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.

Ebola

I haven't posted on the subject of Ebola virus, but I am getting a lot of questions about it, so here goes.

As a general matter, I think the world at large has been very slow to respond to this outbreak.  On the other hand, I think the initial panic and furor are abating and cooler heads are prevailing.

When I say that the world response has been slow (excepting Medicins Sans Frontieres or MSF, otherwise known as Doctors Without Borders) I  mean it has taken months for the World Health Organization, Centers for Disease Control, National Health Service or European Union to respond in any way.  The above photo appeared in the March 2014 breaking news coverage by the British Broadcasting Company of Ebola in Conakry.  Notice the suburban homes behind the guys in Personal Protective Equipment.  That's suburban, not rural village.  Ebola outbreaks up until now have occurred 2,000 miles from the African coast, and have been in isolated locations.  Given the lack of medical care in these isolated areas, Ebola patients generally didn't survive long enough to get to cities of any size.

Conakry is the capital of Guinea and has 1.7 million people in it, an international airport serving Western Africa and Europe, and a deep-water port.  It's in Wikipedia- you don't have to be CIA to figure it out. I find it hard to imagine not breaking out in a cold sweat realizing Ebola is in a large port city with an airport, especially if you are in government or public health.  It does rather appear that the world-at-large only sat up and took notice when Westerners got Ebola. (warning: satire.)

At this point, Ebola has spread to adjacent countries but the ground response is more effective.  This is largely due to hard-won lessons in nursing care, social networking and community support.  For example, family members can now see and communicated with sick loved ones (by phone or the other side of a window) and can see workers don or remove PPE and can see the dead before their burial.  Think about it: if this was happening here, how would we react to sick family members being taken into a big white tent or building from which  no one ever comes out alive?  And you never, never see them again?  We are once again reminded that nursing care is critically important, and communication and emotional support are a big part of it.  This New Yorker piece is an excellent history of the earlier ground war against the outbreak.

A big question now exists over quarantine.

Some perspective should be applied over general air travel out of the three affected countries. Last year, those three countries comprised under 0.02% of the world's commercial air travel.  The US received 2% of these passengers, coming in 12th place as destinations from these countries.  Projections suggest a total of 2.8 commercial air passengers per month flying out of these countries for the next year.

Also, bear in mind that this is not an airborne illness like a cold or flu.  The current CDC recommendations that open with 21 day monitoring but not forced close quarantine are reasonable in this light.Similarly, the New England Journal of Medicine advises against forced quarantine of returning health care workers.

It is reassuring to consider that the only people in the US who have contracted Ebola did so through very direct contact.  In fact, consider the Liberian patient who died in Texas.  He slept with his fiancee for days before being hospitalized.  She and her family were in mandatory quarantine in that apartment for close to a week before it was de-contaminated.  None of those folks went on to develop Ebola.

I think it is now time to turn to increased global efforts to address the outbreak in the currently affected West African countries.  Certainly, forcing returning symptom-free health care workers into 3 weeks of restricted quarantine is not the opening move here and neither is blockading travel in or out of those countries.

Aside from humanitarian reasons, impeding any effort from developed countries to flood in to combat the infection with money, personnel and resources is foolish in the extreme.  As General MacArthur is famously quoted as saying regarding the Pacific Theater of Operations in World War II "Would you rather fight in Saipan, or in California?".  Doing everything possible to quell the outbreak while it is still confined to Western Africa is to avoid fighting it in Karachi or Mumbai.

The sparks that have flown to the US and Spain have been well contained.  It should not be assumed that sparks landing in large urban centers in developing countries with marginal health care and political infrastructure will fare as well.  As an example, consider that 40% of the world's supply of generic prescription medication is manufactured in India.  If Ebola were allowed to become pandemic in India, the humanitarian suffering would be unimaginable.  Additionally, the rapid loss of generic medications for the world would have immediate impact on the entire world's population.

So, my $0.02? Don't panic, take reasonable precautions for self-protection, and put the resources where the real fight is before it gets out of control.

Myth: 8 glasses of water a day

I still get asked whether one should drink eight full glasses of water a day for reasons of health, and the short answer is "No.".

It's a bit of a mystery where that meme got started, but it has never been the advice of doctors as a matter of general health. It may have gotten its start in the 1940's around the amount of fluids in both solid foods and beverages in the average diet.

At any rate, if you are becoming a bit dehydrated you will feel thirsty.  Feel free to have some water or any  other fluid.  Certainly most of us are going to be better off drinking water than alcohol  or sweetened drinks.  It is simply not necessary to push  fluids beyond this point.

How often are people late for appointments?

This is an interesting post in which a doctor is vexed by how often his patients are late and asking whether this is the norm.

The post does address this and found a study showing that 7.7% (one in thirteen) patients are late for doctor appointments.

However, it also pointed out that another study shows an average patient wait time of 38 minutes for the doctor. Gulp. Mea culpa maxima.

My own experience and perspective?

• We do encourage the first patient of every morning and afternoon to arrive 10-15 minutes early to make it easy to start out on time.  I do often run late because the first patient is late to arrive and I am then already starting off 15 minutes behind.
• I do spend a lot of time with  each  patient.  It's difficult to arrive at an accurate diagnosis without an extensive understanding of the development and nature of symptoms and a physical examination.  This takes time.  There's good medicine and fast medicine, but no good, fast medicine.
• I gotta admit that because of this I rarely ask patients to re-schedule if they happen to be running late!

How understanding why you don't like certain people can be helpful to you

Here's a neat thought.  We all meet people we just don't like.  It's pretty unusual to like everyone you meet, and it's impossible to be all things to all people.

However, maybe it would be good to pause and reflect on why you don't like that person.  What if the reason is that that person has some characteristic we wish we had more of?  What if the things we don't like in others are often the things we dislike in ourselves?

What if meeting someone you don't like not only affords an opportunity to learn ways to accept if not like them, but also a way to examine and  better yourself?

Changes in prescribing and dispensing hydrocodone

The Food  and Drug Adminstration of the federal government (DEA) has changed hydrocodone to a Schedule II agent.  This is effective as of Monday 10/06/14. Scheduled agents are felt to have varying levels of potential for dependency or abuse. 

This is due to concerns that this narcotic pain-killer which is  the active agent in Vicodin, NorCo and Lortab (as well as a number of other brand names) is over-used and/or over-prescribed.  Certainly, the US, which comprises about 4% of the world's population, is using about 99% of the world's Vicodin and NorCo.  It is unlikely that Americans have 99% of the world's physical pain.

What this means is that doctor offices will no longer be able to prescribe or refill these medications by phone or fax.  Like morphine, Dilaudid or Percocet, any  prescriptions or refills of hydrocodone pain killers will require a hard copy.

If we are prescribing this  to you for the first time, you will be given a physical prescription.  No refills can be written on the original prescription.  The  pharmacy cannot fill the prescription without this physical prescription.  They cannot act on faxing or phoning it in ahead of you.

Any refills will also require a physical prescription.  If you need one, please call my office and allow two full business days to have it ready for you to pick up and take to a pharmacy.  A friend or family member can pick up the prescription and/or the medication.  If we feel we need to see you about this, we will make an appointment for you. 

If you are using pain medication or other scheduled agents regularly, we will want to see you regularly in order to evaluate its effectiveness and safety.

Doctors in California are being encouraged to use the state Department of Justice's Physician Drug Monitoring Program which allows doctors to determine whether patients are being prescribed scheduled agents by other doctors or providers.

If you are using hydrocodone or any other scheduled agent and would like to be able to reduce the amount you take, or stop taking them altogether please feel free to see me about this.

How safe is vaping?

So far, it's hard to say. As this nice summary in Nature points out, marketing and sales of devices is moving faster than science or regulation.

For now, it seems reasonable to say that the safety of vaping is unknown and that the safety of second hand vapor is also unknown.  It is probably best to avoid vaping indoors in public areas and to be aware that no one actually knows whether it could be harmful to you.

A little exercise goes a long way!

The American College of Cardiology (a professional organization of heart specialists) recently found that daily  exercise can lower your risk of heart attack and add years to your life. 

This is scarcely news in itself.  What is interesting was finding that 5 minutes of running at relatively slow speeds (6 mph or less) every day lowered risk of death from heart disease by 30-45% and added 3 years of life expectancy.  This was found to be true of fit adults, and also of overweight smokers.

It is also reasonable to suppose that it is the intensity of the exercise that was so beneficial and not necessarily just running.  Skipping rope or going fast on a stationary bike is probably just as good for you.

If you have thought of going to a gym to exercise (low cost, air-conditioned, you don't have to buy exercise equipment and find room for it...) it can be intimidating to consider it if you feel like you're not in very good shape.  Here are some tips on what you can do if you feel you might be embarassed at a gym.

Also, realize that you may be self-conscious about exercising in public if you feel out of shape or overweight.  However, studies find that other folks at the gym are either focused on their own exercise and not thinking about you or they think it's great that you're improving your health but just shy about saying so!

Drug Advertising and Side-Effect Information

Everyone who watches TV has seen ads for "new" drugs with 10 seconds of why it's the best thing since sliced bread, and 20 seconds of side-effects including-but-not-limited-to death, deathiness and death-like symptoms. Kidding.

This should raise several important questions.

First, why do drug companies keep running these obnoxious ads?  Because they keep working (pdf).  Despite their disagreeable qualities, most patients who see the ads ask for a prescription for the drug and most doctors who are asked to prescribe it will do so.  Why?  Most patients are hopeful that something "new" may help them, and most doctors find it faster and easier to say yes than to explain no.

Also, ads should raise the question of how is this drug "new'?  Depends on how you define it.  Drugs advertised on TV are certainly not generics: they are newly developed and approved drugs that will therefore be expensive.  On the other hand, only 10% of them will be new insofar as being the first ever of their kind, or better than already available drugs that do the same thing (congeners).  The other 90% are what is known in the trade as "me-too" drugs.  They are no better than older generically available drugs, and are being sold in hopes of obtaining market share for the drug company that makes them.

Last and not least, I get the most questions on side-effects.  The questions are basically around what are the side effects, and how bad are they.

Listed side effects are not inevitable.  They are simply a list of possible side effects.  WebMD does a great job in discussing what side effects actually are and how they can occur.

Common side-effects may occur in up to 10% of people who take a medication. This also means that 90% of people who take the medication experience no side effects.  Severe side-effects are far less likely to occur, as the FDA does not permit the sale of medications that are seen to frequently cause severe side-effects.

The tricky bit is trying to find out for yourself what side effects actually can happen with a medication, and also how commonly they actually occur.

The problem is that the information provided by pharmacies or in with the medications is largely provided by lawyers, and not by doctors or pharmacists or nurses.  The PI (Product Insert) is principally designed to prevent class action lawsuits by listing every possible reaction to the medication  to prevent you from being able to sue for failure to disclose ("You didn't tell me that could happen.").

It would be helpful if the PI also told you how often the side effect actually happens, whether it's real or theoretical, whether it happens in humans or only in test animals and whether it happens in patients like you, or only in ICU patients with organ transplants receiving the medication in their iv (not kidding).  Problem is, they don't.  The PI is not written to inform you, it is written to protect drug companies.  The much-vaunted PDR (Physician's Desk Reference) is simply a copy of PI's from all medications.

There is no shortage of information from sites such as drugs.com which do a pretty good job of providing useful information in plain English about medications.  However, I've still never seen one that tells you how common the side effects actually are with numbers.  Sorry, but it matters.  You might be okay with a medication where dizziness occurs in 1 in 10,000 people, but not so much if it were occurring in 10% of people.

Sider 2 is useful in getting that information.  Its A-Z listing shows side effects in color-coded columns from most common to least common and allows you at a glance to see if a side effect is common or rare and also percentage of occurrence by the color coding in the sidebar.

Micromedex is the first (or second) most widely used medication database used by doctors and pharmacists.  It's smartphone app is available for only $2.99/year. It does a superb job in easily presenting drug information including actual occurrence rates of side-effects.  However, it is targeted to doctors and pharmacists.  If you want to use it, you'll need a medical dictionary at your side to translate it.  Sorry, we say rhinorrhea and you say runny nose.

Low FODMAP Diets

Certain types of foods may cause digestive symptoms we commonly associate with Irritable Bowel Syndrome (IBS)  and gluten intolerance.

IBS is a real problem involving heightened sensitivity to digestive system distension or fullness, which can result in abdominal discomfort, nausea, bloating and diarrhea.

Celiac disease (also known as sprue) is a reaction to gluten (a wheat protein) resulting in progressive injury to the absorptive lining of the gut.  Around 1% of people have celiac disease. On the other hand, many more people report chronic abdominal discomfort, bloating or diarrhea which is alleviated by avoidance of gluten, even though they are proved not to have true celiac disease.

Two researchers at Monash University in Australia since 1999 (a dietician and a gastroenterologist) have found that certain types of foods may be fermented and/or poorly absorbed and could be responsible for these sort of non-specific, hard-to-pin-down symptoms.  The term FODMAP is now becoming more widely known as a result of their work.

FODMAP is acronymic for:

• Fermentable
• Oligosaccharides,
• Disaccharides,
• Monosaccharides
• And
• Polyols.

This handout (pdf) from the Canadian Digestive Health Foundation breaks this down, and further describes what these chemicals are very nicely.

Basically, some naturally occurring carbohydrates such as lactose (milk sugar), fructose (fruit sugar), the fructans in onion, garlic and wheat and galactans in beans can be fermented during digestion leading to discomfort, nausea and bloating. 

Additionally, some of these are not readily absorbed and can lead to water being drawn in to the colon before elimination resulting in diarrhea.  This latter is particularly true of synthetic sweetening polyols such as sorbitol or xylitol which are used to artificially sweeten foods, chewing gum and other products.

Mind you, we're talking about naturally-occurring constituents of common foods.  Some foods contain more of these than others.  For example, fructans are more abundant in wheat and rye than in rice or oats.  Similarly, apples and mangos contain more fructose than bananas or berries.

This pamphlet (pdf) from Stanford University Medical Center nicely shows within the FODMAP's, which foods to limit and which are okay.

If you feel that your digestive symptoms may be affected by dietary FODMAP's you can systematically limit dietary FODMAP's one group at a time for a few weeks to determine which group or groups you may wish to limit long-term.

Alternatively, you can limit all six groups at once.  If you notice improvement, you can then de-limit one group at a time to identify culprit groups.

Please note this is quite effective with limiting intake of culpable types of FODMAP's.  Absolute avoidance is not generally necessary.

(Also, we are just discussing food substances resulting in fermentation and poor absorption. 

Other digestive symptoms such as fever, weight loss, appetite loss, stringy bowel movements, blood or mucus in your bowel movements are warning signs of much more significant problems such as infections or cancers.  Please see me for such symptoms as soon as possible, and do not try to treat them with a reduced FODMAP diet.)

Interesting Perspectives on the Changes in Medical Practice and Ethics

Unless you are a close student of history or of a certain age (*cough*), you probably don't fully realize how much the current practice of medicine really dates from the civil rights movements of the 1960's and 1970's, and how different this is from previously.

Until quite recently, the ethical principle of benificence (or paternalism, as it is also known) was the standard.  This meant that the  doctor was understood to be a professional with a deep understanding of a complex body of knowledge whose duty was to make complex decisions for patients with the best interests of the patient in mind.  Please note that the "decider" is the doctor and that the doctor also determined what was in the patient's interests. 

This article by James Hamblin in The Atlantic is an interview with Barron Lerner, whose father was an infectious disease specialist in the 1950's.  The interview is in the setting of a book written by him on the evolution of medical ethics from the reflections of he and his father, both of whom are doctors.

A part of the civil rights and free speech movements was the development of ethical autonomy, in which the doctor and the patient are understood to be shared decision-makers.  The physician is there to provide expert knowledge and experience, and to provide and describe a full range of options to allow the patient to be as fully informed as possible and to be able to decide for him/herself what is the best course of action.

Hamblin's article nicely addresses the intersection of autonomy with real concerns like time and differences of goals or opinions.  I'm sure every doctor has had cases where they have felt that the patient was making a truly bad decision, and I'm equally sure every patient has had visits or encounters where they've simply wished the doctor would just get to the point and tell them what needed to be done.  And time certainly is a factor.  Fully investigating the medical concerns at hand, performing a physical examination (yes, a good directed physical examination is still valuable and helpful in arriving at a diagnosis, but it does take time) and then fully describing the range of diagnostic and treatment options, their upside and downside risks and fully answering all questions and concerns is pretty near impossible to do in fifteen minutes in all but the most straightforward problems or concerns.  This is of course coupled with patient focus-grouping which reveals the importance of completeness and length of time with the doctor.  And also promptness. Doh!  Hello, quality-control triangle!

This article by Brandon Cohen in Medscape talks about the elephant in the exam room.  Can ethical autonomy go to the extreme of consumerism?  Is medicine another service in which customer satisfaction trumps the actual quality of the service?  Are HealthGrades reviews of doctors just like Yelp reviews of restaurants (read closely how many negative restaurant reviews relate to dissatisfaction with wait service and not so much the actual quality of the food which is what restaurants provide)?  Which is more important: that patients get the best care and have the best health, or that they are personally satisfied?  When are these goals mutually exclusive and when are they not?

If it sounds like I have more questions on this than answers, that's because it's true.  I do know that it's not unusual for Canadians to come to the U.S. for knee replacement because it takes longer in Canada to get MRI's or surgery for chronic conditions.  I also know that Canadians live longer than Americans, and can get timely tests and treatment for serious problems.  I know that most patients complain about TV ads for medicines, but I also know that the ads still run because they work.  I know that a bad rating of a hospital may mean the hospital is really bad, but it also may mean they treat a lot of complicated patients with rare conditions that no one else can treat.

Sunscreens: Summer is definitely here!

If you follow the weather reports (or just step outside) you've noticed Summer is definitely on!

The liberal application of sunscreen every two hours can help to prevent sunburn, skin cancer and wrinkling of the skin.  This is especially important in children, since one single blistering sunburn can double the lifetime risk of melanoma.

Melinda Moyer at Slate Magazine covers (no pun) the topic quite nicely.  Briefly;

• Organic sunscreens are called this because they are carbon-based, and absorb UVA which causes cancer, and UVB which causes sunburn.  
• Mineral sunscreens accomplish this by reflecting UVA and UVB.
• SPF 30 blocks 97% of UVB, SPF 50 blocks 98%.  It's probably not necessary to get anything stronger than that.
• Spray-on, or wipe-on sunscreen may not cover your skin as well as lotions.
• Using combined sunscreen + insect repellent may increase the absorption of the chemicals into your bloodstream, which may not be a good idea.

Environmental Working Group (a non-profit organization) has a great website that provides plenty of information and recommendations on sunscreens and their ingredients, safety, quality and cost.

Their iPhone and Android apps, Skin Deep also makes this information accessible on sunscreens and also  cosmetics in a mobile platform.  You can browse by entering sunscreen as a search word, or barcode scan products at the store.