2005 Health Details

8/3/2019 2005 Health Details

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Friday, April 29, 2005

What's With This PSA, Anyway?

The PSA test is often requested as a gauge of

prostate health. It has utility in the discovery of benign prostatic hypertrophy (BPH) andprostate cancer. But how useful is it? Is it even worth testing for? We will discuss the use of

the PSA test for screening purposes, not for people already diagnosed with one of these

conditions.

Prostate-specific antigen (PSA) is produced by the cells of the prostate. Some PSA spills into

the bloodstream, from which we may draw a sample for testing. High PSA values are

associated with prostate enlargement from BPH or prostates affected by cancer or infection

(prostatitis).

Recommendations for the use of the PSA test vary widely. TheAmerican Urological

Associationrecommends that all healthy men over the age of 50 receive a digital rectalexamination and PSA testing. TheAmerican College of Physicians, on the other hand, does

not recommend routine PSA testing at all. TheAmerican Cancer Societysides with the

American Urological Society. TheUnited States Preventive services Task Forcesides with

the American College of Physicians.

Confused? Yeah, so are we.

It's hard to know what to do when different governing bodies tell us to do different things.

The majority of the difference comes from the fact that screening people with PSA testing

has not been shown to prevent death from prostate cancer. PSA testing may detect small

prostate cancers that would never have caused health problems if they were never found. Andsince most elevated PSA values come from benign prostatic conditions, such as BPH or
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prostatitis, many people with elevated PSA values are subjected to unnecessary prostate

biopsies.

Discuss PSA testing with your doctor. If you want one, just ask for one, but understand the

limitations of the test and the potential need for a prostate biopsy that you wouldn't have

needed otherwise.

Dean F. Giannone, M.D.

posted by Dean G., M.D. |7:27 AM|1 comments

How Much Protein is Enough? Or Too Much?

Proteins are all the rage these days. Protein is an essential

part of our daily meal planning, necessary for the maintenance of lean body tissue and certain

body processes. Intense weightlifters and those on carbohydrate-restricted diets practically

live on proteins alone. But how much protein is really enough? And how much may be too

much?

Technically speaking, the general consensus is that one gram of protein per kilogram of body

weight is enough to maintain lean tissue and support the body's metabolic processes under

normal circumstances (remember that your weight in kilograms is equal to your weight in

pounds divided by 2.2). This holds for sedentary individuals..

For athletes and weightlifters, the recommendation increases to one gram of protein per

poundof body weight. These people need more protein to support muscle building and

performance improvement.

People with kidney disease tend to restrict their protein intake because of the potentialinfluence of dietary proteins on the progression of kidney disease. However, restricting

proteins can also cause malnutrition and accelerate muscle wasting. One gram of protein per

kilogram of body weight should be safe for those with kidney disease.

That's all you need, really. Too much protein can tax the kidneys and impair their function,

can precipitate attacks of gout because of increased uric acid production (resulting from

protein metabolism) and may cause osteoporosis and kidney stones due to increased urinary

calcium excretion.

Obviously, low-fat sources of protein are preferred, such as fish, egg whites and poultry. If

used prudently, protein supplements may also help an athlete to achieve the necessary proteinintake.
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Wednesday, April 27, 2005

Who Has A Healthy Lifestyle? Just About Noone!

We all know what we need to do to stay healthy, right? Exercise, don't smoke, eat fruits and

vegetables, and maintain a healthy weight. But how many of us actually espouse these

values? How many of us truly maintain an optimal healthy lifestyle?

A pitifully small number of us, actually. In a study in theArchives of Internal Medicine

released this week, only 3% of over 153,000 individuals questioned exercised regularly,

didn't smoke, ate five servings of fruits and vegetables daily, and maintained a healthy weight(BMI 18.5 to 25).

3%?!?!

Only 22% of those questioned engaged in regular physical activity, which is now

recommended in the new food guide pyramid. And only 40% of those questioned maintained

a healthy weight; this number is in line with the growing societal prevalence of obesity.

That's terrible. Come on, people, get with it!! Among other things, maintaining a healthy

lifestyle protects your heart, prevents diabetes, increases your longevity and prevents cancer.

So read this study and espouse its values. Exercise regularly, eat your fruits and vegetables,

maintain a healthy weight (BMI Chart), anddon't smoke.


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Tuesday, April 26, 2005

The Magic of Brisk Walking

While perusingMyPyramid, the new food guide pyramid, we notice that near-daily moderate

exercise has become an important part of the recommendations. This solidifies the advice of

myriad health care advocates who praise the value of exercise added to a daily regimen of

healthy eating. But you don't have to become a marathon runner or olympic swimmer to

achieve "moderate exercise". Don't underestimate the power of a simple brisk walk.

In order to achieve your proper exercise intensity, subtract your age from 220, then take 70%

of that result. Your heart rate should be around that number while you're walking. For

example, for a fifty-year-old:

1. 220-50=1702. 70% of 170 equals 1193. Target exercise heart rate about 119

As another gauge, while walking you should feel a little winded, but you should still be able

to hold a conversation without gasping for air.

Now, behold the magic of walking:

You can burn upwards of 500 calories per hour of brisk walking (remember, a daily500 calorie deficit equates to one pound of weight lost per week)

Walking is low-impact, so it puts minimal strain on your feet, ankles and knees You don't need to go to a gym to walk - just go outside Walking, like other forms of aerobic exercise, will lower your total and LDL

cholesterol, and is the best way to raise your heart-protective HDL cholesterol

Walking lowers the blood pressure and resting heart rate Walking will help you control your blood sugar and glucose disposal into the muscles Walking can ease stress, anxiety and depression, and may ward off dementia Older people who walk regularly experience a 50% reduction in mortality compared

to age-matched non-exercisers

Walking improves sleeping habits (make sure you exercise more than four hoursbefore going to bed)
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Walking improves coordination, balance and strength, reducing the risk of falling aswe age

Walking improves the immune system Walking will prevent osteoporosis

So remember, you don't need to run the New York Marathon or ride the Tour de France toreap the health benefits of a regular aerobic exercise program. Get outside, start walking, get

your heart rate up to target, and be healthy.



Monday, April 25, 2005

Causes of Fatigue - Anything and Everything

So many people report feeling fatigued these days. It seemswe're all walking about in somnolent stupors. Without wondering why, we yawn through

each day, listless, inattentive and lackluster, just waiting to go home and go to bed. But what

if you're fatigue were treatable? Let's address some causes.

First, there are many medical conditions that are associated with fatigue. Optimal treatment

of these medical conditions may reduce your feeling of fatigue. These include emphysema,

asthma, congestive heart failure, coronary artery disease, anemia, diabetes, Addison disease,

Cushing disease, obesity, gastroesophageal reflux disease, peptic ulcer disease,hypothyroidism, arthritis and lupus.

Second, psychological conditions can cause fatigue. These include both depression and

anxiety.

Third, disorders of sleep quality will cause fatigue. In these, you sleep throughout the night

but your sleep is superficial, not restorative nor restful. These include sleep apnea and restless

leg syndrome.

Fourth, medications can cause fatigue. Likely culprits include anti-hypertensives, some heart

medications, anti-depressants, anti-anxiety meds, narcotics and muscle relaxants.
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To investigate fatigue, then, see your doctor. Review your medications; see if any of them

may contribute to fatigue, and consider changing them to other medications if possible

(unfortunately some medications are irreplaceable). Review your symptoms to see if any

relevant medical or psychological conditions are present. Have bloodwork done for blood

counts, chemistries, cortisol level, blood glucose, thyroid function and ESR. If this is all

unrevealing, a sleep study may be in order to assess your sleep quality.




Diabetes and the Heart

We say it all the time: diabetes can lead to heart disease, diabetes can cause blood vessel

blockages, diabetes can cause heart attacks. But it seems that we, as physicians, don't

effectively communicate to the general public the intensity with which diabetes can cause

atherosclerosis and heart disease. Here, then, is the argument, as bluntly as I can put it:

Diabetes has been classified by the National Cholesterol Education Program as acoronary artery disease equivalent, which means that for the purposes of cholesterolmanagement, having diabetes is the same as having heart disease already.

Diabetics who do not have heart disease are at the same risk of eventual heart attackas non-diabetics with known heart disease.

Diabetes, and even pre-diabetes, is linked to other risk factors for heart disease in the"metabolic syndrome", which is a potent contributor to heart disease development.

People who are overweight are at risk for having the metabolic syndrome (which

we've discussed previously).

Diabetics who have heart attacks tend to have larger areas of heart damage, and are atincreased subsequent risk for congestive heart failure.

From a physiologic basis, diabetes intensely promotes the growth of atheroscleroticplaques through effects on the inner blood vessel lining, platelets and vascular

relaxing factors like nitric oxide.
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Microalbuminuria (the detection of trace amounts of protein in the urine in peoplewith diabetes, typically viewed as a marker for kidney disease) is a potent predictor of

future heart attack.

75% percent of diabetics die because of atherosclerosis, particularly heart disease. Diabetes eliminates the protective effect of estrogen in reducing the chance of heart

disease in younger women. Aggressive control of diabetes has not been shown to reduce the chance of heart

disease progression.

Convinced? To reduce these risks, you need to control your diabetes well and control any

other risk factors that may be present, such as high blood pressure, high cholesterol and

obesity. Lose weight. Stop smoking. Exercise. Eat properly. Take your medications. You

need to take this risk seriously. If this has piqued your interest, readthis.



Thursday, April 21, 2005

Lupus and the Heart

Lupus, or systemic lupus erythematosus (SLE), is a condition that affects many organ

systems. In particular, lupus can affect the heart through causing pericarditis, heart valve

problems, myocaridits, high blood pressure and atherosclerosis. Its contribution to

atherosclerosis is particularly disturbing because of the possible consequence of heart attacks.

However, the mainstay of treatment of lupus also can accelerate the development ofatherosclerosis. So, what's a person with lupus to do?

In the November 16, 2004 issue of theAnnals of Internal Medicine, an update in

Rheumatology described an article from the New England Journal of Medicine which

revealed a 37% prevalence of atherosclerosis in people with lupus, compared to a 15%

prevalence in those without lupus. Theoretically, this could lead to an increased risk of heart

attack and/or stroke in those with lupus, especially in the young people who typically

experience this condition.

In the same issue of the Annals, a study was described which stated that the use of high doses

of steroids chronically (the study was conducted over three years) lead to an increase in the

prevalence of heart disease. Steroids are the mainstay of treatment of lupus both in the acute

and chronic settings. So a condition which can cause heart disease is treated with a

medication that can cause heart disease. What to do?

First, try to minimize your steroid exposure. Use it for the acute flares, then taper the dose

down to the lowest tolerable dose. Hopefully you would even be able to discontinue it

altogether, symptoms allowing. Low-dose steroid use had no affect on the development of

heart disease.

Second, see if you can use another medication for lupus control. Medications likemethotrexate, cyclophosphamide, azathioprine, and even anti-inflammatories like Motrin and
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Advil, while having their own toxicities and side effects, will hopefully allow you to come

off steroids. Even alternative remedies like cod liver oil, ginger and cranberry may help, but

check out their side effect and medication interaction profiles before using.

So if you have lupus and have been on high doses of steroids, speak to your doctor about

another treatment option.




The Battle Rages On

It seems that the battle rages on between the "traditionalists" and the "alternative-ists" in

the war for righteousness (and patients). My personal conviction regarding the peaceful co-

existence between these two factions seems to have passed unnoticed as my raison d'etre is

bashed as a tool for duping the public, killing people and making a quick buck. While

homeopaths are imaged at the right hand of God, producing miracle cures without a stitch of

harm, practitioners of traditional medicine are deemed as rising from the bowels of Hell to

lull the public into a world of ulterior motives and political machinery.

First of all, when I graduated medical school, I spoke the Hippocratic Oath which dictates

that I treat patients with the intent of healing, no matter what the sacrifice, and with an

intended minimization of harm. I'm not aware of a similar "Homeocratic Oath".

Second, recent drug recalls speak for the integrity and morality of the traditional medical

establishment. Groups such as the AMA and the FDA continue to review the safety of

medications even after they're released to the general public. Studies are constantly being

performed to confirm the safety and efficacy of available medications. If a medication is ever

deemed unsafe, it is recalled from general availability. This is why we no longer have

medications like Bextra and Ticlid. The only recent recall of a non-traditional medication,

Ephedra, was initiated by...the FDA.

Speaking of Ephedra, this brings me to my third point: homeopathic remedies are not always

safe. Ephedra caused fatal heart attacks in young people without heart disease who took

typically recommended doses. Cocaine does that, too. But it took the FDA to push for

removal of Ephedra from the market. It turns out that while the potential efficacy of

homeopathic remedies is publicized ad nauseum, their harms are not. For example, taking St.

John's Wort with other anti-depressants is contraindicated; the combination can exacerbate

side effects like dizziness, confusion and anxiety. Ginseng can raise the blood pressure, and

will interact with Digoxin, increasing the risk for potentially fatal ventricular rhythm

disturbances in people taking both ginseng and Digoxin. Policosanol, frequently referenced

for powerful cholesterol-lowering power without side effects, actually can cause insomnia,

hypertension, hypotension, skin rashes, stomach pains and diarrhea. These interactions and

risks are not commonly publicized because purveyors of these remedies are not required topublicize them. In fact, they're not even required to look for them. Because these items are
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categorized as dietary supplements by the FDA, no investigations into safety are required

prior to their release to the public. You can look for side effects of homeopathic remedies on

www.rxlist.com, orwww.pdrhealth.com.

Be aware that we practitioners of traditional medicine are not politicians or charlatans or

criminals. We just want to make you feel better - to cure what ails you - as best we can. Wehave no problem coexisting with others who wish to achieve that same goal. But if you're

sick and want to feel better, don't go to Congress; go to a doctor.




Types of Weight Loss Surgery

There are so many conditions that can be helped or eliminated by weight loss - diabetes, high

blood pressure, high cholesterol, osteoarthritis, heart disease, sleep apnea, restrictive lung

disease, even depression and anxiety. I tell my patients that weight loss must be achieved by

any means necessary, as long as that means has been shown to be safe. To that end, I wish to

discuss the options for you pondering weight loss surgery, a very effective, relatively new,

and very safe way to achieve large-volume weight loss.

Weight loss surgery is recommended for those who are overweight and who have lacked

success in weight loss over several real attempts. Furthermore, you must be either 100 pounds

overweight, have a BMI 0f at least 40, or have a BMI of 35 to 39 with significantcomorbidities, as listed above. To discover your BMI, checkthis chart.

The Lap-Band is a synthetic band that loops around your stomach, creating a small pouch

into which food enters after eating. The size of the pouch is adjustable, but averages about 4

ounces. So 4 ounces is the amount of food per meal you'll be able to eat after surgery. As

such, the Lap-Band works primarily by restricting food intake - you'll feel quite full after a

minimal amount of food. With this surgery, the stomach remains intact; it ends up being

shaped like an hourglass, with the pinch in the middle being created by the band. After food

enters the small pouch, like an hourglass, it trickles slowly into the remainder of the stomach

to complete the process of digestion.

With gastric bypass surgery, the "plumbing" of the GI tract is surgically altered. A small

stomach pouch (4 ounces) is surgically created, and a portion of the small intestines is

brought up to the pouch. Therefore, a significant loop of small intestine, through which

digestion typically occurs, is avoided. So this surgery works both by restricting food intake

and by causing malabsorption of food.

The duodenal switch works primarily by malabsorption, with some component of restriction

of intake. While a small gastric pouch is created, most weight loss is achieved because of the

bypass of most of the small intestines, through which digestion typically occurs. These

malabsorbed foods enter into the large intestines and are eliminated as waste, with theircalories not being absorbed.
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Generally speaking, less weight is lost after the Lap-Band than after the other procedures, but

the risk of malnutrition is also less because none of the GI tract is bypassed. The band is also

adjustable and, if necessary, removable. Reversing a gastric bypass or duodenal switch is

much more difficult. Overall, the complication rate for any of the procedures at a center that

performs a high volume is these operations should be less than 1%.




Treatments for Prostate Cancer - Even Nothing May Be Something

9 Prostate cancer affects many men. Next to skin cancer, it's the most common form of

cancer in men. It's estimated that prostate cancer affects 1 in 6 men (source), with itsincidence increasing with age. How, then, might we treat prostate cancer?

Prostatectomy (removing the prostate) may be useful with curative intent for non-metastatic

prostate cancer. This can be accomplished either through the abdomen (radical

prostatectomy) or the penis (TURP). Some of the risks of surgery include urinary

incontinence and impotence.

Radiation can also be delivered to the prostate, either externally or through the implantation

of radiation seeds into the prostate itself (brachytherapy). Radiation can sometimes be

considered with curative intent, although typically it will merely shrink the cancer and control

its further growth. Being that radiation exposure decreases with increasing distance from thesource of that radiation, the dose of radiation must be much higher with external beam

radiation than from seeds within the prostate. As such, side effects are more common with

external beam radiation, and include diarrhea, rectal bleeding, urinary incontinence and

impotence. These side effects are much less common with brachytherapy.

Hormone therapy can be used to control the growth of prostate cancer, but this will not cure

it. Prostate cancers are generally responsive to male hormones, and depriving them of such

will slow their growth. One way to achieve this is through orchiectomy, or resection of the

testicles. This can also be achieved through medications, such as Lupron (leuprolide),

Zoladex, Plenaxis, Eulexin (flutamide), Casodex and even Saw Palmetto. Hormone therapy

tends not to be used for advanced prostate cancer.

Chemotherapy is the treatment of choice for advanced or metastatic prostate cancer. Like

hormone therapy, the use of chemotherapy is not intended to cure prostate cancer, but rather

to slow its growth. Chemotherapeutic agents, such as doxorubicin, vinblastine, prednisone

and carboplatin, among others, have their inherent side effects which may be intrusive.

However, these agents may be an unfortunate necessity for patients with advanced prostate

cancer, for which other treatment regimens would be fruitless, or for which other treatment

regimens have not worked.

Since prostate cancer typically grows very slowly, some patients may even be candidates forwatchful waiting, for which nothing is done except for routine surveillance of the cancer. If
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you are older and have a small localized area of prostate cancer which is causing no

symptoms, you would be an excellent candidate for watchful waiting.

If you wish to review the options more thoroughly,thisis an excellent source. Most of the

information in this review came from this source - it's complete and concise, and it comes

from the American Cancer Society.




Are Weight Loss Pills Good For Your Waist, Or Are They A Waste?

A recent review of prescription weight loss pills identified several medications that are

effective for weight loss. However, these medications also have significant side effects that

tend to limit their use. The issue, then, becomes a matter of this: is the amount of weight loss

worth suffering for?

In theAnnals of Internal Medicine, a recent review of the American College of Physicians

guidelines for the treatment of obesity appeared. Several weight loss medications were

reviewed, including Sibutramine (Meridia), Orlistat (Xenical), Phenteramine, Diethylpropion,

Bupropion and Fluoxetine. Their weight loss potentials were details, as were their side effect

profiles. It turns out that the best medication of the six is Sibutramine (Meridia), which

produced a weight loss of 4.45 kg over 12 months.

4.45 kg. That's 10 pounds. Over 12 months!

Sibutramine can elevate the heart rate and blood pressure, and can cause nervousness,

headache, constipation, dizziness, sore throat and insomnia.

Now, usual diet recommendations delineate an appropriate amount of weight loss as one to

two pounds per week through proper diet, modest calorie restriction and exercise. Remember

that a daily calorie deficit of 500 calories (the equivalent of two cans of regular soda, or less

than two typical candy bars) will alone result in weight loss of one pound per week. That one

pound per week equals 52 pounds over twelve months. And losing two pounds per week

would result in a twelve month weight loss of 104 pounds! That's more than ten times the

amount lost with Sibutramine. And people lost the most weight with Sibutramine, compared

to the other weight loss medications tested. Some of these weight loss medications resulted in

mere seven pound weight deficits over the twelve month period. With proper diligence, you

can lose seven pounds in one month without the medications!

Some side effects of the other weight loss medications include heart valve defects,

palpitations, diarrhea, urgent and uncontrollable bowel movements.

So if you have a modest amount of weight to lose, try to follow a proper diet/calorierestriction/exercise regimen. You'll avoid the side effects of medications, and you'll end up
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12/22

losing much more weight anyway. If you have a large amount of weight to lose (more than

100 pounds), you'd be better off considering weight loss surgery. In this ACP review, people

who had weight loss surgery lost as many as 66 pounds. This weight loss was maintained for

as many as 10 years, and many medical conditions (such as diabetes, high blood pressure, and

high cholesterol) disappeared.




Fiber

The benefits of dietary fiber are myriad, but Americans' typical intakes of fiber are lacking.

While recommendations suggest as much as 38 grams of fiber per day, the typical American

diet contains only 11 grams daily (source). In these days of fast and processed foods, we

often neglect an appropriate intake of this health-preserving item. Here, then, is the argument

for fiber.

The health benefits of dietary fiber include:

Reduction of colon, rectal and breast cancer risks Reduction of heart disease risk Reduction of bad cholesterol numbers Control of blood glucose values Possible reduction of duodenal ulcers Promotion of bowel regularity Promotion of healthy weight through reducing appetite

So why don't we get enough fiber? Because the typical American diet is horribly lacking in

this valuable nutrient. To increase your intake of fiber, you need to hunt down high fiber

foods. As an easy recommendation, I suggest people eat 1/2 cup of a high-fiber cereal (i.e.

All-Bran or Fiber One) with each meal. This will provide most of the 20-25 grams that is

recommended as you daily fiber intake. The remainder can be added from the foods you eat.
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As far as your meal planning is concerned,hereis a great list of the fiber contents of various

foods.




The Down Side of Sleeping Pills

Prescription sleeping pills areused quite commonly these days. Prescriptions for Ambien and Restoril, and now Sonata, are

written many times every day by well-meaning physicians who hope to give their patients a

good night sleep. Desperate patients sometimes borrow sleeping pills from their friends or

family members. But be careful; these agents must be used with caution, as they may make a

certain common medical condition associated with insomnia worse.

Obstructive sleep apnea (OSA) is a condition wherein breathing is disrupted at night by

various mechanisms. This breathing difficulty causes an increase in carbon dioxide and a

decrease in oxygen levels in the bloodstream, which trigger the brain to wake you up a bit.

You may not achieve full wakefulness, but you'll end up in a lighter, non-restorative, no-

restful stage of sleep.

OSA is one of the most common sleep disorders, affecting about 4% of men and 2% of

women, with its prevalence increasing with increasing age. Furthermore, most cases of OSA

remain undiagnosed, so you may have it and not know it. Being that most of the diagnostic

symptoms occur while you're sleeping, you may only notice insomnia and daytime

sleepiness.

The point to remember is that sleep agents like Ambien and Restoril, and even Xanax,

Valium and Ativan (not traditional sleep aids, but are often used for this purpose), suppress

respiration and, therefore, would make OSA worse. While you may sleep more soundly, your

body would be in a physiological nightmare. Remember, OSA is linked to high blood

pressure, heart disease and heart rhythm disturbances.
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The moral is to remember that insomnia is a symptom, not a condition unto itself. The goal is

to identify and address the cause of insomnia; by treating the cause, you eliminate the

insomnia. If your sleep difficulty lasts longer than two weeks, you should see your doctor for

a complete workup.




Should We Tolerate the Glucose Tolerance Test?

Much has been said about the utility of the oral glucose tolerance test in the diagnosis ofdiabetes mellitus. However, the test itself is inconvenient, and may not add information to

that gleaned from other, more straight-forward tests. So is the oral glucose tolerance test

(OGTT) a necessary part of the diagnosis of diabetes? [For this blog, I won't be addressing

gestational diabetes, for which test performance and interpretation are different.]

The OGTT is typically performed in a laboratory. You ingest a 75-gram dose of glucose as a

beverage, and then sit in the lab for two hours. You need to stay there so the test is controlled

with respect to the 75-gram dose of glucose; if you leave the lab, those at the lab can't be sure

that you didn't run out to eat a ham sandwich and french fries to make yourself appear to have

diabetes. Furthermore, they can't be sure that you didn't run to a friend's house and take a

dose of Glucophage or insulin to make yourself appear to not have diabetes. In any event,bring a good book to the lab.

After two hours, your blood glucose is measured. Results are interpreted as follows:

Less than 140 - normal 140 to 199 - pre-diabetes (impaired glucose tolerance) 200 or higher - diabetes

So it's a good test, but the question remains as to if it's a necessary test. Fortunately, there are

other simpler ways to diagnose diabetes which are just as accurate. Most commonly, a fasting

blood glucose is measured; a value above or equal to 126 solidifies the diagnosis of diabetes.

Alternatively, if you have symptoms of diabetes (urinating a lot, always thirsty, always

hungry, eating a lot but not gaining weight, blurry vision, or tingling in the fingers and toes),

a random (non-fasting) blood glucose of 200 or greater will solidify the diagnosis of diabetes.

These recommendations are per the American Diabetes Association, as seenhere.

So although the OGTT is helpful, it's not necessary. There are simpler ways to diagnose

diabetes.


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15/22


About Thyroid Function Testing

There's a lot of confusion about

testing of the thyroid gland. People speak of having a slow thyroid despite normal thyroid

function tests. People have trouble understanding what goes up and what goes down. So let's

review the important thyroid function tests and their relevance.

TSH(also thyroid stimulating hormone, or thyrotropin): This hormone is produced in the

pituitary gland and triggers the thyroid gland to produce its hormones. Traditionally, this test

suffered from poor sensitivity and, therefore, reliability. Now, however, the fourth generation

TSH test is considered "ultrasensitive". Simply put, if you are hyperthyroid, and the thyroid

gland is pumping out hormones on its own, it doesn't need to be stimulated by the pituitary

gland and, therefore, TSH levels are undetectable. If you are hypothyroid, the pituitary needs

to try to pummel the thyroid gland with stimulation to get it to work and, therefore, the TSH

is elevated.

Because of the ultrasensitivity of the TSH assay, we need to discuss two more categories ofdisease. If your TSH is between 5.5 and 10, you would have subclinical hypothyroidism. If

your TSH is between 0.01 and 1, you would have subclinical hyperthyroidism. These

conditions are typically found on screening bloodwork; they are subclinical because they

rarely produce symptoms. With TSH values in one of these ranges, you should only be

treated for thyroid dysfunction if you have a relevant symptom.

Free T4: T4 is one of the hormones produced by the thyroid gland in response to TSH, T3

being the other. T4 is converted to T3, which is the form of thyroid hormone which is

functional in the body.

T4 is present in bound and free forms. The majority of T4 is bound to proteins in the

bloodstream; this form is not functional. Only the free fraction, that not bound to proteins, is

functional. Therefore, testing specifically the free T4 value gives an accurate representation

of thyroid function.

And that's about it. All you really need to accurately assess the function of the thyroid gland

is the TSH and free T4. So if you're concerned about your thyroid function, make sure both of

these tests are ordered.


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Not All Sugars Are Created Equal

When it comes to diabetes and pre-diabetes (as we've discussed before), the foods you eat areas important as the medications you take for blood sugar control in both the short and long

term. To that end, you need to know about the glycemic index.

When you eat carbohydrates, they enter your stomach, are broken down to glucose, and are

then absorbed through the stomach into the bloodstream. Once glucose enters your

bloodstream, it can have an effect on your blood sugar reading. It stands to reason that your

blood sugar, then, would reflect the amount of glucose entering your bloodstream at a given

moment (your blood sugar would be higher after 1/2 pound of pasta than after 1/4 pound). It

would also reflect your body's ability to deal with a given load of glucose. If you overwhelm

your body with glucose at one meal, your body will not be able to dispose of it properly and

efficiently and, therefore, your blood sugar will rise and stay elevated.

Remember, also, that there are two basic types of carbohydrate - simple and complex. Simple

carbohydrates are essentially like glucose. They don't need to be broken down in the stomach,

and are therefore absorbed rapidly into the bloodstream. Complex carbohydrates, on the other

hand, need to be broken down into glucose before being absorbed. This process, by necessity,

slows down the delivery of glucose to the bloodstream. Generally, then, simple sugars have a

much more dramatic effect on your blood sugar than complex carbohydrates. For example, if

you eat 50 grams of cake compared to 50 grams of whole wheat bread, your blood sugar will

be higher after the cake, even though the amount of carbohydrate ingested is the same 50

grams. Given that cake is simple sugar, that 50 grams will pass through the stomach quickly,

entering the bloodstream pretty much right away, elevating your blood sugar dramatically.The whole wheat bread would need to be broken down before absorption into the

bloodstream. As each gram of that bread is broken down, that small amount of glucose would

enter your bloodstream. This resultant trickle of glucose into the bloodstream will not elevate

your blood sugar nearly as much.

Are you with me? Here's a chart that demonstrates this well. Notice how much higher the

blood sugar rises after eating a simple (easily digested) carbohydrate compared to a complex

(slowly digested) carbohydrate:

Enter the glycemic index. The glycemic index is a measure of the simplicity of a given source

of carbohydrate. The higher the glycemic index, the simpler the sugar, and the more rapidlythat food will be absorbed. Remember, the more rapidly a food is absorbed, the higher your

blood sugar will rise, as is demonstrated above.

As someone who has diabetes or pre-diabetes, then, you would want to choose foods of lower

glycemic index. Choosing foods of lower glycemic index will reduce glucose elevations after

your meals, allowing you to more easily control your blood sugar.

By reducing glucose excursions after meals, you'll not only lower your fasting glucose

readings, but you'll also lower your HbA1C, the marker of overall, long-term glucose control.

More importantly, you'll reduce your chances of developing diabetic complications, and you

may even require fewer medications and lower doses of your medications.


17/22

You can search for the glycemic index of a given food by clickinghereand choosing the GI

database link. Or you can perusethis excellent list. Remember to select foods with a lower

number (lower glycemic index).




Don't Kill The Messenger

In response to some critiques I received a couple of days ago, I humbly offer the following:

My goal in this column is to inform the general public about health maintenance, symptoms

of concern, health care issues and treatment regimens. The take-home message from theseblogs should be, "I never thought of that," or, "I'm gonna get that checked out right away," or,

"I'm gonna speak to my doctor about this." My purpose is never to doubt, challenge or

devalue any other health care disciplines.

The basic difference between traditional medicine and other disciplines, the ongoing,

neverending traditional versus alternative debate, is in the quality of the evidence presented

by each discipline. Traditional medicine depends on randomized, double-blinded controlledtrials (also called interventional trials) wherein two groups are created, one group is subjected

to an intervention, the other group is given a placebo, and a difference between the two

groups is sought. If all other conditions are controlled and matched, it would be concluded

that any difference between the two groups would be solely due to the applied intervention.Data from randomized, double-blinded controlled trials is considered the strongest data one

can act upon for treating patients. Furthermore, as practitioners of traditional medicine, not

only are we taught this way, but our practices (and our licenses) depend on our applying this

evidence and questioning studies of lesser quality and power.

Practitioners of alternative medical disciplines tend to tout more observational data, wherein

a benefit is assumed from the collection of information from people taking a given agent.

This information may include health benefits, side effects or quality of life assessments.

Generally speaking, observational data is considered weaker because other factors are not

matched or controlled. For example, are people feeling better because of the agent in question

or because of some other thing that they're doing, or because of some other factor that is not

controlled?

A good review of study types can be foundhere.

A good example of this is the treatment of the common cold. Alternative practitioners value

zinc and echinacea for the relief of symptoms of the common cold. They speak of volumes of

observational data proving the benefits of these agents for relief from the common cold -

people take echinacea and zinc and feel better thereafter. However, some randomized,

double-blinded controlled trials have been performed on both of these agents disproving their

efficacy for treating the common cold. Some studies have shown benefit for zinc (1,2,3,4),but not for echinacea (5,6,7). The issue here is one of control. Viral infections, which
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account for 95% of upper respiratory infections, typically resolve in a few days. The issue

then becomes did you get better because of the zinc or echinacea, or did you get better

because the virus went away? A randomized, double-blind controlled trial can answer this

question, an observational trial can't.

This isn't to say that agents proven effective in observational trials don't actually work.Clinical experience with given agents is important, and not every agent has been subjected to

the randomized, double-blinded controlled trial treatment. Heck, acupuncture works great for

some people and, after over 2000 years, we still don't really know how it works.

All of this doesn't make any of us right or wrong, it just makes us different. As an Internist, I

regularly refer my patients to homeopaths, naturopaths, acupuncturists, massage therapists

and chiropractors. In a great number of cases, although my traditional bent may not jive with

the quality of their data, their treatments work really well. There's always more than one way

to treat a given medical condition, just like there's always more than one way to make a pasta

sauce, or more than one way to build a bookcase (I know these examples are overly

simplistic, but you get the idea). Our purpose in these health-related careers is not to compete,but to treat patients and keep them healthy - by any means necessary. As practitioners of

traditional medicine, we cannot be so arrogant as to think that unless something is proven in a

controlled, randomized, double-blinded trial that it's foolish and useless. And practitioners of

alternative medical disciplines cannot generally assume that all traditional medical methods

are toxic and dangerous. We can all work together pretty easily to make patients better.




Leg Swelling

Swelling of the foot and/or leg is

quite a common symptom, and has numerous causes. I wish to present a practical

investigative scheme.

In general, leg swelling can be attributed to one or more of several organ systems, as follows:
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Heart - congestive heart failure due to weakness or stiffness of the heart, heart valveinsufficiency or stenosis

Liver - insufficiency of function will reduce the amount of circulating proteins,thereby allowing fluid to leak from the bloodstream into the tissues under the skin

Kidney - diseases in which protein is excreted in excess, or uncontrollably, from thekidneys will likewise allow fluid to leak into the tissues under the skin

Thyroid - a slow thyroid can cause leg swelling, among other things Local vein disease - the veins in the leg may become congested due to their own

insufficiency and malfunction, or due to blood clotting therein; the increased pressure

will force fluid out of the bloodstream into the tissues under the skin

In these conditions, the legs swell mainly because of the effect of gravity. As we stand, fluid

outside of the blood vessels will be drawn downward by gravity, and will accumulate in the

legs.

To begin a prudent workup of leg swelling, then, the following are necessary:

2D Echocardiogram, to assess the function of the heart and its valvular architecture Bloodwork for thyroid function, liver enzyme levels and kidney function markers Ultrasound of the liver and kidneys to assess for structural conditions Urinary test for protein excretion Doppler ultrasound of the veins of the legs to look for clots

If any of the above are abnormal, then a more specific workup of the organ system(s)

involved can be pursued. For example, if the above suggests a problem with the liver, more

specific bloodwork can be done to look for chronic hepatitis, hemachromatosis, Wilson's

disease, hepatic vein thrombosis, etc.

If all of the above are normal, then considerations for your leg swelling will include:

Venous insufficiency or varicose veins Insect bite or bee sting Trauma Obesity Medications, such as calcium channel blockers (Norvasc, Cardizem, Verapamil),

estrogens or certain antidepressants

MalnutritionOne word of caution. It's common for people to seek a "water pill" to relieve the swelling

until the cause is elucidated. This is a bad idea. Water pills, like Lasix, work by first

removing fluid from the bloodstream. This volume deficit then triggers resorption of fluid

from the tissues under the skin, thereby replenishing the volume within the bloodstream. This

resorption is dependent on an adequate protein content within the bloodstream. Without this

protein content, volume resorption will not occur, and the volume deficit within the

bloodstream will persist, reducing the perfusion of your organs. Several of these conditions

listed above are associated with a reduction in the amount of circulating proteins. Therefore,

until the cause of your leg swelling is known, avoid water pills. Try compression stockings

(Jobst or TED stockings) instead; they increase the pressure within the legs, pushing fluid

back into the bloodstream.


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Monday, April 04, 2005Acne. Antibiotics? Infection. What?

Acne is a troublesome condition

mainly affecting teenagers, but which can also affect older people. It involves obstruction ofthe pilosebaceous units of the skin (as pictured, the cavities within the skin that contain hair

and the sebaceous glands - these glands produce sebum, an oily mixture which normally

protects the skin from infection and water loss). These glands are most prevalent on the face

and neck, chest and back, and upper arms.
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Acne can affect older people who are on certain medications, such as Isoniazid for

tuberculosis, long-term corticosteroids like Prednisone, anabolic steroids for muscle-building,

and Dilantin for seizures. It can also affect adults with certain medical conditions, such as

polycystic ovary syndrome, Cushing's disease or congenital adrenal hyperplasia. Finally, acne

can occur with mechanical obstruction of drainage of the pilosebaceous units, such as in

people who wear tight face masks or turtleneck shirts often.

Acne begins with inadvertent growth of the sebaceous glands. This growth eventually

obstructs the follicle, impairing drainage of sebum and celullar debris. Up to this point, over-

the-counter remedies such as benzoyl peroxide or Retin-A may work to dry up the

pilosebaceous unit and clear up the acne.

However, there comes a point beyond which these agents are ineffective. In the final stage of

acne development, the accumulated sebum becomes colonized and infected with a bacterium

present normally on the skin, Propionibacterium acnes. Eradication of this organism requires

antibiotics. Failure to use antibiotics for most cases of acne explains why acne often fails to

improve on over-the-counter regimens. Antibiotics commonly used are Clindamycin,Tetracycline and Erythromycin, and are available as creams, gels or pills. In more advanced

cases of acne, daily oral antibiotics may be needed for up to six months.

So if you have acne that's not improving on over-the-counter medications, see your doctor for

an antibiotic prescription. You should start with the topical agents (creams and gels), as they

would have fewer side effects than the pills. If the creams and gels fail to clear your skin,

advance to the oral antibiotics.




A Note About Forced-Air Heating

Many homes of newer construction include forced-air heating and cooling systems. Hot or

cold air is blown through ducts that are placed throughout the house. In the winter, these

systems provide efficient, uniform heat delivery. And in the summer, these systems cool the

house quite nicely. However, these systems can also be quite allergenic, and contribute toallergy and sinus symptoms during the winter months. To reduce allergic risk, then, here are

some facts you need to know about forced-air systems.

According to theAmerican Lung Association, about 70% of today's homes have central

heating and cooling systems, and about half of these are not maintained regularly.

Furthermore, these systems typically do not exchange old indoor air for fresh outdoor air;

rather, they continue to recirculate indoor air. If not maintained, indoor pollutants and

allergens build up in the system, overwhelm the filters, and are dispersed into the indoor

environment, triggering allergy symptoms of congestion, runny nose and headache. The tip-

off that this might be an issue for you is if your allergy symptoms occur mainly at night while

you're trying to sleep, and not when you're out of the house.
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To avoid this problem, you need to first change the air filters in the system every two to three

months. Second, the ducts need to be professionally cleaned annually. If these tasks are not

completed diligently, dust, pollen and molds will collect in the system and become dispersed

into your home, contributing to allergy symptoms. A nice review of this is foundhere.

So maintain your central heating and cooling system conscientiously to enjoy clean healthyair in your home, and to reduce allergy symptoms.
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2005 Health Details

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