How Low Should My Blood Pressure Be?

Recently, news outlets reported on a recent medical study (the so-called SPRINT trial) suggesting a goal blood pressure of under 120/80.

While not a bad idea, the question of just what is a good blood pressure is a bit more nuanced.

The first, higher pressure is the systolic blood pressure (SBP).  This is the pressure in your arteries when your heart is actually pumping.  The second, lower number is the diastolic blood pressure (DBP).  This is the "standing pressure" when your heart is filling with blood.

Generally, a high SBP can cause problems involving larger arteries: cardiac arrest, heart attack and stroke.  A high DBP (even if the SBP is okay) can cause problem involving smaller arteries: retinal problems, kidney disease, circulation problems to the feet.  Also, elevated blood pressure is associated with erectile dysfunction and Alzheimer's disease.

The goal of treating blood pressure is to reduce the risk of any of these things from happening to you, while also avoiding negative consequences of treatment or over-treatment.  Something the recent SPRINT trial noted was fewer heart attacks with blood pressures of 120/80 compared to 140/90.  However, there was also a significant occurrence at blood pressures of 120/80 or less of side-effects of blood pressure drugs such as abnormal electrolyte levels, abnormal kidney function, dizziness and fainting.

Medical studies that look more closely at both upside and downside risks are referred to by doctors as the Eighth Joint National Committee (JNC 8).

Goal blood pressure in patients 60 years old or older is 150/90 or less.  In patients with diabetes or chronic kidney disease, the goal is 140/90 or less.  Mind, if you are on medication and your blood pressure is 120/80 and you are not having any problems with it that's okay.  We simply are careful to avoid over-treating blood pressure as well as under-treating it.

Also, this should not detract from methods of lowering your blood pressure that don't involve medications: smoking cessation, weight loss, exercise and avoiding salty foods!

Treating and Preventing Constipation

Constipation occurs when your bowel movements (BM's) tend to be hard, dry, pebbly and require straining.  Sometimes, if the blockage is large enough, the only bowel contents that can make it around the blockage have to be liquidy.  This appearance of constipation plus diarrhea is called obstipation.  If this is the case, do not use medicines that treat diarrhea because they make the underlying constipation even worse!

Normally, your food is broken up by your stomach.  Nutrients are digested and absorbed by the small intestine.  The large bowel, or colon, serves to reabsorb water and important electrolytes such as sodium and potassium.  What's left by this point is mostly indigestible fibers from fruits and vegetables (also known as roughage or dietary fiber) and also bacteria from your bowels.  This fecal material is stored in the rectum which is at the very end of the colon.  When the rectum becomes full and stretched out, you feel the urge to go to the bathroom to have a BM.

If you do not eat enough roughage, then feces will stay in your rectum for longer than usual and become dehydrated.  This is how constipation is caused, and why the constipated BM's are dry, hard and pebbled looking.

Preventing constipation is mainly through eating enough fruits and vegetables to have normal, daily, formed BM's.  Eating more fruits and vegetables also helps to lower your risk of heart attack, stroke, diabetes, obesity and colon cancer.

On the other hand, folks who are long-standing "meat and potatoes" types can develop constipation to the point where their rectums no longer even feel fullness and they don't feel a need to go to the bathroom until they haven't had a BM for days. At this point they may even become dependent on fairly powerful laxatives or enemas to be able to have a BM at all.

Please note; it's the chronic constipation that results in a need for medications.  Laxatives and the like are not "addictive" in the strict sense.

At this point, over-the-counter (OTC) medications are available to help to establish a more normal and healthy pattern of BM's. There are a lot of them, so it helps to understand how they work so you can use them effectively.

First, add more fiber. Using Metamucil, Citrucel, flax seeds or bran every day can help to have more normal BM's.

Also, keep your BM's soft by using a daily stool softener such as DSS, or Colace.

It is also OK to use a plant-based mild stimulant (a cathartic) such as Senakot once or twice a day to be able to have daily soft BM's.

If you are using fiber, a stool softener and a cathartic once or twice every day and still have not had a BM in 2-3 days, then you should use a series of increasingly strong laxatives to help clear the blockage.  Try these one at a time a half day apart, to allow each one a chance to work:

1. Milk of Magnesia, 30 cc/1 fluid ounce
2. Magnesium Citrate
3. Dulcolax suppository

Not Too Late For a Flu Shot!

This year's flu is pretty nasty; there have been two deaths from it in California in the past 2-3 weeks.  The good news is that about 90% of the flu that we're seeing is prevented by this year's flu shot. These are still widely available at pharmacies and big-box retailers, so don't think it's too late to get one!

The Statins

"Statin" is shorthand for a class or type of medications that have been around since the late 1980's, which my daughter reminds me was a really long time ago.  It happens that their generic, chemical names all end in statin: pravastatin, lovastatin, simvastatin, atorvastatin, Brand-Xostatin... Hence, the name statins.

They were originally developed from naturally occurring chemicals, and only more recently (the mid-90's) synthetically created (Lipitor and Crestor).  Taking them reduces the production by your liver of LDL, or so-called "bad cholesterol".  The newer synthetic ones also reduce triglyceride production and increase HDL or "good cholesterol" production.

Perhaps more importantly, they turn out to have an unintended by benefical effect on reducing inflammation around cholesterol plaques and the blood vessel lining around them (the endothelium).  Lowering LDL production reduces the formation or enlargement of cholesterol plaques.  Raising HDL's actually reduces the number of cholesterol plaques in your arteries.  The statin-induced decrease in inflammation prevents cholesterol plaques from rupturing and actually causing heart attacks or strokes.

On average, you can lower LDL's through diet improvement by 7-14%, and raise HDL's through aerobic exercise by 2-3%.  I have certainly seen some patients do way better, but it's safe to say they added motivation to a lifestyle where there was lots of room for improvement.  Overall, this means most of the problems with cholesterol levels are genetic and tough to control.

As mentioned in the previous posts not everyone needs to be on a statin, and statins are not a substitute for a diet of modest amounts of meat, whole grain carbs, and plenty of fruits and vegetables and also putting in 150 minutes of cardio a week.

At the same time, there are a lot of myths and misunderstandings about statins.  I have already explained how statins work. The rest of this posting is to address what they can do for you, and their side effects (both real and putative).

Downsides:

• Can they hurt your liver? No.  This has been shown several times over the years.  Why do warnings still appear on the materials you get with the medications? Warnings are never removed.
• Can they cause severe muscle damage? Yes, but it's rare at well under 2% of the time.  (By comparison, your odds of "dying on the table" during a routine surgery is also less than 2%.) One study demonstrated occurence at a rate between 8-25 times in 10,000,000. That's mighty rare.
• Can they cause obnoxious muscle or joint pains that go away when you stop taking the statin? No?  We can't tell.  When you take a few thousand people and give half of them a statin and the other half a placebo (in which none know for sure which they are getting), 8-9% of the people on statin report this side-effect.  Thing is, exactly 8-9% of the people on the placebo report the side-effect, too.  So, either this is a side-effect that occurs in 8-9% of people, or in none.  It does demonstrate the "nocebo" effect: people are likely to experience a side-effect if they expect to.
• Otherwise, the most common side-effect is excessive flatulence (farting more than usual).  This may occur as frequently as 15% of the time, though I've never had a patient (or their spouse) comment on it. Hmm....

Upsides:

• Reduce your risk of ever having a cardiac arrest, heart attack, or stoke by nearly half.
• Also, reduce risk of Alzheimer's disease and colon cancer. (Technically these are side-effects, but we like them.)

The upshot?  Is it possible to have side-effects to a statin? Yes. Everything is possible.  However, the benefit significantly outweighs the down side. Risk of bad stuff: no higher than 8%, probably less. Risk of good stuff: 40-50%. 

Frankly, I don't prescribe medications lightly. Statins don't replace healthy eating and exercise, and not smoking.  But if you need one, taking one is a safe and effective way to prevent heart attacks and strokes.

More on the subject of Healthy, Balanced Diet

There has been a lot in the news about healthy diets, especially about trans fats and processed or red meats.  This is relevant to the earlier post on cholesterols.

It turns out that eating foods that are high in cholesterol doesn't necessarily translate to high cholesterol levels.  For example, eating eggs turns out to be a very high-quality source of protein that is relatively inexpensive and widely available and doesn't affect cholesterol levels. (Yes, we were wrong about that.  I think there was even a Simpsons episode on that...)  What's probably more the issue is the use of trans fats in mass-produced foods that increases risk of heart attacks and strokes.  So yes; it turns out eating butter instead of margarine is not only better tasting it's also healthier.  Just bear in mind that the reason Paula Dean is diabetic is not because she cooks with butter, it's because she cooks with a lot of butter which is a lot of calories.

The announcement by the World Health Organization last week that processed meats (smoked, pickled, salted or otherwise preserved in ways that were used before refrigeration) can cause colon cancer, and that red meats may also do so has been known for about 40 years.  If you want to stop eating them in favor of fish and chicken, or want to eat a completely vegan diet that's fine.  If you want to simply eat less red meat and more whole grains, fruits and vegetables that's also fine.  Like eating eggs, or butter the amount is key.  It doesn't have to be all or nothing; balance is the important part; just like the rest of life : ).

As an addendum for  hunters: venison, elk and boar are red meats.  However, by comparison to beef and pork they are much leaner and lower in carbs, and thus are generally healthier.  (Native Americans didn't get diabetes until after they were forced onto reservations.)  Do remember that "mad cow disease" or Bovine Spongiform Encephalopathy has been found in elk.  Stay away from the brain and spinal cord, or better yet have your elk professionally butchered.

A New Look at Cholesterol

Doctors actually have real interest in knowing whether or not what we are doing works.

For example, we know that managing your cholesterol reduces your odds of cardiac arrest, heart attack and stroke.  We know this based on a scientific understanding of cholesterol, and also by the fact that we have reduced the occurrence of heart attack and stroke by about half over the past 20 years, which is pretty fantastic.  We treat heart attack and stroke more effectively than in the past, but it's certainly better to just not have one at all!

Also, we know that diet has a  part to play in helping with your cholesterol and have been making recommendations about diet and not just medications for years.

On the other hand, when we re-examine things  and come up with better or different ideas we look closely at these ideas and then come to a consensus as to what to do with the new information.  This would be called science.

In that vein (no pun intended, here), two things within the last year or two have come to light and have become widely accepted about cholesterols.  One has to do with when to use drugs for high cholesterol, and the other is about diet.

Since the 1990's we have seen that cholesterol lowering through dietary modification, the use of prescription drugs (the so-called 'statins) or both results in preventing cardiac arrests, heart attacks and strokes.

The role of statins has been around your LDL (low-density lipoproteins; the so-called "bad cholesterol"). Specifically, we have seen that you are at 40-44% lower risk of a heart attack or stroke if your LDL is less than 160, under 130 if you also smoke or have high blood pressure, under 100 if you have diabetes, and under 70 if you have already had a heart attack and we are trying to prevent a second one.

The American Heart Association and the American College of Cardiology (a professional organization of U.S. heart specialists) periodically examine efforts to prevent heart attacks and strokes; in other words, is what we're doing working, and can we do better?

Towards the end of 2013, they recommended a really sweeping change in how doctors should use statins (a widely used type of cholesterol lowering medicine since the 1980's). They basically took how we already know statins work to prevent heart attacks and strokes and applied them to already existing ways to determine a person's risk of actually having one over the next ten years in an effort to figure out whether a patient would actually benefit from being on a statin at all, and if so what kind and how much.

These recommendations were widely debated, re-tested and verified, and the bottom line is that they are regarded as valid and beneficial and over the past half a year or so are being put into practice.

So instead of looking purely at a static LDL level, we now use age, gender, blood pressure, your cholesterol results and whether or not you smoke or take blood pressure pills to calculate your risk of having a heart attack or stroke in the next ten years.

If this risk is under 5%, there is no need of using a statin as you are already at low risk and adding a statin isn't going to improve on this.  At 5-7.5%, a statin dose sufficient to lower cholesterol by about 25% would reduce risk to less than 5%.  At over 7.5%, that's quite high and using a statin capable of lowering cholesterol by about 50% would also cut your heart attack or stroke risk by half.

This is not to take away from the value of eating a healthy balanced diet, exercising regularly and not smoking.  It is also not a way to put more people on statins.  In fact, this new way of looking at cholesterol test results plus personalized information reduces the overall number of folks needing statins.  In other words, the idea is not to use more statins, it's to use them smarter.

All you need to calculate your own risk is your systolic blood pressure (the first, higher number) and your lab results.  Feel free to check it out using the above link, or this free iPhone app from the American College of Cardiology (I'm sure there's an Android version, too).   There's a lot of information in the app and in plain English.  It also is interesting to tweak the numbers a bit to see how much lower your risk would be if you lowered you blood pressure or stopped smoking!

Changes in How Obesity is Treated

The medical treatment of obesity has fundamentally changed within the last two years.  Some of this is due to ongoing research on the underlying physiologic mechanisms of obesity, which we hope will lead to effective and targeted treatment options.

Additionally, obesity is accepted as a complex life-long condition warranting life-long treatment options.

Some things are fundamental.

Make realistic goals.  Trying to lose 30% of your total body weight is very unlikely to happen without surgical treatment.

Losing  5-7% of your weight over three to six months by diet and exercise is considered great, and reduces blood sugar, blood pressure, snoring, arthritic pain, acid reflux and urinary incontinence.

Using medication and lifestyle change; losing 10-15% is great and over 15% is excellent.

150 minutes of exercise a week is a reasonable goal, and so is reducing how much you eat to result in about a pound a week of weight loss is generally sustainable for longer periods of time.  If you are counting calories, this is going to generally be 1200 calories a day or more.  Certainly, if you are not losing weight on a diet of 1200 calories a day or less you may not be recording them accurately and should reduce portions by half and see if this solves the problem. 

Admittedly, more benefit is to be gained by eating less than by exercising more (a can of soft drink has about 200 calories; running a mile burns off about 100 calories. Ouch.).  So if you have a lot of back or knee pain and exercise is limited, make the most of reducing how much you eat.

In the past few years, a number of prescription medicines have come out that can help you to lose about 5-10 of your total weight.  Furthermore, they are safe to use long-term.  This is quite different from phentermine and others which may not be safe to use for more than a few months.

Contrave, Qsymia, Belviq and Xenical all are found to be safe and effective in long-term weight loss and weight loss maintenance. They each work differently, and can be switched if using one along with diet and exercise is not resulting in at least a 5% weight loss over 3 months.  Also, they have different possible side-effects and safety profiles so by all means, research them thoroughly to make sure that a medication you are interested is safe for you to use.

So far, insurances are willing to cover surgery, but not pills. Go figure.  Look over your formulary carefully as far as not only cost tier but also authorization requirements for coverage.

For the most part, you are probably going to be paying cash straight up on these medicines.  Happily, goodrx is a really useful website (and also a free smartphone app) that allows you to find the best prices close to where you live.

Please feel free to ask about losing weight whether you are interested in using prescription medication or not!

California's Physician-Assisted Suicide Law

As of last Friday's signing by Governor Brown, California becomes the fifth state in which physician assisted suicide is legal, which affects 1 out of every 6 Americans.

Note that this is not euthanasia: doctors will not be giving lethal injections to people.  Rather, this law will allow terminally ill patients to ask for a prescription for medication they could take if they wished to die in a manner of their own choosing.

Similar to other states,

• a patient would have to request such a prescription twice, at least 15 days apart
• the requests have to be verbal and also must include a written request 
• the patient must be a consenting adult
• the patient would have to be agreed on by two different doctors to be terminally ill with six months to live (similar to the criteria for hospice care)
• the doctor cannot administer the medication; the patient must do so.

Oregon was the first state to pass such a law in October 1997.  Looking back over the last eighteen years of Oregon's experience, several things can be seen:

• since 1997, 752 people have died through lethal prescriptions at their request; 72 of these deaths were last year.  This comprised 0.22% of all deaths in Oregon last year (22 out of every 10,000 deaths).
•  1,173 prescriptions were written since 1997 and  752 (64%) were used.  It may be that for many patients, the prescription serves as an assurance that they will not have to suffer a horribly painful death.
• Oregon doctors wrote lethal prescriptions for only one out of every six patients who requested them.  Patients with untreated depression and patients indicating that they felt they were a burden to others were unlikely to be given a prescription.
• 53% of patients who requested lethal prescriptions were college-educated with at least a 4-year degree, and 97% had health insurance.  This argues against the notion that physician-assisted suicide laws are used to cull poor or under-educated patients.
• 85% of patients were already enrolled in hospice services; lethal prescriptions are an addition to hospice, and not so much a replacement for it.

My earlier postings on this matter make my position clear.  I do not feel this law will be abused and it will not be a mechanism for euthanizing elderly or disabled people.  Rather, it will allow dying patients an option to be able to die comfortably in a time and manner of their own choosing if and only if they should wish to do so.  My experience tells me that we do not so much fear dying as we fear dying in miserable pain and alone.

The law for California is likely to take effect some time later in 2016.

Are heartburn/reflux medicines safe?

Stanford widely publicized a literal data-mining result on their patients suggesting a link between proton-pump inhibitors (PPI's) and heart disease.  While data mining may (or may not) be effective for Amazon in trying to suggest other things you might like to buy, it may not lend itself so readily to the practice of medicine.

PPI's (such as Prilosec, Prevacid and Nexium) are medicines that suppress stomach acid production and are effective in treating hearburn/reflux/GERD, curing ulcers and preventing esophageal cancer in patients with a pre-cancerous inflammation of the esophagus called Barrett's esophagitis.  Prilosec was the hot new thing back in about 1989. Fast forward to the present and there are about half a dozen drugs like it and several are over the counter.

Stanford reported that patients on PPI's had a greater-than-random occurrence of heart disease.  While concerning, this data-mining did not stratify patients or look at their overall health.  For example, people who smoke, drink or are obese are more likely to have reflux.  They are also more likely to have other metabolic problems such as diabetes, and are more at risk for heart disease in the first place.  It would be much more interesting and useful to group patients by pre-existing health conditions putting them at risk for heart disease and see whether there is still a real correlation with PPI's and heart disease once that is taken into account.

Perhaps this will be done.  Until then, the PPI's are not proven across all comers to be related to (let alone actually cause) heart disease. 

If you prefer to err on the side of caution, a previous class of acid reducers called H2 blockers (Tagamet, Zantac, Pepcid and Axid- all over the counter) can help to relieve GERD symptoms and are not being related to heart disease.  You can simply try switching to one of these to see if it works as well for you.  Do NOT do this if you have already failed H2 blockers or are treating pre-cancerous Barrett's.

Treating your allergies

If you feel like your allergies are getting worse, or never had them before, you're not alone.  The climate has been changing and the allergy season is getting longer and longer.  Remember when "Spring" started in April or May, and not in January or February?  Remember when there was often skiing on Mothers' Day weekend? (Remember when there was skiing?)  This area has always had a lot of irritants in the air from wind-pollinated trees and grasses and also smog from down the hill; but the weather warming so much earlier sure isn't helping!

All the once-a-day anti-histamines for allergy are over-the-counter. As a rule of thumb, the better a pill works for allergies, the more potential there is for the pill to make you feel drowsy.  Zyrtec is the strongest, and Allegra is the weakest.  Claritin is a good "work-horse" anti-histamine; strong enough to work for most people, but usually doesn't cause drowsiness.  These can be used every day, or just as needed.

Flonase went over-the-counter about 4-5 weeks ago, and this is great news.  It is easy to use, doesn't irritate your nose when you use it and the amount of medication getting into your circulation is so low it doesn't cause long-term side-effects.  Most people with allergies find that it works better than pills, though you can use both if this works better for you.  Flonase is not "addictive", does not elevate blood pressure and should not be confused with decongestant sprays like Afrin or Neo-Synephrine.

The only difference between Flonase and anti-histamine pills is that Flonase has to be taken every day during the allergy season to work.  However, if this makes the allergy season manageable for you this is not a problem!

Allergies: what are they FOR?

I have wondered what on earth allergies are for: can there be some underlying benefit?

This essay in Mosaic Science proposes a new theory (it's your bodies way of getting rid of toxic or noxious substances) in comparison to the prevailing theory (it originates in the way your body fights off infectious parasites such as ticks and worms).

I'm not sure I totally agree with the new theory, though I think it raises some good ideas.  Frankly, I was never wholly convinced by the prevailing theory anyway...

On Death With Dignity

The widely publicized physician-assisted death of Brittany Maynard has resulted in California reconsidering legislation that would permit physician-assisted death in this state.

Ms. Maynard was a 29 year old graduate student who had recently married before being diagnosed with inoperable brain cancer.  As her pain and seizures worsened, she moved from California to Oregon to be able to legally be prescribed medication to use for her death.  She took the medication after a last walk in the woods with her family and friends, and died painlessly and peacefully (and legally) half an hour later.

Oregon, Washington and Vermont legally allow physician-assisted death; New Mexico and Montana have court rulings that allow the practice.

Oregon legalized this practice first, 17 years ago.  This is not a quick or simple procedure.  In order to legally be prescribed a lethal dose of medication,

• You have to be at least 18 years old,
• you have to be diagnosed with a fatal illness,
• your must be felt to have less than 6 months to live,
• you must be able to take the medication yourself,
• you have to have the mental capacity to understand the diagnosis,
• you must make the choice freely and without coercion,
• the fatal illness must be agreed upon by two physicians,
• psychiatric evaluation must be obtained if mental competency is in question,
• two oral requests must be made at least 10 days apart,
• a written request must also be made, and signed by two witnesses,
• the request may be rescinded at any time, and 
• tampering with the request is a felony.
• Physicians and patients are legally protected.

Like I said, not fast and loose.  These safeguards are in place to balance the desires of terminally ill patients to be able to choose to die comfortably with assuring that lethal doses of medications are not used in a hasty or ill-considered fashion.

In the past 17 years in Oregon,

• There have been zero incidents of abuse.
•  Out of 25 people requesting medication, 1 person receives it.
• 1,200 prescriptions have been written in 17 years.
• 752 of these patients took the medication and died.
• 92% of patients who used medication died at home, most with hospice involvement.

At this point, about 66% of Californians support such a law for California, and also 54% of doctors.

For what it's worth, I am one of those doctors and one of those Californians.  I was a medical intern and resident in Washington where physician-assisted death is a legal practice.  (No, I was never asked for any medication for this purpose.)  I was aware of the procedures around it which were similar to Oregon's.  I also recall that no physician was required to participate, nor was any patient: it was up to the individual doctor and the individual patient.  Certainly, it would have been impossible to legally obtain medication for the purpose of "euthanizing" elderly or disabled people.

The California legislature has an End of Life Option Act before it.  It is similar to Oregon's Death With Dignity Act  insofar as it would require that a patient be a mentally competent adult with a fatal illness and a life expectancy of less than six months diagnosed by two doctors.  It would also require two oral and one written request at least 15 days apart co-witnessed by two other people.

Also, this Act would require doctors to discuss other treatments such as pain medication or hospice care.  Furthermore, the Act exempts Catholic hospitals and allows doctors, pharmacists and other providers to opt out.

In much the same respect that terminally ill patients have every right to pursue vigorous treatment even if odds are not in their favor, I think patients should also be able to have control over the time and means of their death if they wish  to do so.  In my experience, patients do not fear dying so much as they fear dying in pain or dying alone. 

What diet should I use to lose weight? (Hint: the one you'll stick with.)

Interestingly, all popular diets yield equally effective results at six months out.

Bottom Line: don't worry about whether you should avoid carbs, do the Paleo diet or eat less meat.  Any dietary change that reduces calorie intake and helps you to safely lose weight is the one you should do!

How helpful is cancer screening?

Well, that depends on the kind of cancer.

This article very nicely addresses how many forms of cancer (such as thyroid, breast and prostate) are often very indolent.  The problem is that routine screening is most likely to find these harmless tumors and most likely to miss rapidly fatal malignancies.

The study of cancers at the genetic and molecular level offers more promise in turning testing into a more effective way of saving lives and also of avoiding unnecessary over-treatment.