Finally we are beginning to recognize the long standing shortage of Primary Care Physicians! Health and Human Services has approved additional funding for Primary Care Residency training programs. This is just one of the things that will help grow the field of Primary Care. I feel another strategy to increase Primary Care interest for emerging students is to offer loan forgiveness and competetive loan repayment programs, as well as raise reimbursement rates for Primary Care Physicians.
Well, the summer is upon us and it is time to head to the beach! As everyone’s Vitamin D goes up in summer, let’s not forget to put on that sunscreen to prevent skin cancer, skin aging and those nasty wrinkles! But there are just so many products out there so how do you pick what’s right? Well, this article will give you some tips on what we look for when picking the best sunscreen.
One of the most important things to look for when selecting sunscreen is that it should be “Broad Spectrum”. This means that these products protect you against both UVA AND UVB. UVA causes aging and wrinkles, whereas UVB causes most of the sun related skin cancers, sun burns, and inflammation–you need protection from both.
I recommend products which have Titanium Dioxide or Zinc Oxide as their sunscreen agent. These agents are more stable and tend to cause less skin irritation.
I recommend using SPF of 30 or higher, this is because most of us don’t use the recommended amount of sunscreen on our bodies (which is about 1 oz or 30ml at each application for an adult) so using the higher SPF of 30 or more helps compensate. There is no linear relationship with the amount of protection to the level of SPF–so if a product has SPF of 100, it doesn’t mean that it gives you TWICE the protection than SPF 50–it definitely gives you more than SPF 50 but it may not justify the cost. The greater the SPF the sticker the sunscreen can be so pick something that goes on smoothly so you are more likely to continue using it!
Sunscreens should be applied 15 to 30 minutes before sun exposure. This gives enough time for a protective layer to form over the skin. Don’t forget to REAPPLY! You should reapply your sunscreen at least every 2 hours. Sweating and getting in water will wash the sunscreen away, so you need to reapply after each water exposure and after excessive sweating (like after playing beach volleyball or running!). Even if your sunscreen says its water proof, you still need to reapply. In Fact, the FDA will no longer allow products to be labeled as “water-proof” or “sweat-proof” as it is misleading.
Makeup and facial moisturizers that have SPF included in them are good to use as they increase compliance so go ahead and use them!
I recommend all my patients use sunscreen; regardless of the color of their skin! Lighter skin is more likely to have sun damage, aging, burns and skin cancer risk compared to darker colored skin; however, it is important for everyone to use sunscreen! So even though that extra melanin pigment is protecting you, give it a little extra help!
American Academy of Pediatrics recommends avoiding the use of sunscreen in children younger than 6 months of age. It is recommended to have them wear sun protective clothing and keep them in the shade. If sun protective clothing or shade are not available then a small amount of SPF 15 sunscreen can be applied to small areas like the child’s face, top of their ears and back of hands.
High Blood Pressure, or Hypertension, is one of the leading health problems in our society. There are many different types of excellent medications we have to help lower blood pressure; however, I like to encourage NON-MEDICATION ways of lowering blood pressure as the first step for my patients. [Of course, if your blood pressure is very high, sometimes we have to use medicines first to get you in a safe zone in conjunction with alternative strategies]
BLOOD PRESSURE NUMBERS:
Below are some alternative strategies to help you lower your blood pressure.
Obesity/Overweight and hypertension have a strong relationship. Weight loss significantly helps lower blood pressure. Studies show that losing 8Kg of weight results in blood pressure drops of 8.5 points in your Systolic Blood Pressure (SBP–the TOP number of your blood pressure reading) and 6.5 points in your Diastolic Blood Pressure (DBP–the BOTTOM number of your blood pressure reading).
All forms of excercising including Aerobic (cardiovascular excercise), Dynamic Resistence, and Isometric Handgrips have been shown to help with lowering of blood pressure. Excercising alone can help lower your blood pressure readings by 3.5 points on the SBP and 2.5 points on the DBP.
REDUCE SALT AND SODIUM!
Sodium or Salt can increase your blood pressure. Unfortunately, in general our diet is quite high in salt. There are many different sources of salt that we need to be aware of. Table salt or salt we add to our foods is a definite source, but there are many foods that are inherently high in salt. Foods such as: deli meats, cold cuts, canned foods, and soups are to name a few. Processed and packaged foods are also very high in salt/sodium. As a general rule, any food that has to stay fresh for a prolonged period of time until you are ready to eat it, is high in sodium/salt because salt is a natural preservative. So try to avoid microwave dinners, frozen meals, and canned foods OR look for Low Salt/Sodium versions of these foods. Eating and cooking fresh is the best way to go!
Eating out at restaurants can also open you to getting foods high in sodium. Foods with a lot of spices, marinades, sauces have high sodium. Certain cuisines are inherently high in sodium/salt such as Thai, Chinese, and Indian to name a few.
Aside from increasing your blood pressure, high sodium can lead to fluid retention and cause bloating and swelling especially in your ankles and feet. Avoiding the salt will help keep that fluid weight away and help some weight loss as well!
When we are trying to lower blood pressure through salt/sodium restriction, I recommend my patients to read the food lables of all their food and drinks and have a goal of getting LESS than 1500mg of sodium a day.
You can also check out the DASH diet website as it is a great source of information on foods and recipes to help lower your blood pressure.
LOWER YOUR CAFFEINE!
Caffeine is a stimulant and all stimulants can lead to high blood pressure. In our fast paced soceity, we rely on outside sources to give us a little boost! Caffeine in the form of coffee, tea, energy drinks, and pills can all negatively affect your blood pressure.
Getting enough sleep is very important to help your mind and body restore itself. There are many important chemical and metabolic reactions that happen during your sleep which are essential to keep your body functioning at its best. Lack of sleep or not getting good quality sleep are risk factors for problems with your blood pressure.
If you snore at night, toss and turn, have difficulty falling asleep, or wake up in the morning and do not feel well rested from your sleep, you should speak to your doctor about getting tested for Sleep Apnea or other sleep disorders.
Easier said than done! But this is so important in managing your blood pressure. Increased stress and anxiety definetely raises your blood pressure.
Below are a few techniques to try to help with stress reduction:
2. Relaxation and deep breathing–studies have shown that in stressful situations, stopping and taking deep breaths and counting slowly from 1 to 10 in fact helps you through the stress.
6. Prioritizing tasks–yes, everything is important and everything has to get done, but not right now. So reevaluate your tasks and really prioritize them and tackle them one at a time.
7. Delegating–although you are the best at doing it, you really can’t do it all so get help and learn to let go and delegate!
Recently, I was at a local restaurant and ran into a patient who is 75 and her husband is 81 years old. They inquired about things they can do to help with their memory. This is a common question now that we all are living longer and want to live healthy independent lives!
There have been a lot of studies to see if certain foods and supplements can help prevent memory loss. Although these studies have had mixed results, below is a list of things that have been tested and shown to help.
ANTIOXIDANTS: Studies have shown that Dementia patients, in particular Alzheimer’s, have a lot of “oxidative stress” so Antioxidants have been shown to help.
Vitamin E: The Alzheimer’s Disease Cooperative Study suggested that Vitamin E may be beneficial in slowing the progression of disease in patients who already have Alzheimer’s Dementia. Vitamin E has also been shown to lower risk of developing dementia in some patients.
Note: Vitamin E can think the blood and cause easy bruising and bleeding so if you are already on blood thinners (such as Pradaxa, Xarelto, Warfarin (coumadin), aspirin) then you should discuss with your doctor before taking extra Vitamin E. Also, if you are already on Vitamin E supplements, you should stop it 1 week before any surgeries as it can increase your bleeding risk.
Beta Carotene: supplementation with Beta Carotene helped improve testing scores on memory testing.
Flavonoids: Flavonoids are nutrients found in berries (blueberries, strawberries) and have antioxidant and anti-inflammatory properties both of which have been associated with slowing the rate of memory decline.
Folic acid, Vitamin B12, Vitamin B6: low levels of these vitamins can cause memory loss and impaired memory function so taking these may help strengthen your memory. I typically recommend that patients take 400 to 800mcg of folic acid; Vitamin b12 1000mcg, and Vitamin B6 of 25mg to 50mg daily.
Vitamin D: There is some evidence that Vitamin D deficiency may be related to memory and cognitive impairment so taking extra Vitamin D supplementation of 1000 I.U. to 2000 I.U. daily may help.
A diet high in saturated fats, trans-fat, or cholesterol has been shown in some studies to cause cognitive decline.
Omega-3 Fatty Acids: These help both brain and heart! The key thing to look for in “Omega-3 Fatty Acids” is the EPA (Eicosapentaenoic Acid) and DHA (Docosahexaenoic Acid). Fish oil also helps lower cholesterol and helps with cardiovascular health. In the Framingham Study, patients with higher level of DHA showed lower rates of incidence of Dementia at their 9 year follow up and patients with high levels of EPA showed to have lesser amount of hippocampal atrophy (shrinkage). [The Hippocampus is an area of the brain responsible for memory.]
Fruits and Vegetables: A diet high in fresh fruits and vegetables helps with your heart as well as your cognitive function!
Mediterranean Diet: Although a vague term which is at mercy of interpretation…this is typically a diet rich in fruits, vegetables, whole grains, beans, nuts, and seeds and includes olive oil as an imporant source of fat. This diet has very little red mean and low to moderate amounts of fish, poultry and dairy products. Patients who were strict about sticking to this type of “mediterranean diet” had less cognitive decline over time and less incidence of cognitive imparment and Alzheimer’s.
LIFESTYLE AND ACTIVITY
Many different studies have shown that higher levels of mental and physical activities slow the rate of cognitive decline. So get out there and EXCERCISE!
Mental activities and memory games such as Crossword Puzzles, Reading, Sudoku, Scrabble are all great ways of challenging and keeping your mind engaged. Simple socialization with friends and family also helps keep the mind sharp. Social interaction is very important for elderly patients who may be home bound. Adult daycares, afternoon activities at the local YMCA, social clubs or church events are wonderful ways to stay engaged.
We know that uncontrolled and/or suboptimally controlled hypertension (high blood pressure) causes decrease in blood supply to the brain which over time can lead to decline in memory and cognitive funcitoning. Goal blood pressure is to keep it less than 140/90, ideal blood pressure is around 120/80.
Gingko Biloba and estrogen therapy in menopaual women are no longer recommended to be used for prevention of dementia because studies showed that they did NOT help with memory loss.
Bone health has been a topic of a lot of discussions and controversies in the past few years. With new treatment medication options, conflicting reports about calcium supplementation, questionable effects of fosamax and such drugs, it can be quite overwhelming! This post is dedicated to teach patients about the basics of bone density to get a better understanding of what we are looking for.
Strong and healthy bones are very important because it is our bones that keep us strong, mobile, and upright! Weak and unhealthy bones can truly affect the quality, as well as the quantity of our lives. When we talk about “healthy” or “strong” bones we are referring to their mass and density. You can have normal bones, Osteopenia (“thinning” bones) or Osteoporosis (“brittle” bones). Low bone mass/density can put you at high risk for fractures. The density of our bones is measured by a radiological x-ray test called BONE DENSITY (DEXA SCAN)—Dual Energy X-ray Absorptiometry. These DEXA scans give us a number called T-score which has helped standardize our discussion about bones–so when you talk to one doctor about your T-score, another physician knows exactly what you are saying and the health of your bones! T-score is your bone mass compared to normal healthy young adult. There is another number called the Z-score, which is your score compared to patients of your age/gender/ethnicity group. We make our treatment decisions based on the T-score. Although all bones in our body can weaken, we measure the bones in our lower spine and hips. Sometimes if patients have a lot of arthritis in their spine or an artificial hip, we check the arm to measure bone density.
The radiation levels involved in a DEXA scan is very low—almost negligible. The technician doing the test does not need to wear protective shields. For safety reasons, it is recommended the technician sit 3 feet away from the table when a patient is being scanned.
There can be significant difference in technologies used by different manufacturers and sometimes different models of the DEXA machines; therefore, it is very important for you to go to the same facility each time you have a bone density scan to get more consistent readings. Of course if you move out of town due to relocation or can no longer go to the facility due to insurance reasons, then you need to start at a new one.
Decision to treat low bone density is quite individualized. Not everyone necessarily needs prescription medicines. The World Health Organization released an algorithm to help physicians decide which patient will benefit from treatment and which can be monitored. The algorithm is called “FRAX” score. It is an algorithm that takes into account your Age, Gender, Weight, Height, Ethnicity, Smoking status, Prior fractures, Family History of fractures, Alcohol use, use of steroid medicines, T-score, and history of autoimmune arthritis to help decide if you will benefit from medicines to help with Osteopenia or Osteoporosis. You should speak with your physician to see if you need treatment.
There are many causes of low bone density including family history, low body weight, ethnicity, loss of estrogen for women in menopause, low testosterone in men, medications like steroids and antacids, calcium and vitamin D deficiency, hyperthyroidism (overactive thyroid) to name just a few.
To read more about prevention options, please read “What Can I Do To Help My Bones?”
Vitamin D is an essential nutrient that plays an important part in our bodies for balance and metabolism of calcium and bone health. The main source of Vitamin D is from sunlight as sunlight is needed to help convert pro-Vitamin D which is in our skin to the active Vitamin D (called cholecalciferol) which the body can use. Other sources of Vitamin D are through diet such as fortified milk (which means that we as a society have added Vitamin D in the milk we purchase, it is not naturally present in animal milk), fatty fish, cod liver oil, and eggs to name a few.
Vitamin D deficiency is increasingly being diagnosed for multiple reasons. One of the big ones is because we, frankly, are checking for it! Another big reason is because we have become more of an “indoor society” which limits our sun exposure: we are either indoors at home, inside a building for work, or in our cars trying to get to one of those two places! When we are outside, we use sunscreen which blocks the absorption of the rays needed to do the Vitamin D conversion. Sunscreen is important! So don’t stop using it, especially if recommended by your doctor! People with pigmented skin (African Americans, South Asians, Africans etc) have higher incidence of Vitamin D deficiency than their lighter skin counterparts due to the melanin content in their skin. Melanin is the substance in our skin that gives us our color–more melanin a person has the darker their skin color. Melanin also helps prevent skin cancer because it blocks sun rays absorption, but as you can imagine, this is the same reason why darker pigmented people would have higher risk of low Vitamin D.
During winter people tend to have lower Vitamin D levels because there is less sun around due to shorter days thus less sun exposure. Elderly are more prone to Vitamin D deficiency because they tend to stay indoors more. Residents of certain cold countries such as the Netherlands, Greenland etc are low in Vitamin D due to less sun in those regions.
People who avoid dairy due to medical or personal preferance reasons tend to be low in Vitamin D as well due to lack of dietary intake.
Aside from bone health, Vitamin D helps your immune system. It has been shown to help prevent certain cancers including Melanoma, Prostate Cancer, and Colon Cancer. It helps with autoimmune conditions. Multiple studies have shown Vitamin D to help prevent falls; especially in the elderly population (one of the best ways to prevent bone fractures is to prevent falling!). Vitamin D has also been shown to help with decreasing depression. Certain neurological conditions such as Multiple Sclerosis have shown to benefit from Vitamin D supplementation as well. Low levels of Vitamin D have been associated with development of Dementia or decline in memory.
American Journal of Clinical Nutrition published an article where they found that low levels of Vitamin D were “associated with an increase in all-cause mortality [i.e.: death] and mortality from cardiovascular disease, cancer, and respiratory illness.”
Normal levels of Vitamin D are greater than 30. I typically like most of my patients to be around the 40 to 50 range. I recommend my patients with history of Melanoma keep their Vitamin D above 50. If your Vitamin D is low, your doctor will likely give you the prescription dose of Vitamin D of 50,000 I.U. to take once a week for a typical course of 12 weeks to help restore your levels. It is recommended you go back in at the end of the treatment and get your levels rechecked to see if the levels got better.
Many times I have cases where patients tell me “my Vitamin D always comes as low” or “I had my Vitamin D level checked, it was low, I took the prescription medicine so why is it low again?”. The prescription Vitamin D is an excellent way of helping RESTORE OR INCREASE your levels to a NORMAL range; however, you need to do something on a regular basis to help MAINTAIN and KEEP your levels up. Remember, our main reason for low Vitamin D is our LIFESTYLE: a lack of sun exposed lifestyle, which will not change regardless of the prescription Vitamin D. Therefore, after you are done with your Vitamin D prescription, speak with your physician about MAINTAINENCE Vitamin D. I typically ask my patients to take Vitamin D-3 (cholecalciferol) 1000 I.U. to 2000 I.U. daily to help keep their levels up.
Whooping cough, also known as pertussis, is a highly contagious respiratory tract infection. Although initially it resembles a simple cold, whooping cough may eventually become more serious especially in children and infants as it can lead to hospitalizations, dehydration, pneumonia etc. A typical course of this infection is that you have slight cold-like symptoms of runny nose, post nasal drip in the back of the throat, scratchy throat and just feeling a little under the weather but then it progresses into a dry or productive hacking cough that just doesn’t get better and can progressively get worse. Often times the coughing is so severe that it can cause “post-tussive emesis”–which means that you cough so much that you start vomiting. Unfortunately, Whooping cough is most contagious BEFORE the coughing even starts. The best way to prevent it is through vaccinations. The childhood vaccine is called DTaP which contains immunity against three different infections including Diphtheria, Tetanus and Pertussis (whopping cough); adolescent and adult vaccine is called Tdap (which also protects against the same three infections). Children usually get up to 5 doses of the DTaP combination vaccine from birth to 6 years of age and get a booster between 12 and 13 years of age with the Tdap.
As you can see majority of us have had this vaccine as children but we thought that we had lifelong immunity to the Pertussis (whooping cough) part of the vaccine so we dropped it from the adult tetanus boosters (Td). Unfortunately, a few years ago we started seeing a re-emergence of this infection by seeing local outbreaks in schools which made us realize that just like the tetanus and diptheria immunity wanes over time so does the Pertussis immunity. Now the CDC recommends routine use of a single dose of Tdap for adults 19-64 years of age to replace the next booster dose of plain tetanus and diphtheria vaccine (Td).
All these efforts being made to help immunize everyone is so that we can have a “herd immunity” so the bacteria never gets a chance to re-emerge and infect the most vulnerable patients like infants and children who have not had a chance to get enough vaccines to build up immunity against this infections. Therefore, if you are an adult who has had a plain tetanus shot (Td) more than 2 years ago, you should speak to your physician about getting a complete Tdap booster.
PEOPLE WHO SHOULD CONSIDER A WHOOPING COUGH BOOSTER:
1. If you are a woman PLANNING on getting pregnant
2. A male who just found out his significant other is pregnant
3. All adults who will be around small infants (younger than 12 months)…includes all you soon-to-be grandparents, aunts and uncles!
4. Healthcare providers or professionals who will be around a lot of people because risk of transmission is high
NOTE: Women who are already pregnant should not receive the pertussis component of the vaccine. If they need a tetanus vaccine it needs to be the PLAIN Td. Hospitals are likely to vaccinate women with the Tdap booster right after delivery of the baby while they are still in the hospital so the babies are protected.