Healthy Skin

Prevention of skin damage is the first priority for healthy skin. No sun, No smoking, No Aging. Sun is important for Vitamin D. The rule to remember is to put on sun screen if you are going to be exposed for more than 20 minutes. Smoking decreases elasticity to the lungs and skin. That is why smoking causes emphysema and wrinkles. Aging thins the skin and decreases elasticity. Unfortunately, aging cannot be prevented....yet.

A common skin condition is called eczema. It can be related to dry skin and allergies. The treatment involves avoiding skin irritants (perfumes, allergens, etc). Moisturizing is the second key. Hot bathes will dry out skin as will cold wind. Protect against the cold by bundling up in the winter. Take cold or warm bathes and blot dry only. Apply an emolients that will block the moisture in the skin (e.g. Eucerin, Petroleum Jelly, Aquaphor, etc). It is best to put the emolient on like frosting and then cover it with clothing. Cotton gloves can allow you to use your hands while having them covered in creams.

The most common skin cancers are basal cells and squamous cells. These tend to occur on the face. Both are treated fairly easily if caught early and usually aren't fatal. Melanomas on the other hand are almost all fatal. If you think you have a melanoma you should have it checked as soon as possible to increase your chances of survival. I also recommend making sure you have good life insurance before you have a diagnosis. The worrisome signs of melanoma are the following:

• Asymmetry. One half doesn't match the appearance of the other half.
• Border irregularity. The edges are ragged, notched, or blurred.
• Color. The color (pigmentation) is not uniform. Shades of tan, brown, and black are present. Dashes of red, white, and blue add to a mottled appearance.
• Diameter. The size of the mole is greater than 1/4 inch (6 mm), about the size of a pencil eraser. Any growth of a mole should be evaluated.
• Evolution (not shown in the picture). There is a change in the size, shape, symptoms (such as itching or tenderness), surface (especially bleeding), or color of a mole.

Healthy Mouth

First and foremost to a healthy mouth is good oral hygiene. Oral hygiene is maintained by minimizing the damage of plaque. Plaque is the sticky film on the gums and teeth. Bacteria in plaque causes cavities and gum disease. Cavities and gum disease can lead to toothache, abscesses, and tooth loss. Plaque can be prevented by minimizing the sugary foods and drinks that bacteria thrive off of. You should also minimize the amount of acidic foods that you consume that promote cavities such as soda pop and some juices (e.g. orange juice). Rinsing your mouth after eating and preferably brushing can decrease the bacteria/food buildup that causes damage. Baking soda (sodium bicarbonate) has been used historically because it combats the acidity of foods and the acids bacteria produce to cause cavities. Regular flossing is also important to clean plaque between teeth and keep gums healthy. If your gums bleed when you floss you are not flossing often enough.

It is recommended that you see a dentist at least twice a year for tooth cleaning. This often involves scaling, polishing, fluoride, and checking for cavities. If you get a cavity, you should have it filled as soon as possible to prevent it from getting larger. The last thing you want is a root canal, which is usually a last ditch effort to save you from losing a tooth.

Other recommendations include: Cleaning your tongue regularly to decrease the amount of bad breath causing bacteria. The fluoridation of water is known to prevent tooth decay and is considered by the U.S. Centers of Disease Control and Prevention as "one of 10 great public health achievements of the 20th Century. There are critics to water fluoridation but one has to look at the dental hygiene of countries that do not fluorinate to see the benefits (e.g. England). Dental Sealants also have been shown to prevent dental caries. Sealants are a plastic resin that a dentist places on the teeth to protect the enamel. It is usually recommended for children to get sealants once they have their adult molars.

A quick note on canker sores. Canker sores are small ulcers in the mouth that can often be painful. These can be caused by infections (viral), acidic foods, or can be a sign of an underlying medical condition. If you get Canker sore a few times a year this could be a sign of a gluten sensitivity and you may want to be checked for celiac disease.

A quick note on tonsils. Tonsils are disease fighting lymphatic tissue. They serve an important role in fighting infections. It used to be commonplace to have your tonsils and adenoids removed but this is no longer the case. The only reason to have tonsil removed nowadays is for recurrent streptococcal infections or if the tonsils are so large that they cause you to snore and cause sleep apnea.

A quick note on oral cancers. It is relatively uncommon cancer. Anything that causes chronic irritation can increase the risk of oral cancers. However, well known risk factors include: tobacco, alcohol, and the HPV virus (the same virus that causes genital warts and cervical cancer).

A quick note on cold sores. Cold sores are caused by the herpes virus (a different strain from the genital herpes). Once you have this virus you will always have it. Fortunately, the virus will go dormant in the 5th cranial nerve (trigeminal). It will only rear its ugly head when you are under stress and your immune system is weakened. This can be from illness or mental stress. Once you have a cold sore you will shed the virus and can give it to others so be careful (no kissing babies). Otherwise, if you do not have a blister you cannot give it to others.

As always, I am willing to answer any questions you may have as it relates to the mouth.

Heathy Esophagus and Stomach

Healthy Esophagus & Stomach

The stomach begins the process of food digestion through the production of acid. The stomach is designed to handle acid but the esophagus is not. There is a sphincter between the esophagus and stomach that usually prevents the acid from backing up into the esophagus. Irritation of the esophagus can be painful. Chronic irritation places a person a risk for developing a condition called Barrett’s Esophagus, which is a precursor to esophageal cancer. So what causes excessive sphincter relaxation and acid reflux?

First, abdominal obesity or tight fitting clothing can increase stomach pressure and push acid backward into the esophagus. Weight loss can decrease this problem. Esophageal sphincter relaxation can also be caused by smoking, alcohol, caffeine, spicy foods, acidic foods, fatty foods, chocolate, and mints. If reflux is a problem you can take the following measures to prevent esophageal irritation: lose weight, avoid tight-fitting clothes or betls, avoid excessive consumption of foods that relax the sphincter or increase acid production, elevated the head of your bed to use gravity from refluxing all the way up, and the Mayo Clinic has found that relaxation techniques can help as well. Those who have had bariatric surgery and have a smaller stomach are at a higher risk for reflux and have to be more careful about these foods that relax the sphincter. Fortunately, as they loose weight the pressure on the stomach will decrease somewhat.

The stomach can also also get irritated by excessive acid production and cause heartburn (gastritis) or even ulcers. Heartburn can be increased by the following: Helicobacter pylori (bacteria in stomach- see last week's blog), overeating, eating in a hurry, fatty foods (they linger in the stomach longer), acidic foods (vinegar in salad dressing, tomatoes, citrus, etc), caffeinated beverages, carbonated drinks (soda pop), Chocolate, spicy foods, and alcohol. Stress and anxiety can also contribute to heartburn and gastric ulcers.

The stomach should be nice and pink like the muscosa in your mouth. Imagine how your mouth would hurt if it looked like this.

Aspirin and Non-steroidal anti-inflammatories (ibuprofen, aleve, etc) also increase the risk of gastritis and gastric bleeding. Some carry a higher risk than others. If you must take any of these medications long-term you should discuss with your physician how to minimize your risk. You may need to take a proton-pump inhibitor (prilosec, nexium, etc) to decrease acid production. You may be able to switch to a less risky NSAID (sulindac, celebrex).

All of the above foods can increase the risk for stomach cancer because they cause irritation. However, smoked foods, salted fish and meat, pickeled vegetables, and smoking have all been found to be even greater risk factors. The reason for this is because they contain nitrates and nitrites that can be converted by bacteria in the stomach into dangerous compounds that increased the risk for cancer. Many believe that the Japanese and Chinese carry a much higher risk for stomach cancer because of their diets.

Healthy Small Intestine

The small intestine is an often neglected organ despite its average size (16 feet long). The surface area of the small intestine mucosa could cover a tennis court if stretched out. The small intestine has three parts: duodenum, jejunum, ileum. Why is it neglected? Because it never really has too many problems. If there were common diseases associated with it we would talk about it more. For example, it is very rare to develop cancer of the small intestine. It is much more common to develop oral, esophageal, stomach, colon, or rectal cancer. So how do you keep a healthy small intestine? Is there much you need to do?

In reality, there is not much that needs to be done to maintain a healthy small intestine. However, you need to pay attention to this organ and catch the signs that something may be wrong. The small intestine performs the important role of absorbing your nutrients once they have been digested. You need to maintain a healthy mucosa to perform this role.

What can cause the mucosa to be unhealthy?

Helicobacter pylori is a bacteria that causes 90% of the ulcers in the duodenum. Duodenal ulcers can be life-threatening as they can bleed profusely and even perforate. This organism was discovered a little over 10 years ago and was found to cause a significant number of ulcers primarily in the duodenum. Duodenal ulcers cause epigastric pain that radiates to the back. A bleeding ulcer can cause you to have black tarry stools. This ulcer can be caught through a upper GI series (barium swallow), esophagealgastroduodenoscopy (EGD), or a blood test for the bacteria. The treatment is a long course of antibiotics to eradicated the organism.

Celiac disease (celiac sprue) is an autoimmune disorder where the body reacts to the wheat protein gluten. This reaction results in inflammation and the loss of healthy intestinal mucosa. The loss of intestinal mucosa leads to poor absorption of nutrients. The symptoms may include diarrhea, weight loss, poor growth (in children), fatigue, abdominal pain, bloating, irritable bowel syndrome, aphthous ulcers (canker sores), or no symptoms at all. This disorder is becoming more and more common. The diagnosis can be made by a blood test, biopsy, or by elimination diet. Elimination diet is where you cut out all gluten. If your symptoms improve then it is a good possibility that you have the disorder.

Lactose intolerance can be caused by a genetic deficiency of the enzyme (lactase) needed to digest lactose. It can also be caused by damage of the cells that produce the enzyme such as celiac disease. Very rare that it is caused by a true allergy to lactose. It is estimated that 75% of adults have some form of lactose intolerance. It varies by your genetics (5% of northern europeans to 90% of some asians and africans).

Green indicates a low percentage. Red indicates a high percentage. There is a test for this diagnosis but again an elimination diet where you cut out all lactose may be all you need. You don't have to go overboard to do this. There is milk with the enzyme added (lactaid), yogurt has bacterial enzymes that helps digest lactose, cheeses have very little lactose (the harder the cheese the less the lactose).

Dairy product	Lactose Content
Yogurt, plain, low-fat, 240 mL	5 g
Milk, reduced fat, 240 mL	11 g
Swiss cheese, 28 g	1 g
Ice cream, 120 mL	6 g
Cottage cheese, 120 mL	2–3 g

[edit]

Small Bowel Obstruction is usually caused by another problem. It can be caused by the bowels twisting on themselves, by scar tissue from prior surgeries, by masses, or severe infections. People with SBO often present with intractable nausea and vomiting. The treatment is to avoid eating until it either resolves on its own or the problem is repaired.

The key with all of these problems is to listen to your body and to catch the problem early before it becomes a severe problem. Do not ignore nagging symptoms. The second hint is to find a doctor that is willing to listen and work with you as many of these symptoms can be vague and the diagnosis can be difficult. Physicians, like patients, get frustrated when they cannot put a diagnosis to a symptoms. Sometimes the best course is to experiment with an elimination diet to see if it helps before you even go to the doctor. Just don't go overboard and eliminate all nutrition.

Remember don't neglect those "small" bowels and keep em' healthy.

Healthy Colon

The last post was on the rectum so I thought I would work my way backward through the digestive system. The colon or large intestine is the last part of the digestive system and is composed of 4 parts: Ascending colon, Transverse colon, Descending colon, Sigmoid colon.

The colon has 3 major functions. First, it reabsorbs a large amount of water that was used in the digestive process. If food moves too quickly through the colon (irritable bowel, viral infection, etc) the water does not get reabsorbed and the result is watery stool (diarrhea).

The second major function is fat soluble vitamin absorption. In particular, vitamin K is one of the vitamins absorbed by the colon. Vitamin K is obtained through the consumption of leafy green vegetables (spinach, kale, cabbage, broccoli, cauliflower, avocado, kiwi) and from the bacterial flora in the colon that produces the vitamin. Vitamin K is absorbed by the colon and then is used in the liver to produce coagulation factors. If you get cut, a cascade of coagulation factors work to stop the bleeding. If you are deficient in vitamin K you will not produce coagulation factors and you will not stop bleeding. Babies receive a vitamin K shot at birth because they do not have intestinal flora yet and can be deficient in vitamin K and at risk for bleeding. An interesting side note: warfarin (coumadin) a blood thinner (originally a rat poison) "thins" the blood by blocking vitamin K from producing coagulation factors.

The third major function of the colon is to provide a home for bacteria that serve a symbiotic with their host. First, bacteria produce vitamin K as previously discussed. We eat several foods that contain fiber. Our digestive systems cannot digest many forms of fiber but bacteria can. The bacteria feeds off the fiber and in turn produce acetate, propionate, and butyrate which is used by the colon lining for nourishment (can you say kreb cycle?).

So how do we maintain a healthy colon? Most problems in the colon can be resolved by eating a diet high in fiber and fruit and low in meats and carbohydrates. Fiber keeps the bacteria happy as well as the colon lining. It prevents constipation by preventing reabsorption of all the water. It prevents diarrhea by bulking up the stool.

The most common pathologies of the colon are as follows:

Diverticulosis/Diverticulitis: Diets rich in processed carbohydrates and low in fiber result in increased pressures within the colon. This pressure results in small out-pouchings within the lining of the colon wall. These out-pouching can get infected and bleed. It was previously thought that seeds, nuts, and popcorn blocked the openings of these pouches but this has been disproven. The best way to avoid this condition is to avoid diets high in carbohydrates and eat more fiber!

Clostridium Difficile colitis: This can be a life-threatening infection of the colon. It is usually caused by an antibiotic killing off your normal flora allowing a bad bug to take up residence. This organism can be very resistant to antibiotics and difficult to treat. This can be prevented by avoiding frivolous use of antibiotics, good hand washing, and keeping a healthy bowel. There is some evidence that probiotics while taking an antibiotic may help. Some hospitals are worse than others when it comes to transmitting this bug between patients so it wouldn't hurt to know how good your hospital is at preventing these types of infections.

Colon Cancer: There is no reason in this day and age for someone to have colon cancer, let alone die from it. Colon cancer usually starts as a polyp that grows slowly over time into a cancer. If you catch and remove the polyps early you should not get colon cancer. It is recommend that everyone have a colonoscopy at age 50, sooner if you have a family history. A full colonoscopy that is free of polyps will buy you 10 years peace of mind before you need another one.

Irritable Bowel Syndrome: We do not completely understand irritable bowel syndrome. It is recommended generally that you eat fiber and maintain a healthy bowel to prevent problems. Remember fiber helps to prevent constipation and diarrhea. Anxiety and stress can also affect the colon and speed the transit, resulting in diarrhea. Relaxation techniques and reducing stress are important to maintaining a healthy colon and happy stools.

Remember, fiber is your friend. I do not think you can eat too much of it. And it wont make you fat because you can't digest it. Now only if we can make it taste like krispy kremes;)

Healthy Rectum

I spent the last couple months on the heart and thought I needed to move on to a different part of the body. You may laugh at the title but there is no laughing when the rectum is unhealthy. The two major problems associated with the rectum are fissures and hemorrhoids. Both are caused primarily by constipation. Avoid constipation and you will keep your rectum healthy. This can be done by keeping the simple carbohydrates at a minimum (cakes, cookies, candies, white bread, white pasta) and increasing the fiber. The second problem is sitting on the toilet. Many people cherish their time on the toilet for a moment of solace. Many people will use this time to catch up on their reading. The problem with this is the pressure it creates on the rectum. The blood flow is backed up causing venous dilation, resulting in hemorrhoids. My suggestion to people is to get in and get your business done and get out. Get rid of the reading material and do not sit for prolonged periods. If you want a moment of solace, finish the job and put the lid down. It is the sinking into the seat that cuts off the blood flow.

The rectum has many nerve endings which makes it very sensitive. That is why some people like to put foreign bodies in there. I recommend against this of course. If you have problems with burning in the butt or irritation, look at what you could be eating that could be causing the irritation. You may like spicy food as it goes in but it can cause unpleasant burning on its way out. If you are having diarrhea and prone to irritation my suggestion is blot and do not wipe. Excessive wiping can cause irritation, just ask anybody that has had a colonoscopy and had to do a bowel prep beforehand. You could also consider buying a bidet, something I highly recommend ;)

Keep those rectums healthy!

Healthy Exercise

Exercise is generally considered an element of a healthy lifestyle. Lately, research has not only confirmed this but it has also revealed a few less known benefits. There are various forms of exercise and all carry with them their own benefits. Each form of exercise can be categorized into one, two, or all of the below categories:

Flexibility/Yoga

Benefits: Improved flexibility, Improved balance, Mental relaxation

Aerobic

Benefits: Heart strengthening, Lung conditioning, Weight loss, Lower Blood Pressure, Lower Cholesterol (increased good cholesterol-HDL)

Strength Training/Resistance

Benefits: Increased strength, Weight loss, Increased bond density

Diseases and their recommended form of exercise:

Heart Disease/HTN/High Cholesterol: Aerobic exercise results in heart conditioning, lower BP, lower cholesterol

Chronic Lung Disease: Aerobic exercise results in improved lung tolerance and conditioning.

Fibromyalgia/Chronic pain: Yoga improves muscle functioning and decreased pain

Mood Disorders: Exercise improves mood

Old Age: Exercise improves balance and reduces the risk of fall, strength training increases bone density decreasing the risk of osteoporotic fractures, exercise decreases the risk of dementia.

Federal Recommendations:

Aerobic Exercise: 150-300min/wk moderate exercise or 75-150min/wk vigorous exercise. Vigorous exercise is something you can only maintain for 15-20 minutes.

Muscle Strengthening: Twice a week. Moderate to intense level. All major muscle groups

Tips on how to start and maintain an exercise routine:

Choose something you like to do. Make sure it suits you physically, too. For instance, swimming is easier on arthritic joints.

Get a partner. Exercising with a friend or relative can make it more fun.

Vary your routine. You may be less likely to get bored or injured if you change your exercise routine. Walk one day. Bicycle the next. Consider activities like dancing and racquet sports, and even chores like vacuuming or mowing the lawn.

Choose a comfortable time of day. Don't work out too soon after eating or when it's too hot or cold outside. Wait until later in the day if you're too stiff in the morning.

Don't get discouraged. It can take weeks or months before you notice some of the changes from exercise, such as weight loss.

Forget "no pain, no gain." While a little soreness is normal after you first start exercising, pain isn't. Take a break if you hurt or if you are injured.

Make exercise fun. Read, listen to music or watch TV while riding a stationary bicycle, for example. Find fun things to do, like taking a walk through the zoo. Go dancing. Learn how to play a sport you enjoy, such as tennis.

Healthy Weight

Obesity is an epidemic that has brought with it increased prevalence of cardiovascular disease and diabetes. The current benchmark that is used to determine whether someone is obese or not is the Body Mass Index (BMI). The BMI is calculated by taking height and weight into account. The problem with this measurement is that a muscular 250lb 6 foot person will have the same BMI as a non-muscular 250lb 6 foot person. But how many muscular people really care what their BMI is?

BMI	Weight Status
Below 18.5	Underweight
18.5 – 24.9	Normal
25.0 – 29.9	Overweight
30.0 and Above	Obese

How does someone acquire and maintain a healthy weight? The science is simple: burn more calories than you take in. Oftentimes, people will complain to me that they do not eat that much and don’t understand why they cannot lose weight. That is where a food diary may come in handy to identify where the hidden calories are coming from or why someone’s metabolism is so low. An underlying medical condition can be contributing to a slow metabolism, such as hypothyroidism. I often recommend making small changes that can be sustained rather than a complete overhaul that is unsustainable. Consider the following to start:

1) Eat a healthy breakfast: Breakfast is important because it sets your metabolism for the day. Remember your body is a delicate machine that adjusts subconsciously to signals. If you skip breakfast you send the signal to your body that you are starving and then when you eat throughout the rest of the day the body tends to put those extra calories into storage (fat) rather than burn them. By eating a healthy breakfast you are signaling to the body that it is ok to burn those extra calories.

2) Cut out simple carbohydrate beverages: Soda Pop, juices, and alcohol have a lot of simple carbohydrates (sugar). These are a source of a lot of calories because people can throw back several 20oz sodas a day. The reason for this is because simple sugars easily absorbed and spike your blood sugar. Spiking blood sugar gives you a sudden burst of usable energy but this is problematic for three reasons. First, if your body is in starvation mode it sends those calories to storage rather than to burn. So use those drinks before exercise (soda pop is not conducive to exercise). Second, the quicker blood sugar spikes the quicker it crashes. Crashing blood sugar cause you to be hungry again and crave more. Third, repeatedly spiking blood sugar leads to insulin resistance. Insulin resistance eventually turns into diabetes.

3) Exercise at least 30 minutes a day or walk. Exercise not only burns calories but it also ramps up your metabolism. Your body is more likely to burn calories if you are active and less likely to burn calories if you are a couch potato. You don’t have to kill yourself on the treadmill to do this either. It has been shown that if you can walk 13,000-15,000 steps a day you will lose weight. If you cannot exercise, I often recommend wearing a pedometer. A pedometer will count your steps throughout the day. If you reach your goal you can reward yourself by relaxing and watching tv at the end of the day. If you haven’t reached your goal, you go for a walk.

4) Change your evening routine: Evenings tend to be a weak time of day when people tend to snack more. You can be good all day long and ruin it with a few treats in the evening. Remember, food is a source of energy to do work. If you are going to go to sleep soon there is no point in eating. It is best to eat a dinner with protein and complex carbohydrates so you do not have a spike of blood sugar and subsequent crash that brings cravings. Avoid simple carbohydrates (sugary drinks, white breads, white pasta, desserts). Your current routine has not worked for you up until now and so making a few simple changes can make a big difference. If you haven’t met your walking goal, go for a walk. Keep yourself busy so you are distracted and less likely to graze in the kitchen.

Once you have met these goals you will find it easier to lose weight. You may still reach plateaus and this is just the body resisting change. The body likes to maintain homeostasis and will resist weight loss. You have to persist and the body will find a new homeostasis. Building muscle mass will help with this. The more muscle you have the more calories you will burn at once. That is why you see them focus so much on resistance/strength training during the Biggest Loser. This is also why men tend to lose weight easier than women Stay tuned for the blog focused solely on exercise.

Healthy Cholesterol

High blood pressure and elevated cholesterol were among the first known risk factors for cardiovascular disease. When you have your cholesterol checked it is reported in at least 4 categories:

Triglycerides: Goal <200

Total Cholesterol: Goal <200

LDL (bad cholesterol): Goal <120 [<70>

HDL (good cholesterol): Goal >60

Triglycerides

Triglycerides are often elevated by diets high in simple sugars (cakes, cookies, and candies) as well as simple carbohydrates (breads, pastas, cereals). It is also often elevated in those with low thyroid levels. Triglycerides are lowered by avoiding simple sugars and simple carbohydrates. Fish has also been found to lower triglycerides and that is why fish oil (omega 3) is often recommended as a supplement.

LDL

Bad cholesterol is often elevated by diets high in saturated fat (animal fat) and trans fats. Saturated fats are found in animal fats and diary fat. Trans fats are found in 4% of animal fats, up to 15% of margarines fats, 30% of shortening fats, and 45% in artificially hydrogenated fats. There has been a huge push by the public interest groups to decrease the production of oils with artificial trans fats because of their significant risks. The FDA has also required companies to label the content of trans fats. That is why you have noticed a change in the taste of KFC, McDonald’s French fries, and Oreos.

HDL

This is actually a protective type of cholesterol and the higher it is the better. It is lowered by a poor diet as explained above. The biggest factor found to raise HDL is regular exercise.

The Mediterranean Diet has been described as the best diet to lower cholesterol. This diet is composed of fresh vegetables, no processed or fried foods, fish (not much meat), and olive oil. Unfortunately, diet alone is not the only factor that can cause high cholesterol as genetics can often play a significant role.

There are a few categories of medications that can lower cholesterol but most of them have not been proven to decrease mortality. Statins are one of the few medications that have been proven to do this. It is believed that statins may protect the heart by some other mechanism than lowering cholesterol. Some have suggested that it may stabilize plaques so they are less likely to break off and cause a heart attack or stroke. In fact, going off a statin can be risky as it may cause plaques to become unstable. Unfortunately, statins are not without their risks or side effects.

If you want to avoid a prescription medication, the following supplements have been proven to be effective: fish oil, niacin, and red yeast rice. In fact, red yeast rice functions almost exactly like a statin. All of these supplements have their own risks and side effects as well and so you should discuss with your doctor which medication would benefit you most. Different supplements and medications will target different cholesterol categories and so your cholesterol profile may determine which medications would work best for you.

Healthy Blood Pressure

High Blood Pressure is a big risk factor for cardiovascular disease. High blood pressure not only leads to coronary vessel damage but it affects all small blood vessels (microvascular) and capillaries. Hence, high blood pressure is a risk factor for strokes, heart attacks, kidney failure, etc.. The reason why blood pressure damages small blood vessels is twofold. First, Bernoulli’s principle states that as the diameter of a vessel decreases the velocity of the liquid within the vessel increases. This increase in velocity causes more damage to the lining of the blood vessel because of the second reason; Second, end organs tend to have capillaries that branch off at 90 degree angles which leaves the vessels walls open to repeated damage and thickening. Over time, the repeated damage and thickening leads to plaque formation and decreased blood flow to the organ and subsequently higher blood pressure. If that plaque happens to break away it will completely block the blood vessel and cause an infarct (stroke, heart attack, etc).

So what is a healthy blood pressure? The committee that reviews the various studies on blood pressure and makes the recommendations for physicians to use is known as the JNC (Joint National Committee on the Evaluation and Treatment of Blood Pressure). Their last report (7^th) came out in December 2003. The 8^th report is due out in March of this year. For the average adult the recommended blood pressure is under 140/90. If you have heart disease or diabetes it is recommended to keep blood pressure below 130/80. In fact, the lower the blood pressure, the better as long as it is not too low. It is best to check your blood pressure throughout your normal daily activities and not just at the doctor’s office because the anxiety of the doctor’s office can raise your blood pressure. Caffeine can raise your blood pressure for up to 2 hours while smoking can raise your blood pressure for up to 30 minutes.

How do you lower your blood pressure? Smoking, Caffeine, and stress can all raise blood pressure but not long term unless you are smoking and drinking all day long which some people do. Salt (Sodium) is the big problem most people face with our western diet. Sodium is everywhere! Sodium makes you retain fluid and hence raise your blood pressure. This can be so drastic that if a person with heart failure has a large sodium rich meal (cured ham, brined turkey, Chinese food, Brats with Saurkraut etc) they can put themselves into fluid overload and respiratory failure from fluid filling up in their lungs.

If you have high blood pressure; you can lower your risk for stroke by 20% and heart attack by up to 50% by decreasing your pressure by 10 millimeters of mercury (e.g. 140/90 systolic to 130/80 systolic). The DASH diet is a low sodium diet that you can follow. Exercise temporarily raises blood pressure but long term lowers blood pressure. Relaxation lowers blood pressure as well. If you can’t lower your blood pressure with the above measures, medications may be necessary.

I am more than happy to answer any specific questions you may have on medications. In general thiazides and calcium channel blockers are considered first line agents. However, there may be a compelling indication for another medication. Every medication has its pros and cons, side effects, contraindications, etc. Genetics and race may even play a role in how well your respond to a specific medication. It is best to discuss with your physician which medication is best and most affordable. Fortunately, almost every class of blood pressure medication can be found on the $4 dollar formulary at your local pharmacy.

Heart Health

As cardiovascular disease is the number one cause of death and illness, the heart is probably the most important muscle/organ in the body. The heart serves the role of delivering oxygenated blood to the brain, vital organs, and muscles of the body. The risk of heart disease becomes more of a problem between the ages of 40-60. The heart like the other muscles of the body starts to malfunction because of a poor blood supply (atherosclerosis). In fact, a heart attack is caused by a blockage of a coronary artery that leads to muscle death and potential arrhythmias or sudden cardiac death. The heart is preserved by placing a stent in the blocked vessel or replacing it with a venous graft (CABG- coronary artery bypass graft). The goal of heart health is to prevent the blockage in the first place. So what are the risk factors for coronary vascular disease (CVD)?

In 1948, the National Heart Institute started a landmark study in Framingham, Massachusetts. 5,209 men and women between the ages 30 and 62 were followed every 2 years to identify those who died of heart attacks and the associated risks factors. In 1971, a second generation of 5,124 patients were enrolled. In 2002, the third generation was enrolled and is currently being followed. A couple other diverse groups have also been enrolled in 1994 and 2004. Below are the major findings of the study so far...

1960 Cigarette smoking found to increase the risk of heart disease

1961 Cholesterol level, blood pressure, and electrocardiogram abnormalities found to increase the risk of heart disease

1967 Physical activity found to reduce the risk of heart disease and obesity to increase the risk of heart disease

1970 High blood pressure found to increase the risk of stroke

1976 Menopause found to increase the risk of heart disease

1978 Psychosocial factors found to affect heart disease

1988 High levels of HDL cholesterol found to reduce risk of death

1994 Enlarged left ventricle (one of two lower chamber of the heart) shown to increase the risk of stroke

1996 Progression from hypertension to heart failure described

1998 Development of simple coronary disease prediction algorithm involving risk factor categories to allow physicians to predict multivariate coronary heart disease risk in patients without overt CHD

1999 Lifetime risk at age 40 years of developing coronary heart disease is one in two for men and one in three for women

2001 High-normal blood pressure is associated with an increased risk of cardiovascular disease, emphasizing the need to determine whether lowering high-normal blood pressure can reduce the risk of cardiovascular disease.

2002 Lifetime risk of developing high blood pressure in middle-aged adults is 9 in 10.

2002 Obesity is a risk factor for heart failure.

2004 Serum aldosterone levels predict future risk of hypertension in non-hypertensive individuals.

2005 Lifetime risk of becoming overweight exceeds 70 percent, that for obesity approximates 1 in 2.

2006 The National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health announces a new genome-wide association study at the Framingham Heart Study in collaboration with Boston University School of Medicine to be known as the SHARe project (SNP Health Association Resource).

Over the next several weeks, I will discuss the following risk factors of cardiovascular disease: Hypertension (high blood pressure), Hyperlipidemia (high cholesterol), inactivity, and obesity. Stay Tuned!

Muscle Health

Most people don’t realize how important muscle health is until they reach their 40’s to 60’s. As we age blood flow to our muscles decreases and that is why cardiovascular disease is the leading cause of death. This post, however, is not about heart health. I would like to address the skeletal muscles of the body. Skeletal muscles suffer from poor blood flow as we age and that is why stiffness becomes more of a problem as we get older, particularly after we have been sedentary for some time. Have you ever been stiff in the morning?

Blood flow is important for bringing oxygen to the muscles. Oxygen is required to couple muscle fibers to cause contraction. If this is true you would think decreased blood flow would mean less oxygen which means less ATP and less contraction (stiffness). Well oxygen and ATP are needed even more to uncouple muscle fibers and relax. Let me illustrate it this way…when we die, oxygen no longer reaches the muscles. This leads to decreased ATP in the muscle which causes a release of stored ATP in what is called the sarcoplasm reticulum. This ATP causes coupling of the muscle fibers that are no longer moving. Hence rigor mortis sets in within 3 hours of death and maximizes by 12 hours. So essentially the stiffness that comes with old age is caused by decreased blood flow and inactivity. Rigor mortis actually starts setting in to some degree before we actually die.

How do we prevent rigor mortis from setting in too soon? The formula is simple: improve blood flow to the muscles and keep active. Both of these can be achieved through stretching. Have your ever seen an animal stretch after a period of inactivity? They are increasing blood flow to their muscles just in case they need to sprint, but they are also preventing stiffness. Unfortunately, in our western society we look at retirement as a time to sit back in our recliner and relax. This just speeds up the process of rigor mortis. If you look at eastern societies they spend their retirement in the park doing Tai Chi and keep active.

Not only will stretching prevent stiffness but it can also prevent pain. Myofascial pain and fibromyalgia are becoming more prevalent as well as better understood. Myofascial pain is essentially bands of tightened muscles that are stuck in contraction because of poor blood/oxygen supply. Not only are muscles stiff but they can cause a significant amount of pain. Stretching alone may not be sufficient. Aggressive therapy to break up the bands of muscles may be required to improve the blood flow. This can be achieved through (physical therapy, rolfing, deep tissue massage, trigger point injections, acupuncture). I often recommend that patients get a tennis ball that they get wet and freeze. Then use this ball to work into the tissue. This may be painful at first but will do the job. I also recommend all my fibromyalgia patients and chronic low back pain patients to look into yoga which has been shown in multiple studies to decrease pain.

When I mention Yoga. Many people think of the above picture. I have to explain to them that there are several forms of Yoga. The idea is to improve muscle health through stretching and relaxation both of which can be accomplished by Yoga. This has to become a habit in order to be effective. Rigor mortis does not take a day off, nor should you.

Healthy Sleep

"Early to bed early to rise makes a man healthy, wealthy, and wise..."

-Benjamin Franklin

There is a large body of research going on in the field of sleep and sleep disorders because we are realizing how important good restorative sleep is but we don’t understand how to induce this type of sleep. Sleep disorders are becoming more and more prevalent as are the consequences of poor sleep: obesity, depression and other mood disorders, and chronic pain.

Restorative sleep is important for healing, memory, and mood. Unfortunately, not all sleep is equal. People can go for years sleeping several hours a day without getting much restorative sleep which can lead to the above dire consequences. I have several patients that realize they are not sleeping well and will come to me for help. Thanks to pharmaceutical commercials people are convinced that they need a sleep aid. I have to explain to them that a sleep aid may help you fall asleep but it does not guarantee deep restorative sleep. So what is the key to deep restorative sleep? The best we can suggest is good sleep hygiene.

What is sleep hygiene? The best way to explain this is to illustrate how the body functions. We have a circadian rhythm that is dependent on many environmental factors that allows us to go through sleep and awake cycles. Several hormones are involved in this process, including melatonin and cortisol. Bad habits have wrecked havoc on our circadian rhythm such as: excessive sleep and napping, no sleep schedule, alcohol and caffeine, staying up late watching TV… The key to good sleep is the return balance to the circadian rhythm through good sleep hygiene. Consider the body a machine that requires the right signals and send the right signals that it is time to sleep. Eating just before bed sends the signal “here is energy because we are going to do something.” The body gets confused when you then try to sleep. The following are some suggestions on how to return order and send the right signals. .

Personal Habits

• Fix a bedtime and an awakening time dependent on your age
• Avoid napping during the day (nap=>30 min)
• Avoid alcohol (at least 4-6 hours before bed)
• Avoid caffeine (at least 4-6 hours before bed)
• Avoid heavy, spicy, or sugary foods 4-6 hours before bed
• Exercise regularly (not within 2 hours of bed)

Sleep Environment

• Use comfortable bedding
• Comfortable temperature (cold is best)
• Block out noise and light
• Use bed for sleep and sex only (remember we need to signal the right messages to our body)

Getting Ready For Bed

• Have a routine
• Practice relaxation techniques
• Clear mind of worries (prayer)

If you have tried these techniques and cannot restore order there may be a medical problem that needs to be addresses such as an enlarged prostate that makes you get up several times a night to go to the bathroom, sleep apnea, pain, acid reflux, hot flashes…

It is my goal this week to establish a sleep time and routine, practice relaxation techniques, and pray every night. I suspect that I may have some sleep apnea; which I hope improves with weight loss. I may have to get this checked out.