Heart Rate Zones for Exercise

I like using heart rate zones to guide exercise recommendations. Brace yourself for some math: First you need to calculate your max heart rate, which is 220 minus your age. So lucky for me as a 40 year old, the math is easy and my max heart rate is 180 bpm. Heart rate zones are a percentage of this number. So at 50-60% of my max heart rate, around 90 bpm, I am moving at a light warm up pace and quite comfortable. Around 60-70% of my max heart rate, I have entered a more moderate exercise zone, where I might be breathing harder but I could still have a conversation. At 70-80%, I am now at a moderate to high intensity and less able to talk while exercising. Higher than 80% is a very high intensity exercise that is hard to maintain for more than a few minutes at a time.

Your body gets different benefits based on which heart rate zone you are in. While getting your heart rate into the 60-70% zone, your body looks to break down fat to fuel your activity, hence why this is often called the fat burning zone. When your heart rate is sustained at a higher level, your body switches over to burning sugar/carbs, and this is considered a cardio zone.

One reason I like using heart rate zones for exercise is because it allows people to scale their activity to meet their goals. Exercise should not always be a painful experience! Generally when you are pushing your heart rate to those max zones, you will feel uncomfortable. But the majority of your exercise, at least 80%, should be done in the lower intensity zones with a mix of fat burning and cardio. Based on your current level of fitness, varying activities will get your heart rate to the needed zones. So for example, an older patient that is new to exercising might be able to get to 70% of their max heart rate with going for a walk, whereas a younger and more active patient might need to jog to get to the same zone.

Using heart rate zones to define exercise also helps to broaden what constitutes exercise. If working out in the yard raking leaves gets you to 60% of your max heart rate - counts! When I ask patients if they exercise, some answer yes and reference their work. While it’s great to have a job that isn’t sedentary, check your heart rate to see if you are actually ‘exercising.’ If you maintain your heart rate in those zones during work, then yes - counts!

The American Heart Association recommends 150 minutes per week of moderate intense activity - so the 60-80% max heart rate level. This can be broken up throughout the week. If that seems daunting, a recent study showed that being a ‘weekend warrior’ and doing all 15o minutes on the weekend had similar health benefits to doing exercise throughout the week, such as 30 minutes 5 days per week.

My bottom line is to encourage everyone to keep moving and get your heart rate up. It doesn’t matter if it’s walking, dancing, jogging, biking, jumping rope, lifting weights, yoga, pilates or a combination of everything! And it also doesn’t matter if you find it takes light activity to get your heart rate to a higher zone - you are getting the same benefit being in that zone while walking as the marathon runner who needs to jog to get there. Plus, you will find that the more active you become, the more intense you will need to make your activity to reach the same heart rate zone. This is building your endurance.

So find some activity you enjoy, or at the very least tolerate, and get moving today!

When should I start an antibiotic?

Sinus infections are very common. With this time of year, as the colder weather sets in, I usually see an increase in appointments for sick visits like sinus infections. They are typically easy to diagnosis, and most patients know when they have one. The classic symptoms are headache, sinus congestion, increased mucus production, fever and so on.

The challenge is deciding when it’s time to start an antibiotic. Sinus infections can be caused by viruses, bacteria, or allergens, but only the bacterial sinus infections benefit from starting an antibiotic. It can be really tough clinically, meaning based on signs and symptoms, to differentiate between the different possible causes. The main factor used to determine if an antibiotic is prescribed is duration of symptoms. Viral sinus infections typically resolve on their own in less than a week, whereas bacterial infections persist for longer than 7-10 days. Another clue is “double worsening,” which refers to a resurgence in severity of symptoms after initial improvement.

Frequently I will have patients reach out because of a fever, thinking this is a sign for sure that antibiotics are needed. This is not the case though, as viral infections can cause fevers just like bacterial infections. Another reason I hear from a patient is because of a change in the color and consistency of their mucus from clear to thick/green/yellow, thinking this represents the presence of bacteria. Rather, the color change means that there are white cells present, which is what the body uses to fight off infection, so this happens with both viral AND bacterial infections. So again, this doesn’t really help to pin down the cause of the infection.

Sometimes I get a call from a patient on day one of symptoms, because they want to start an antibiotic and take care of it before it gets worse. While I love the preventative mindset, it is not generally the right approach to sinus infections. Commonly sinus infections will resolve on their own without any treatment. Taking an antibiotic comes with a lot of risks, so ideally you only want to take one if necessary. When starting any treatment, you always want to weigh the risks and the benefits. If you have a viral infection, the benefit of the antibiotic is nothing, whereas the risks are many, ranging from uncomfortable side effects like stomach upset to more serious effects like allergic reactions, dangerously irregular heart rhythms, or even a terrible diarrheal infection called c diff.

So next time you feel a sinus infection coming on, stick to supportive care for the first few days - over the counter medications like Tylenol or Motrin, soothing fluids like honey in tea, rest and self care. The benefit of direct access primary care is that you can keep in touch with me throughout your illness, so we can decide together when it’s the right time to start an antibiotic. And in the meantime, keep focused on preventative measures to stay healthy, like hand washing!

Tackle Vertigo Head On!

Vertigo is a common problem that I see in primary care. A lot of times patients tell me that they feel ‘dizzy,’ so the first thing I have to do is figure out if a patient is feeling generally off balance or lightheaded, vs true vertigo. Vertigo is a room-spinning sensation, as if you are on an amusement park ride and can’t get off. The most common presentation of vertigo I see is the type that happens on and off. This is called BPPV - Benign Paroxysmal Positional Vertigo. Let me break that down a little.

Benign in medicine refers to something that is not harmful. Mostly this is contrasted with malignant ( = badness), though benign conditions in medicine are generally not ‘pleasant and kind,’ which is the lay definition of benign. Paroxysmal means it happens on and off as a sudden attack. Positional is in this diagnosis because these on and off sudden attacks are typically related to the position of the body, or in this case, usually a change in position.

BPPV classically presents with a sudden onset of a room-spinning sensation triggered by a position change such as standing up, rolling over, or turning the head. The room-spinning sensation goes away on its own within seconds to minutes. It is generally a very uncomfortable and scary experience, and can increase a person’s risk of falling. So the symptom itself is not necessarily benign, but the underlying cause is not something alarming or harmful.

In our ear canals, we have calcium crystals sitting within fluid. These crystals shift with head movement, bending little hair cells that report the movement back to the brain. When you turn your head, the crystals move and then stop, sending that signal to the brain. At the same time, your eyes move and then stop, sending a matching signal, and all is well. With BPPV, these crystals are either not where they should be, or there is some other debris within the ear canal also stimulating those hair cells with extra messages that don’t align with the message your vision receives, resulting in the room-spinning sensation.

Luckily there is a fairly simple and low risk treatment for BPPV, called Epley maneuvers. By doing a simple repositioning exercise at home, three times a day, the majority of patients with BPPV will improve within a few days to a week! Some resistant cases need to work with a vestibular physical therapist rather than doing self-treatment. A lot of people will experience recurrent episodes of BPPV, but still should improve with starting up the Epley manevuer again. There are some studies that suggest taking a Vitamin D supplement can reduce recurrence rates by almost half (see my youtube video on soaking up some Vitamin D!).

There are many other reasons you might feel dizzy, so if you think you have BPPV but you aren’t getting better with Epley maneuvers, make sure you reach out to your doctor to talk it over!

What is *peri*menopause, and how do I make it go away?

This post is for my fellow 40 and fabulous crew out there who feel like they are spiraling towards something big and bad and inevitable - menopause. While there is no escaping menopause, you do not have to feel powerless or unprepared!

Peri means “around”, or really in this case, going through. It’s the years that lead up to menopause, which is technically defined as one year with no menstrual period. Perimenopause can last for several years, even a decade for some women. And while everyone experiences it differently, there are several common themes.

Most obvious is a change in menstrual bleeding. Often women in their 40s start to experience a heavier period that lasts longer and is closer together, before spacing out, skipping, lightening, and eventually stopping. Women also see changes in mood, trouble sleeping, hot flashes, and vaginal dryness which can cause sexual discomfort.

During this time of change, I often have patients reach out asking about blood work to test hormones. The diagnosis of perimenopause does not need blood work - the criteria is simply a woman over the age of 45 with a change to her period, with or without menopausal symptoms. But it is a good idea to do some blood work to rule out other causes, such as a thyroid disorder or pregnancy (eek!). GYN hormones, like FSH and estrogen, do not have to be abnormal and in fact, if you are still having a period, probably aren’t significantly abnormal. Unfortunately, lab tests don’t reveal how long perimenopause has been going on, or how much further you have to go.

So while it’s usually pretty easy to diagnose perimenopause, treatments are not as straightforward. Interestingly, there has been a fairly recent shift on the approach the medical community takes to treating menopausal symptoms. When I was a resident, the general idea was that menopause is a natural experience and hormonal therapies = badness, so essentially tell your patients to buck up.

Then, thankfully, the data was revisited with the ultimate conclusion that hormone therapy for women during menopause in the absence of significant risk factors is indeed safe, and maybe women don’t need to silently and needlessly suffer through it. Yes, menopause is a natural part of life, but it does not have to be something women grin and bear!

Hormonal therapy may not be appropriate for all women though, and some women may prefer to avoid the risks associated with taking medication. In these cases, as with any patient interested in non-medical therapies, I focus on lifestyle and behavior adjustments. Exercise is very significant during perimenopause - as discussed previously, exercise helps to improve sleep and increase energy. I like a focus on strength training for women in theirs 40s as well. The loss of estrogen that occurs during menopause results in lower bone density, so a focus on building muscle strength and weight bearing exercises like walking and jogging are essential to maintain bone health. Also important is diet - calcium for the bones and protein to support building up muscle mass, all while paying attention to calories. In menopause, an internal process that was burning calories is no longer happening. In general this leads to an output of about 200-300 calories less than before, which is why many women see weight gain.

Hot flashes can usually be managed with avoiding triggers (alcohol, spicy food, hot beverages), dressing in layers, carrying a fan or spray bottle, keeping the temperature down at night for sleep etc. There are many over the counter herbal supplements offered, but unfortunately none of them hold up under more rigorous testing. And though I have offered exercise as a treatment for most things thus far, it’s no help here and could actually trigger a hot flash due to rises in body temperature. But still necessary anyway (see above)!

So if you are confused or apprehensive as to what lies ahead, or you have already started to experience some of these symptoms but had no idea what was happening, and you are interested in discussing further, consider joining SFP! With direct access care, we will have the time and space to discuss your personal experience with perimenopause, examine how it is effecting you, and review treatment options that fit your preferences, symptoms, and lifestyle. Let SFP help you feel empowered and prepared to sail through this transition…or at the very least commiserate with you as you do :)

Can the FLU SHOT give me the FLU?

Spoiler Alert - No!

As winter approaches, it’s time to start heading to the doctor’s office or your pharmacy of choice to get yourself and your family protected from the flu this season. But when I remind patients that it’s time, I often get hesitation because of fear that getting the flu shot might instead cause one to get the flu. The flu vaccine, however, is just fragments of the influenza virus, not a live vaccine, and therefore cannot make you sick with the flu.

Here are several reasons why this misconception is so common:

1. Immune response. Most of the symptoms you feel when you are sick are actually caused by your immune response — the natural way your body fights off infection. Mucus is created to trap invaders (such as viruses and bacteria) so you can cough, sneeze, and/or blow them out, plus the temperature of your body increases so that the virus or bacteria can’t survive. All of this leaves you feeling tired and achy. It's not uncommon for the flu vaccine to stimulate this immune response, which can cause you to feel a bit out of sorts for a day, but quickly resolves and leaves you prepared to handle the actual flu virus with no muss, no fuss.

2. Delayed protection. You might not know that it takes about two weeks for the flu vaccine to be fully effective. This is why the big push to get vaccinated is now, in October, even though flu season doesn’t really hit Maryland until December. So if you were to get your flu shot on Monday and get exposed to the flu on Tuesday, you could be sick with the flu in short order and understandably want to blame the vaccine! The best way to avoid this is to get your vaccine early.

3. Cold season. The timing of the flu vaccine often coincides with the typical cold season. Influenza is no common cold, but if you were to get sick with a cold virus right after getting your flu shot, you might be tempted to think it was because of the vaccine.

So now that you know the flu vaccine can’t give you the flu, it’s time to get yourself protected so that you can stay healthy this winter. Many locations, such as Walgreens and Target, will give you a $5 coupon when you get a vaccine at their store, so reward yourself with something fun for protecting yourself and our community from the flu!

The Root of Hair Loss

One common concern that I address in primary care is hair loss. This is something brought to me by women of various ages, and often literally: patients will bring plastic baggies full of hair, or scroll through multiple pictures on their phone of their brush or shower drain. I get it - it’s alarming! But most of the time, thankfully, it’s totally normal.

Hair exists in 3 different phases - growing, resting, or shedding. Each individual hair follicle cycles through these phases independently, so not every hair follicle sheds at the same time. This is why despite the baggies full of lost hair, the patient in the office is typically not bald or even balding. There are external factors though that can cause a higher proportion of hair to shift from one phase to another. Stress is an example - a major shock to the body, such as childbirth, will cause a lot of hair to shift from the anagen (growth phase) to the telogen (shedding) phase. This is called telogen effluvium. Thankfully most women fully recover after suffering through a short period of excessive frizzies.

Most of the time women are concerned that something deeper is going on. While it is appropriate to check blood work, such as thyroid and iron levels, I rarely find any lab abnormalities. Occasionally I will diagnose skin conditions such as aloprecia areta, which cause patches of baldness on the scalp. There is also a female pattern hair loss, such as men commonly experience, which is seen as thinning hair along the front or crown of the scalp. Other causes for hair loss include medications, supplements, dietary restrictions, or use of hair products.

The treatment for hair loss or thinning hair depends on the underlying cause, which commonly is telogen effluvium as described above. Biotin supplements are heavily advertised as solutions for hair loss, but there has been no evidence to suggest this helps. The main intervention that has shown to be effective is minoxidil shampoo. This is the active ingredient in Rogaine, and is available over the counter. Generally safe, this treatment has to be continued to maintain effects.

If you feel you are experiencing excessive hair loss, try to remain calm and reassure yourself it’s likely temporary. If you have patches of hair loss, skin changes to your scalp, or other symptoms going on that concern you then absolutely make an appointment to discuss and start an evaluation. But don’t feel like you need to bring a baggie of proof…I promise, I will believe you :)

Shine a light on S.A.D.

As I write this post today, the weather outside is beautiful. It’s one of those warm and sunny days in October, the kind where I thought I would be pumpkin picking in a sweater and boots with a hot latte but end up sweating and looking as orange as my pumpkin in all my ‘fall’ photos. But despite these warm sunny gems that always pepper mid fall in Maryland, shorter days and colder temperatures are near.

Many people at this time of year develop something known as SAD - Seasonal Affective Disorder. This is the onset or worsening of depression symptoms that happen in a seasonal pattern, and typically include symptoms like increased sleep, increased appetite, carbohydrate craving, and weight gain.

SAD typically responds well to the same type of medications that are used to treat major depressive disorder. However, there are two non-medication treatments that offer significant improvement in symptoms, either on their own or when used along with anti-depressant medications: Light therapy and Dawn Stimulation.

Bright light therapy involves exposure to a 10,000 lux light for about 30 minutes a day, ideally in the early morning. Dawn stimulation starts with low lux level exposure during sleep, which gradually increases as you awake. Studies of these treatments show a significant improvement in SAD symptoms in about 60-65% of patients. Both of these treatments are very safe, though if you have eye conditions or take photosensitive medications (like doxycycline for example) then make sure you talk to your doctor before trying.

At SFP, I’m always happy to help patients explore evidenced based non-drug therapies to improve their health or treat their conditions. I plan to continue to highlight these strategies in this blog, so stay tuned, stay cozy, and light it up this winter!

The Stress is Real

To say we live in stressful times would be an understatement. In the news we follow unsettling headlines while in our personal lives we worry about our family, our finances, our careers, our relationships. The pressure at times can seem inescapable, and it carries real health consequences.

When our bodies feel stress, there is a physiologic response that happens - the fight or flight reaction. The response that our body creates to stress does not really differentiate between a physical threat, like a bear that’s about to attack, versus other kinds of threats, such as concern about an ill family member, or ruminating over an argument with a spouse, or straining to meet a deadline for work. In any of these cases, the reaction is the same: the body prepares to fight or run. Literally, your heart rate spikes, your pupils dilate, your muscles constrict, your blood pressure raises. A lot of the reactions that happen internally are harmful to your overall health, but the body figures ‘hey, let’s escape this bear first and then we’ll deal with high blood pressure leading to a stroke in 10 years.’ But the stress that we experience is (hopefully!) rarely a bear attack. Rather, it’s this constant simmering tension that doesn’t have a clear end point.

Since we do not live in a perfect world, the stress is never really going to go away - as my husband always chides me, “you’ll find something new to worry about soon.” Instead, we need to find ways to help close the feedback loop, and reassure our bodies that today, we survived the bear attack and it’s ok to shut down the red flashing emergency lights.

One great way of doing this (see yesterday’s blog!) is exercise. Going for a walk, riding a bike, dancing some hip hop - this all works to satisfy that ‘flight’ option. Maybe you still have a deadline to meet at work, but now your body feels as if you successfully survived the bear attack, and so your heart rate can settle, your muscles can relax, and your blood pressure can return to healthy, non-stroke threatening levels. So don’t wait until you start to feel the stress getting to you - plan a daily exercise routine. It only takes about 10 minutes of moving to release those calming, feel good brain chemicals. Just don’t go walking in areas that might lead to a bear attack…

Can Exercise Help?

One of the questions I like to ask patients about at most visits is their exercise habits. I know a lot of times patients feel frustrated about questions pertaining to weight, diet, and exercise from their doctor, especially when it doesn’t feel relevant:

I’m here for my anxiety, why is she asking about exercise?

I know I’m overweight, but can we focus on my trouble sleeping? That’s why I came!

What does asking me about my exercise have to do with my memory issues?

And to be fair, doctors do often ask questions that are irrelevant to the reason a patient is there, in an effort to check off all of the boxes required to get reimbursement from insurance companies. So while I won’t need to worry about jumping through those hoops in a direct access primary care model, I will continue to discuss exercise often and here’s why.

Exercise is good for SO MANY THINGS! When I am helping a patient with their mental health concerns like anxiety and depression, I discuss how exercise helps to release those feel good brain chemicals that help you reduce stress and improve mood. In terms of sleep, trials have shown that exercise helps you fall asleep faster and improve sleep quality, with better next day results compared to sleep medications. Observational studies also show that higher rates of physical exercise are associated with lower rates of dementia, so when a patient talks to me about memory or concentration deficits, or just concerns about family history of dementia, exercise is always a part of the conversation. And those are just a few of the benefits of exercise, not to mention the reduction in cardiovascular disease, diabetes prevention, lower rates of cancer, improved bone health, lower fall risks in older adults etc etc etc.

I encourage all of my patients to exercise, but starting a routine or trying to figure out if your level of activity is enough can be overwhelming. As part of primary care at SFP, I am happy to help you create an individualized exercise regimen to start reaping the health benefits of exercise today!

Is Direct Primary Care Affordable?

Before I started Slack Family Practice, I worked for a large healthcare system. By the time I left, my patient panel was over 2000 and counting. If that sounds like a lot - it is. If that sounds uncommon for primary care - it’s not at all. Having such a large number of patients to care for was a direct and significant contributor to my burn out and ultimate decision to leave. I found there was not enough time in the day to provide patients with the level of care they deserve on such a large scale, not to mention leaving time for my kids, my family, myself etc. So this led me to direct access primary care - a model that allows physicians the time and mental space to really get to know their patients, and become a more integral partner in their healthcare and well being.

But can patients afford this? Is it something only available to the wealthy?

I acknowledge that paying an annual fee for primary care is not an expense that everyone can manage. A membership with SFP is not low cost - but I do believe it is high value. And when the membership fee is broken down and really considered, I don’t believe it to be an unreasonable investment. For a monthly cost similar to your cell phone bill, you have direct access to your doctor. A doctor who knows you, your situation, your health, your values. You have someone with credentials who you can ask for advice on over the counter medication and vitamins, whether or not that mole should get looked at, or if it’s normal for a knee to make that sound, rather than asking Dr. Google. For the cost of my kid’s monthly taekwondo membership, or a dog grooming appointment (Doodle’s are bougie!) or LESS than the cost of smoking a pack a day, you could avoid a trip to urgent care vs a 3 month long wait for an appointment when you are having symptoms now.

You can continue to use insurance to cover costs of things like labs, images, specialty visits, or hospital stays. And if you have private (non-Medicare) insurance, or a health savings account, you may be able to get at least partial reimbursement for your membership fee or in office visits. So don’t wait for the next time you find yourself feeling abandoned by the healthcare system, needing care but at a loss for how to get it or where to go. Instead, consider joining the SFP family now!

Weight Loss

In addition to direct access primary care, SFP offers medical weight loss management. I have gained a lot of experience over the past couple of years prescribing and managing GLP-1 medications like semaglutide and tirzepatide. I have seen first hand how successful these medications are at helping patients lose weight, and the data backs this up! Weight loss medication is generally considered successful with 5% of baseline weight lost after 3 months of use (so a person that weighs 200lbs is able to lose 10lbs in 3 months). However, studies of GLP-1 medications have shown up to 20% or higher of baseline weight loss!! And even better, a study showed that this weight loss was sustained years later.

These medications work in two basic ways, one physically and one mentally:

Physically, they slow down the movement of food in the GI tract. This helps you feel full for longer, thus reducing appetite. This mechanism of action is what is underlying the most common side effects when taking GLP-1s - nausea, constipation, bloating, and other GI upset. Starting the medication at a low dose and increasing over several months, along with learning how to change your eating patterns, will help reduce side effects.

Mentally, these medications work on the area of the brain that tells you “eat that!” A lot of patients describe this sensation to me as quieting down the food noise. They are no longer constantly thinking about food, and find themselves able to easily walk by something tasty in the break room that they previously couldn’t help themselves from devouring.

This combination of feeling mentally and physically full is what leads to such successful weight loss outcomes. If you have struggled with being over weight or obese, reach out to SFP to schedule a consultation to see if these weight loss medications might be right for you!

Slack Family Practice, Coming Soon!

Welcome to Slack Family Practice!

Exciting updates to share - While the practice is open and accepting new patients, I am currently offering telehealth services only since my office is under construction. This week, I was able to move forward with some of the more fun aspects of building a new space - picking out floors, cabinets, countertops etc. The office is going to be beautiful! My goal is to create a space that is warm and inviting, and aligns with the more personal and familiar relationship direct access primary care allows. There will be a comfortable waiting room, custom built reception desk, two offices and two exam rooms. Stay tuned for details on an open house once the office is complete!