Be Pro-Active with Pre-Diabetes

The term pre-diabetes is used to define blood sugar that is above normal readings, but not quite high enough to be considered diabetes. Pre-diabetes will progress to diabetes, unless changes are made - this is why screening blood work is important. I like to check A1C levels for those at higher risk, because this gives a three month average of blood sugars rather than just one sugar reading at one point in time. A normal A1C is less than 5.7, and diabetes is diagnosed at 6.5. The A1C values in between are the pre-diabetes range.

These A1C values are picked for a reason. When sugar levels are significantly elevated to an A1C of 6.5 or higher, we start to see complications of diabetes happen. Treating pre-diabetes is essential to prevent this slow snow ball effect of rising sugars. The course of diabetes tends to be quite deceiving in this way. Usually when diabetes is diagnosed, a person has no symptoms. And if they chose to not take medications or make life style changes, they generally don’t develop any symptoms in the short term, so it’s often hard to convince patients to buy in. However, after about a decade, things start to fall apart. And with diabetes, they fall apart epically - heart attacks, strokes, neuropathy, retinopathy, ulcers that won’t heal and lead to amputations….the list goes on.

So really, the time to get serious about sugars is when an A1C enters that pre-diabetes range. I don’t typically start with medication, although an argument certainly could be made to go for a GLP-1, especially if weight loss is a looked for benefit. Rather, just as with my approach to high blood pressure and cholesterol, the real effort starts with life style changes.

The first change to make is reducing added sugars in your diet. Sugar hides EVERYWHERE in food. This is one reason it’s so important to check nutrition labels, with an eye towards ‘added’ sugars specifically. Natural sugars, as found in fruits for example, are much healthier than refined sugars and therefore a preferred substitute to satisfy a sweet tooth.

Next in diet, look to substitute simple carbs for more complex carbs. The body turns carbs into sugar. This process is fast when digesting simple carbs like white bread, leading to a spike in blood sugar. Complex carbs, like whole wheat bread, take longer to break down to sugar and thus result in a slower, more controlled rise in blood sugar.

Exercise is also key to managing blood sugar. When you increase movement, your muscles need sugar to convert to energy. This helps the body to clear extra sugar out of the blood stream.

There are a few programs in the area and online that are available to help with diabetes prevention, and certainly worth exploring if your A1C is in that grey zone of pre-diabetes. Check out the CDC National Diabetes Prevention Program or Upper Chesapeake’s Diabetes Prevention Program.

Frustratingly, medical insurance doesn’t typically cover interventions for pre-diabetes. You can, however, work with your direct access primary care provider to create your own personalized approach to preventing diabetes!

Turkey Day - Have A Plan!

Holidays can be very challenging for those who are trying to stay on a healthy eating plan, whether it is because of a condition like diabetes or high blood pressure, trying to lose weight, or just focused on preventative care. This time of year is tough for many reasons. The weather is turning cold which tends to make us less active, there is less daylight which can reduce our energy, and the stretch from Halloween to New Years is full of tasty temptations.

But holiday gatherings do not have to derail your health journey efforts! Here are a few recommendations to help you survive, be it office gatherings, school functions, or parties with family and friends:

• Keep to your exercise routine. My neighborhood hosts a turkey trot for Thanksgiving, and I know many other neighborhoods, churches, and the YMCA do the same. This is a great way to start the holiday, whether you can run a full 5k or walk a mile or so with family and friends and neighbors. This will boost your metabolism heading into a day that is focused on stuffing, while also stimulating the release of all those feel good brain chemicals to help you navigate any family drama!

• Make a personal appetizer tray. One thing that gets people into trouble on holidays is over snacking. It’s too easy to grab a bite here or there as you are chatting and catching up with people, not realizing how much you have had to eat. Instead, grab a small plate that you can load up with a reasonable number of snacks, and pick from there throughout the day. Most families will have some sort of veggie tray or fruit platter for healthier options. Plus some cheese and crackers will add protein and whole grains!

• Moderate your alcohol intake. Remember that drinks have calories too, so try and opt for water or flavored sparkling water for something different. Plus the more alcohol you drink, the less you will start to care about sticking to your personal appetizer tray…

• Portion control your dessert. Everything in moderation, right? So if you love pumpkin pie, or prefer pecan, sweet potato or apple, then by all means have a slice on Thanksgiving! But if you are trying to keep within a certain calorie limit, or avoid a big sugar spike, then opt for a small slice and skip the a la mode.

  I hope everyone is able to enjoy their holiday, spend good quality time with family and friends, and stay healthy!

Lowering Blood Pressure without Medication

As with many health conditions, tackling high blood pressure without medication focuses on diet and exercise! The main diet that is recommended is referred to as the DASH diet - Dietary Approaches to Stop Hypertension. The essentials of the DASH diet include fruits, vegetables, legumes, and low fat dairy while limiting sweets, meat, and intake of saturated fat. Specifically, the diet calls for:

• 4-5 servings each day of fruit. An example of one serving would be a medium apple, or 1/2 cup berries.

• 4-5 servings each day of vegetables. The serving size for vegetables depends on cooked vs uncooked. For example, a serving size of fresh spinach is 2 cups, whereas a serving size of cooked broccoli is 1/2 cup.

• 2-3 servings each day of low fat dairy, such as 1 cup of milk or yogurt, or 1.5oz of cheese.

• 6-8 servings each day of whole grains. Ideally look for high fiber as well. 1 slice of wheat bread, 1 oz dry cereal, 1/2 cup whole wheat pasta are all good options.

• 2-3 servings each day of healthy fats. Healthy fats can be found in nuts (1/3 cup for a serving), olive oil (1 tsp), and fish like salmon.

• 4-5 servings each week of legumes or nuts. For these serving sizes, aim for about 1/2 cup of cooked beans or chickpeas.

• Limit salt intake to less than 2300mg per day

• Limit alcohol intake (less than 1 drink per day on avg for women, 2 for men)

As with exercise recommendations that I make, try not to do everything at once! Set yourself specific goals and plan ahead. For example, maybe right now you drive through for breakfast on your way to work as part of your routine. Instead, set a goal to have a breakfast of 1 cup of yogurt with 1/2 cup of berries and a slice of toast two days per week. If you are usually pretty good with breakfast but struggle when it comes to dinner, set a goal of cooking 2 days per week instead, and plan the meal over the weekend so you can hit the grocery store and have the necessary ingredients on hand. Maybe one night you bake salmon served with brussel sprouts roasted in olive oil. A vegetable stir-fry using a reduced sodium soy sauce and brown rice can be dinner on another night. Check out more sample menus from Mayo Clinic or Cleveland Clinic. Another great website for healthy eating tips and examples is Myplate.gov.

Sticking to the DASH diet consistently for 2 weeks has been shown to reduce systolic blood pressure (the top number) in those with hypertension by about 10 mmHg! Combine this with an exercise routine and weight loss, and you can most likely avoid blood pressure medication while at the same time lowering your risk for heart disease, diabetes, stroke, and many many other health conditions. So start small, start slow, but start today!

Thoughts on Osteoporosis

This morning I fell down the stairs. I’m fine - a bit scraped up on my elbow and sore in my shoulders and back, but no major injuries. My first thought as I was laying stunned on the landing is wow, I am turning into my mother. But that immediately led to whew, thank goodness it wasn’t my mother who fell! As women age, especially women who are slight like my mom, their bone health declines. This is something triggered by the loss of estrogen that occurs with menopause, hence the reason most society guidelines recommend a screening DEXA scan for all women at age 65. Other risk factors that might necessitate earlier screening include smoking, excess alcohol intake, long term steroid use, low body weight, and parental history of hip fracture.

A DEXA scan will show one of three findings - normal bone density, osteopenia, or osteoporosis. Osteopenia is the in-between finding, with not quite normal bone density but not quite osteoporosis either. The report will also estimate a 10 year risk for fracture. The ultimate goal of addressing bone density is to prevent fractures, and more specifically fragility fractures. If you fall down the stairs and fracture your forearm, it’s not necessarily a sign of low bone density, depending on how dramatic the fall was. But if you fall from a standing height and shatter your tibia - I would suggest investigating for osteoporosis.

As with most conditions, prevention is key! To prevent loss of bone density, focus on weight bearing exercises with strength training. Weight bearing exercises include walking, jogging, jumping etc, as opposed to exercises like biking and swimming which are great for cardio but not overly helpful for your bones. In your diet, look to get about 1200mg of calcium per day. If you don’t think you are getting this much, which those who have to avoid dairy likely aren’t, then start an over the counter supplement. Most over the counter calcium supplements come with Vitamin D, which is necessary to absorb calcium.

If, despite all of the above prevention, you are diagnosed with osteoporosis, then there are several treatment options available to help rebuild and strengthen bones. Those with osteopenia or osteoporosis, on medication or not, are recommended to have follow up DEXA scans every 2 years. Interestingly, it’s important to have DEXA scans done on the same exact machine, otherwise the results can’t be compared. This is different than most other radiologic studies - it doesn’t matter if you get your mammogram in Bel Air one year and Towson the next. The radiologist can still pull the images and compare them easily. However, with DEXA scans, the instruments have to be calibrated and the positioning and labeling of bones can be variable. So when you go for your first DEXA scan, make sure it’s somewhere local!

I encourage everyone to discuss bone health with their primary care, as well as ways to prevent falls - stay active, stay healthy, and stay vertical!!

Can Your Diet Lower Your Cholesterol?

As part of a routine lab panel, cholesterol is typically checked and often a source of discussion upon review. Many patients, understandably, are reluctant to start a cholesterol medication right away. Rather, I am often asked, “Can I just repeat the labs in 6 months? I’m going to work really hard on my diet!” And as I mentioned in previous posts, I am always willing to work with patients on non-drug therapies to address health concerns. But I think it’s also helpful to set expectations - how much can your diet affect your lab results? And is that really the outcome we should be aiming for?

When doctors make recommendations on starting a cholesterol medication like a statin, the results of the lipid panel blood test are only a part of that decision. Because while it feels nice to see no red on your lab results, it’s really a person’s risk of having a heart attack or a stroke that drives the decision to start medication. Sometimes I see a healthy 35 year old with a significantly elevated LDL (that’s the bad cholesterol) and I spend the visit talking about diet and exercise. Other times I see a 60 year old with high blood pressure and diabetes who smokes, and I’m bringing up cholesterol medication before I even see the blood test results.

This is because statin medications are all about risk reduction. If taking a statin reduces your risk of heart attack and stroke, but your risk as a 35 year old healthy person is super low, then you aren’t getting much benefit. But if your risk for heart disease is high, even if it’s based on factors like age or other health conditions besides cholesterol, then your benefit will also be high.

All patients, whether it’s the 35 year old with high LDL or 60 year old with high blood pressure, should focus on the impacts of diet on cholesterol. A sweeping diet change, such as adopting the Mediterranean or a vegetarian diet, can lower LDL cholesterol by about 20%, assuming you are changing from a pretty poor diet at baseline. It can be challenging to make such a drastic diet change, so I recommend starting small. Try to limit meat to lean products like chicken, turkey, and fish. Aim for one vegetarian meal per week, using tofu as a substitute. Opt for whole grain with your carb choices.

These smaller changes might not drop your LDL as much as you would like to see, but remember the ultimate goal here is to lower your risk of heart attack and stroke. So even if you still see some red on your lab report, don’t give up on your diet! These efforts are affecting that which matters most - your cardiovascular risks and overall health. With direct access primary care, we can work together to create a plan to make these lifestyle interventions successful for you!

Dietary Supplements

I mentioned in a previous video that I am hesitant when it comes to dietary supplements, and I wanted to dig a little deeper on that today. I often find that patients are eager to address their health in natural ways, and I fully support this. You can look back at my blog posts thus far to see that my first approach is typically to review lifestyle, habits, behaviors, diet, and exercise when trying to make a diagnosis or create a treatment plan. My natural approach to health care however does not typically include dietary supplements.

Yes, some people will be deficient in vitamin B12, Vitamin D, Iron etc and need to take supplements of these. Yes, at times I recommend a probiotic for those with GI issues or when taking an antibiotic. Yes, there are likely health benefits associated with red yeast rice or saw palmetto or cranberry products etc.

But here is why I am not often suggesting these products for my patient. When the label of dietary supplement is used, as opposed to a medication, it means it escapes the regulations and monitoring offered by the FDA. A huge red flag for me is the disclaimer, ‘this product is not intended to diagnose, treat, prevent, or cure any illness.’ If a company is not intending their product for those reasons, then there is no need for them to provide customers with evidence that their product is effective, or safe, or that it even contains the ingredients it claims to contain.

Take for example Melatonin, which I discussed in my video as generally safe. Thank goodness it is, because a Canadian study tested about twenty different over the counter melatonin products to see how much melatonin, the active ingredient, each sample contained. They found that the miligrams of melatonin in the tablet or gummy varied from -80% to 400% of the miligram amount listed on the bottle - that’s a lot!! Further, they found that the miligrams of melatonin varied as much as 400% between lots from the same manufacturer. This is why someone might take melatonin and have no help with their sleep, while another person might try melatonin and have trouble waking up the next morning.

The same type of inconsistency is seen with red yeast rice. Sometimes I have patients requesting to try this rather than take a statin like Crestor or Lipitor to reduce their cholesterol. It’s true that red yeast rice will help lower your cholesterol - they actually work quite similar to statins! But I think marketing red yeast rice as a ‘natural’ way to lower your cholesterol is quite misleading. First, you are still taking a pill every day. Second, a similar study to that done with Melatonin was done with red yeast rice, and again found that the amount of the active ingredient varied from 0.3mg to 11mg per capsule. Many argue that taking a dietary supplement would be safer than taking a medication, but the same study that tested for the amount of active ingredient in the red yeast rice capsules found that 4 of the 12 preparations studied contained a nephrotoxic (kidney harming) agent.

So the bottom line for me is that dietary supplements do have a role for some people, but they should really be considered medication-adjacent. What I mean by this is don’t think of a dietary supplement as something separate than a medication. Most people are hesitant to take a medication without talking to a medical professional first. Think about supplements the same way, and discuss with your primary care! Another option is to look for dietary supplements that use a third party organization that does quality testing, such as US Parmacopeia, ConsumerLab, and NSF International. Just keep in mind these independent organizations are looking at quality, not weighing in on the supplements effectiveness or safety for all patients. I like the ConsumerLab website, linked above, to review various supplements, foods, and health products.

Sleep Hygiene

As mentioned in my video yesterday, here are my recommendations in regards to sleep hygiene:

Sleep hygiene refers to behaviors or habits that help you get good quality sleep. I think habits is a better term, because really these behaviors need to be repeated and maintained for best outcomes. I remind patients that if you go home tonight and do every single thing we discuss, you still might not have a good night of sleep! It’s really the repeated behaviors over several weeks that lead to success.

When it comes to sleep, routines are very important. Going to bed at the same time and waking up at the same time is recommended, and it makes sense when you consider it. If you go to bed at 2am on Saturday night and sleep in until 10am, it’s going to be really hard to fall asleep at 10pm Sunday night. So a lot of people will get out of their Monday through Friday sleep schedule on the weekend, and struggle to get good quality sleep to start off the work week.

Extend the idea of keeping to a routine to the hour or so before your planned bedtime. Start winding down your body and your mind to ease the transition to sleep in a set, repeatable number of steps. An example could be each night at 9:30 taking a shower, brushing your teeth, dressing in your pajamas, writing down a few thoughts or a to-do list in a journal to help empty your mind, practice a 5 minute meditation or yoga stretch, and then get into bed.

This is vastly different then what I hear from most patients when we talk about bedtime routines. Many people are watching TV in the evenings, falling asleep on the couch, waking up a couple of hours later and going to their rooms, unable to fall asleep again (I know you’ve done this, I see you!). A few things are happening here. It’s essentially like taking a nap right before bed, which when said in that way doesn’t sound like a successful way to help you fall asleep. Also you are getting screen time in the evening, which is just shining a bright flashing light directly to your brain, counteracting the release of melatonin that is supposed to be happening as the sun sets. Melatonin levels are meant to gradually rise to signal to the brain that it is night and time for sleep. Lights from screens, which includes tablets and phones and TVs etc, reduce the brain’s natural production of melatonin and interfere with the ability to fall asleep and stay asleep.

I also think those who are falling asleep on the couch are missing their ‘sleep window.’ To be transparent, this is something that I have postulated, not something that I find in studies on sleep behavior, but rather something that I observe in patients and in myself. If you try and stay awake past your normal time for sleep, you are initially tired but then get a second wind, preventing you from falling asleep when you finally do lay down. Instead, listen to your body’s cues and go to bed when you feel tired, rather than allowing yourself to fall asleep on the couch. Even consider stopping screen time an hour before bed. This is when you can instead implement your sleep routine!

Sleep hygiene is not just for habits right before going to sleep. Things that you do throughout the day will also have an effect on your sleep quality. Exercise has been shown in many different studies to improve sleep duration, ability to fall asleep, and sleep quality. Diet plays a role as well - caffeine in the afternoon or eating a heavy meal in the evening could affect your sleep quality. Alcohol is interesting when it comes to sleep - it is a sedative, so it might be tempting to have a glass of wine or other drink in the evening to help you feel relaxed and fall asleep. However, alcohol has an overall negative effect on sleep quality, with more night time awakening, especially in the second half of the night.

The environment for sleep is also a part of sleep hygiene. Most people find a cool temperature better for sleep, ambient noise such as a sound machine or a fan beneficial for staying asleep, and of course dark or low lights. Consider investing in a good mattress and pillow - you spend (ideally anyway!) 8 hours of every day in your bed, so it’s worth paying for higher quality supplies.

Some of these behaviors might be fairly easy to implement, like turning down the temperature in your bedroom a few degrees, while others might take a much greater effort to change - I know, Netflix after the kids go to bed!! But perhaps start by picking a few that seem easy and just one that seems more challenging, and roll out these changes slowly. Ultimately it is worth it, because sleep is essential. Without sleep, we have low energy, sour mood, weakened immune system, concentration deficits, worse cardiovascular outcomes and so on. Even obesity has been linked to poor sleep, so if you are struggling to lose weight and feel you are doing everything you should be in terms of diet and exercise, take a look at your sleep habits next!

If you end up talking to your primary care about your sleep and you are first offered a medication, think about making a change to direct access primary care. In most primary care practices, there is not enough time to review these habits, let alone discuss which ones might be more of a challenge with your lifestyle and brainstorming how to make adjustments. The benefit of direct access primary care is that we do have the time to focus on this - writing a prescription for Ambien is way faster, but has significantly more side effects! And that’s not to say that sleep medications have no role, because I do prescribe them as well, but an assessment of sleep hygiene and implementation of these habits as best able should always be included!

PVCs - Off the Beaten Path

PVC stands for Premature Ventricular Contraction. This is a normal thing that the heart does, and you have probably felt one a few times in your life. It’s that flip-flop sensation in your chest that catches you for a few seconds. Usually it goes away on it’s own and you go about your life, but sometimes people develop frequent enough PVCs that they seek out their primary care.

I think about PVCs like a fire drill for the heart. Your heart has one main center that is responsible for sending the signal to beat. The signal comes from the same place each time, follows the same path down the middle of the heart, and the heart moves in response. This produces a nice uniform beat that you typically don’t feel going on. But if something were to happen to that main center responsible for sending out the signal to beat, then ————- nothing. Which would be bad, of course.

So the heart has a lot of back up centers that are able to also send the signal that results in the heart beating. Because these centers are located in a different area, the signal is sent out in a different wave resulting in a different movement of the heart. This sudden shift in heart movement can sometimes be felt, especially if you happen to be laying on your side at the time, which positions your heart closer to your chest wall.

Typically the back up center only sends a few test beats, and then the main center takes over again and all is well. If you feel off beats in your chest for a few seconds that go away and don’t cause you to feel bad otherwise, it’s probably a PVC. PVCs have a characteristic appearance on an EKG so they are easy to spot, though it can be difficult sometimes to catch a PVC if it only happens once or twice a day when you run an EKG. This is because an EKG shows only 10 seconds of heart beats. Instead, what may be recommended to ensure the flip flop sensation you feel (or what we refer to as palpitations) is just something harmless like a PVC, is an event monitor. A few EKG stickers are applied to your chest and report to a monitor, which you can also notate on when you feel the sensation to help pin point what’s happening at that time. These monitors can be worn for days or even weeks if needed.

Though most people have PVCs rarely, some people are actually bothered by frequent PVCs that can happen often, even hourly! It’s not a sign of a diseased heart, but it can be quite disturbing and so these patients are often referred to a cardiologist to discuss treatments. And of course you don’t want to just assume that if you feel palpitations they are just PVCs - talk it over with your primary care, and see if you might need some more investigating to be sure!

Headache Prevention - Know Your Triggers

Another common issue addressed in primary care is headaches. Today I want to discuss prevention. Once a headache starts, it’s often hard to treat, especially without medication. And the sooner medication is taken, the more effective it is, which means I often recommend erring on the side of treating to prevent a mild headache turning into a migraine. However, to avoid needing to reach for medications and manage their side effects, or develop something called a ‘medication overuse headache,’ it’s worth focusing on headache prevention.

Headaches have very typical triggers, and I suspect those of you out there that are ‘headache people’ will likely identify with one or more of these triggers. Things like stress, lack of sleep, skipping a meal, not drinking enough fluid, and having too much or too little caffeine are all frequent and common triggers of headaches. If you are prone to headaches, it’s essential that each day you make sure you are drinking enough water, eating consistently, managing your stress, and being consistent with your caffeine intake.

Some headache triggers are unavoidable, such as pressure changes associated with weather. My mom and I are both headache people, and we pretty consistently text each other on those very cloudy overcast days to commiserate over our headaches. Various lights, sounds, and even odors can trigger headaches and might be challenging to avoid. Some people are sensitive to foods like chocolate (the horror!) or additives in foods like MSG or aspartame.

With so many possible triggers, I find it helpful for my headache patients to keep a diary. This can help to identify patterns - maybe your headaches are happening with your periods, or when you travel, or when you’ve fallen off your exercise routine. Include foods in your diary, making note of caffeine amount, as well as daily intake of water and hours of sleep. Figuring out what your triggers are is key to avoiding them! Tracking your headache also helps to determine if something has changed, or if you have reached a point where you should discuss prevention medication with your doctor.

And if thinking about the hassle of trying to get an appointment with your doctor is a headache trigger, then consider Direct Access Primary care with SFP!!

Low Back Pain - When do I need an MRI?

Today’s topic is another common complaint I see in primary care - low back pain. I see back problems in patients of all ages and activity levels. Sometimes patients have to reach out for an appointment within hours of back pain starting because of its severity, while others seek me out because it’s been weeks without improvement. In many cases, patients are wondering about getting imaging, like an MRI. I understand the impulse - when something is very painful, the body is telling the brain something is wrong. Therefore, why not get an MRI to see what it is and fix it!?

The majority of the time however, with acute onset low back pain, an MRI is not indicated. The main purpose of getting an MRI of the lumbar spine is really to prepare for an invasive intervention - either spinal injections or surgery. Most patients presenting with a day to a few weeks of back pain are not at the point of considering invasive procedures. Rather, it makes more sense to start with lower risk, non-invasive treatment such as anti-inflammatory medication and physical therapy. In the absence of concerning neurologic symptoms, any finding on an MRI (degenerative discs or other signs of arthritis, herniated discs, spinal stenosis etc) will first be treated with at least 6 weeks of physical therapy before considering any surgical treatment. This is why physicians typically don’t recommend an MRI at the first evaluation for back pain. Regardless of what it shows, the recommendation will be to start with conservative treatment including physical therapy. Most of the time back pain will resolve with these treatments over several weeks to a few months. Only if back pain persists after the typical treatment are we ready to move forward with imaging and likely referral to either a pain management specialist for injections or a spinal surgeon.

Sometimes patients are frustrated when they seek an evaluation for back pain and it doesn’t include an MRI. I hope that the take away from my post is not to avoid seeing your primary care if you are bothered by your back, but rather to help temper this expectation of imaging. Many times in medicine a history and physical exam are better for diagnosis and treatment than imaging. This is true for low back pain. An MRI of the low back is just as likely to show abnormal findings in someone without back pain as it is in someone that has back pain. The key is to order the MRI on the right patient at the right time, and see if the location and type of abnormalities on the image match up with the reported pain and physical exam findings. When this happens, a patient is much more likely to benefit from an intervention like injections or surgery.

But it is important to get checked out by your primary care if you are having concerns - this is easy with direct access primary care, whether it’s the first day of pain or the 3rd week of pain! My patients are able to send me an email, a text, or a portal message to let me know what’s going on, arrange an appointment within a day or two for an exam, and together we can discuss when it’s the right time for an MRI and how to get you feeling better in the interim!

Holiday Reset!

I hope everyone enjoyed their Halloween! The weather was beautiful, and I really enjoyed seeing everyone outside and getting some steps in while reconnecting with neighbors. I chased my kids around for trick or treating, and even got some good upper body work out since my friend’s toddler decided I was her preferred method of transportation. You can’t say no to a 2 year old in a care bear costume - it’s just plain fact!

Holidays are notoriously challenging for people who are trying to stick to a healthy diet, or control their blood sugar and keep their blood pressure and cholesterol down. Halloween of course is no exception! I’m a firm believer in ‘everything in moderation’ so no guilt today if you had more than a few pieces of candy yesterday. BUT today is a good day to do a reset, and it’s starts with getting the temptation out of the house!

A great way to do this is through donation programs, such as Treats for Troops. There are various locations collecting left over Halloween candy to send to our military around the world, to show them we are thinking of them and we appreciate them. I definitely plan to be a donation center once my new office is up and running, but check the link above for places that are accepting candy now!

Also looks like our streak of beautiful weather continues into the weekend, so I hope everyone can get outside and enjoy!

Health Benefits of Puppies!

My sister got a puppy over the weekend, so naturally I am looking for an excuse to post pictures! Lucky for me, pet ownership (dogs in particular) have several positive effects on a person’s health, both mental and physical. Studies have shown that dog owners tend to exercise more, have lower blood pressure, lower cholesterol levels, and improved cardiovascular outcomes. Interactions with dogs have also shown to reduce self reported anxiety scores. In elderly patients with dementia, animal assisted therapy can reduce behavioral and psychological symptoms of dementia and depression.

Just take note that this study looks at animal assisted therapy - it’s generally not a good idea to surprise your mother with a puppy because you want her to start going for more walks, maintain her socialization, and have a warm welcome every time she gets home. Because if you, and maybe let’s say your sister, were hatching that kind of plan, you should cross your fingers that your sister falls in love with the puppy and takes it herself when your mother looks at you like you’re crazy…. Just saying.

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…