nasacrom, Opticrom, Intal) and nedocromil (Tilade), and Alamast (for eyes) which are also mast cell stabilizers; the non-steroidals Zaditor and Acular (for eyes), and leukotriene inhibitors Singulair and Accolate.
Fifth, corticosteroids are the ultimate anti-inflammatories. These include prednisone, methyl-prednisolone (Medrol, etc) and dexamethasone (Decadron, etc) by mouth; various inhalers for the lung (Aerobid, Azmacort, Beclovent, Flovent, Pulmicort, Vanceril, etc), and for the nose (Beconase, Flonase, Nasacort, Nasonex, Nasalide, Nasarel, Rhinocort, Vancenase, etc)
The Future? Xolair on the Horizon
Omalizumab (Xolair) is a recombinant, humanized monoclonal anti-IgE antibody. A study in the Journal of the American Medical Association found that the drug decreased levels of IgE in the blood and reduced symptoms in patients with runny noses from ragweed or pollen. Those on Xolair missed work or school 75% less than those on placebo. In another study, the drug also reduced the need for steroids in asthmatics. There are drawbacks - the drug is given as an injection every 3 weeks throughout the allergy season. The FDA is expected to rule on the drug for asthma in 2003.
What Is Congestive Heart Failure? CHF, as we will refer to it, happens when the demand on the heart exceeds its blood supply. There are many reasons: damage to the heart’s valves, to the muscle directly or to the arteries. The most common cause in the U.S. is diseased coronary arteries and previous heart attacks. The most common symptom is fatigue; the next is breathlessness. CHF is deadly: for men, ½ are dead in 5 years; for women, 1/3. In this update, we’ll review the most common treatments and what’s coming up.
Tried and True: Diuretics "Water pills" are used to reduce the amount of blood that the heart has to pump, hence less "back up" into the lungs. The most common are furosemide (Lasix), torsemide (Demadex), and hydrochlorthiazide (Hydrodiuril, others).
Digitalis: This extract (Lanoxin) of the foxglove plant is used to help keep rapid rhythms under control and to boost the heart’s output slightly. Recent studies have shown it can help keep patients out of the hospital, but does not extend life.
ACE Inhibitors: Angiotensin Converting Enzyme inhibitors such as enalopril (Vasotec), lisinopril (Prinivil, Zestril), ramipril (Altace), and others help extend life (mortality drops 25%) and reduce symptoms. The reasons are several, involving blood pressure control, improved kidney function and changes in the hormones affecting the heart.
ARBs: Angiotensin Receptor Blockers are close cousins of ACEIs. Early data indicate that these drugs such as losartan (Cozaar), valsartan (Diovan) and others can substitute for or add to the effect of ACEIs.
BetaBlockers: Metoprolol (Lopressor, Toprol) and carvedilol (Coreg) have been shown to dramatically improve life expectancy by again changing hormone effects.
Aldactone: or spironolactone has been shown in 1 study to cut death by 30% and hospitalization by 35% in 2 years.
COMING UP: Omapatrilat (Vanlev from Bristol-Meyers Squibb) combines 2 effects: it blocks ACE and it inhibits neutral endopeptidase (NEP), to keep atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) levels up. ANP & BNP work to get rid of sodium (and thus excess fluid), lower blood pressure, and open blood vessels. Studies are underway to see about this drug with and without ACEIs, and are promising.
Endothelin Receptor Antagonist: endothelin is the most potent substance known for causing arteries to "clamp down" or constrict. It is elevated in CHF. Bosentan (Tracleer) is an entothelin antagonist that has been released for high pressure on the lung or right side of the heart (Pumonary hypertension). Other antagonists are in early human study, including at NY’s St. Vincent’s. So far, it looks like the class will be most helpful in right heart failure.
Pacing: One of the problems in CHF is that the contraction of heart muscle is disordered. There is less time for the main pump (left ventricle) to fill, and there’s a back-leak ("regurgitation") through the mitral valve into the left atrium. Trials are underway to use pacemakers to "resynchronize" contraction.
ADH Receptor Blocker: anti-diuretic hormone is elevated in CHF. Blockers are in early trial (at St. Vincent’s & elsewhere) to combat salt and water retention.
Enoximone is an inhibitor of phosphodiesterase, and increases the calcium available in heart muscle cells to increase pumping. It is the latest in a series of these to be tried in CHF.
Pumps: Mechanical left and right ventricular assist devices (LVAD/RVAD) have improved and permanent implants are being investigated; the ultimate replacement pump is a heart transplant, but only 2500 per year are done in the U.S.