Zika Virus: how long should we wait to try to get pregnant?

Our understanding of Zika virus is developing daily.  As many are aware, the link between Zika virus exposure or infection and birth defects (microcephaly) is becoming stronger.

The Centers for Disease Control (CDC) has just issued recommendations on family planning and Zika.

Long story short;

1. If you are a woman who traveled to a Zika endemic area and developed symptoms, wait at least 2 months before trying to get pregnant.
2. If you are a man who traveled to a Zika endemic area and developed symptoms, wait at least 6 months before having unprotected sex.
3. If you are a man or woman who traveled to a Zika endemic area and did not develop symptoms, wait at least 2 months before trying to get pregnant.
4. If you are a man who traveled to a Zika endemic area with a pregnant partner, use condoms for any form of intercourse for the duration of the pregnancy.
5. To prevent the spread of Zika through sexual intercourse, men who have traveled to Zika endemic areas should use condoms for any form of intercourse for 2 months if they did not develop symptoms, and for 6 months if they did develop symptoms.
6. If you are a man or woman living in  a Zika endemic area, then it gets really tricky:
1. The CDC did not recommend that women delay pregnancy.
2. El Salvador has recommended that women wait until 2018 to get pregnant.
3. Brazil, Ecuador, Columbia and Jamaica have recommended that women delay pregnancy indefinitely for the time being.

Please read the link for more detail, and also my previous post on Zika for further information including a description of symptoms of Zika infection.

Zika Virus

I think we're only going to be hearing and reading more about Zika in the very near future. Spring is here, more people will be traveling on vacations, and the possibility of Zika outbreaks in the lower 48 will increase (the range of the carrier mosquitoes includes the Southeast US). This could raise issues of governmental regulation, access to abortion, climate change and immigration during a presidential election year.  I hope that any such discussions will be in the interests of the public health, and will shed more light than heat.

Zika has actually been identified in the 1950's in West Africa, then in the late 1960's in the South Pacific.  Since then, it has emerged elsewhere and most recently in South America and now Central America, including Puerto Rico which is a US territory.  It is carried by two species of Aedes mosquitoes whose effective range includes large areas of the Southeast and Atlantic Seaboard.  Aedes was responsible in the 1900's for yellow fever outbreaks in the South and as far north as Boston and New York City.  Aedes can also carry dengue hemorrhagic fever and chikungunya which are being seen in Central America and border states in the US.

 

 

At this point, Zika has been linked to a rare birth defect called microcephaly in which a baby is born with an abnormally small head and may develop lifelong developmental delays.  Happily, this appears to affect only 1% of women who were infected with Zika.  On the other hand, Zika infections are acquired through mosquito bites and are in 80% of cases without any symptoms at all.  In the other 20% of cases, the symptoms are quite mild: fever, aches, rash and reddened eyes are the most common.  Those symptoms are of course quite common to any viral illness at all, including common colds and flu.  And on top of this, Zika can be sexually transmitted for an unknown period of time after initial infection.

Due to the recent emergence of Zika in the Americas and the alarming link to microcephaly, Zika raises a lot more questions than answers at this time.  A vaccine is years away, and there are no readily available commercial lab tests for Zika.  Fluid specimens can be tested by a special division of the Centers for Disease Control (CDC) in Atlanta, but we are far from simply taking a lab slip to the lab for testing.

So, what to do at this point?

• Eliminate standing water near your home including old tires, up-turned buckets and the like.
• Use DEET-containing mosquito repellent and clothing that covers you.  If you are using it along with sunscreen, apply the sunscreen first and then the repellent.  Do not use combined sunscreen plus repellent products as this can lead to bloodstream absorption of DEET.
• Get window and door screens.  
• Use a mosquito net over your bed.
• Exercise these precautions and pack accordingly in travel to endemic areas, if you cannot avoid travel there in the first place.  (Personally, I would stay away from the Summer Olympics in Brazil.)
• If you are thinking of getting pregnant, this is a tough choice.  There are no clear choices and the best news is that even in the face of Zika infection, the odds your baby will be normal and healthy are 99% in your favor.

Here are links to some helpful information and resources on Zika Virus: 

• A Zika FAQ list from the New York Times: NYT FAQ List
• The El Dorado County Department of Public Health: County Public Health
• California Department of Public Health (having server issues at time of this writing): State Public Health 
• Centers for Disease Control, for Pregnant Women: CDC/pregnant women
• Centers for Disease Control, Zika Home Page: CDC Zika Virus

Exercise for Your Brain

This is a pretty interesting discussion of the effects on different types of exercise regimens on brain function.  Mind, it's an academic study on rats looking at the effects of different types of exercise on growing new brain cells.

If this is more broadly applicable to humans, then it suggests that distance running would be more beneficial for your brain than weight lifting or short-duration high-intensity workouts.

Please note that it's certainly possible that weight training may have other beneficial effects on the brain not looked for in this study.  As a general matter, physical exercise is not only healthy for your heart, muscles, weight and sense of balance but also good for brain function.

Fitness Apps

Sorry to be a bit late with this link to the January issue of the American Journal of Medicine; the issue got buried in a pile of cookbooks : ).

We have been repeatedly finding that smartphone applications can be very helpful for fitness and weight loss.  This article provides discussion and a handy table of recommended apps by name, type, features and cost.  Yes, it includes Zombies, Run! for those who need to run from something for proper motivation...

On the power of positive thinking

Texas Monthly's article describing the last hoodoo pharmacy in Texas is interesting to read in its own right.  As a bit of cultural history, it's a great read.  The article develops more into a discussion of positive thinking and visualization.

The part I found particularly interesting was the owner's response to whether or not she "believed" in what she was selling:

---

Stephanie May has two degrees. In past lives, she’s worked in the restaurant business and as an oil and gas executive. A self-described “gun-totin’ liberal,” she’s also a Southern aristocrat—her ancestors owned thousands of acres of Arkansas plantation lands (and when not in Houston, she’s farming some of that same land today). All of that would make it seem unlikely that she was a true believer in hoodoo, and May says a TV reporter once asked her if she believed in the magic she was selling.
“I told her I believed in positive visualization,” she says. “If it takes lighting some incense, burning a candle, saying a prayer, wherever you find that positive energy, then yeah, I believe in it. We stopped counting after more than ten of our customers had won the lottery. We don’t sell Lotto tickets, but there’s not a convenience store in town that could tell you that. Now is it because all my customers play the lottery? I don’t know.”
The same principles May applies on her holistic farm in Arkansas also are at play in hoodoo. “It’s like the butterfly effect—everything you do affects the whole. The way your raise animals on the farm, your business, the way you live your life, you have to consider that your overarching goal is maybe to be happy and out of debt. Everything you do needs to march toward that goal. It’s the same way with the people who buy candles, herbs and incense here: they are attempting to achieve that goal, and it’s one more step in that direction.”
The successful practice of hoodoo is more about changing your path than merely performing a ritual or making a sacrifice, May believes. It’s also about positive thinking. “If you change yourself, amazingly everyone else around you changes too,” May says. “You change your attitude, the way you look at life, suddenly, the world changes. It’s so much easier to try to change yourself. But you wanna try to change someone else? I’ll happily take your money, but don’t expect it to be easy.”
She cites one timely example. A popular New Year’s hoodoo ritual: “Bayberry kit burned to the socket brings love to your life and gold to your pocket,” she recites. “The kit has the Psalm you read and a bayberry bubble bath and there’s a whole ritual you perform on New Year’s Eve. There’s a candle you burn every day for seven days to bring positive influences into your life. If you believe your life’s gonna be better this year, your life is gonna be better this year. If I spend the first week of the year thinking positive thoughts, it’s gonna help. And the fact that your house now smells awesome doesn’t hurt.”

Is eating more protein helpful in losing weight?

As usual, the answer is "it depends".

The Phys Ed column in the NY Times discusses a recent publication in the American Journal of Clinical Nutrition (abstracted here) examining very intensive exercise regimens coupled with 40% calorie reduced diets with high protein content.

As with many clinical studies, the idea is not that everyone should be doing this; rather, the idea is to use a somewhat extreme testing method to see what the role of high protein intake is during weight loss involving both diet and exercise.

We have long known that losing weight can be achieved by taking in less calories (eating less), and expending calories and increasing metabolic rate (exercising more).

However, what can happen is that both fat and lean muscle are lost which can result in lower metabolic rates and also more difficulty exercising.

It turns out that having a relatively high protein diet can prevent the loss of lean muscle when you reduce calorie intake and also exercise.  Again, the specific diet and exercise regimens were literally a "boot camp" testing method and not meant to be sustained over the long run. 

The take-home message is that if you are using an app to assess your diet's content of protein and find it be less than 10-15% of your total calorie intake, you might want to shift some of the fat calories to protein and also step up your weight training.

Who do you want with you in a REAL fight?

I am taking no sides here, just sharing this cuz I found it laughing-out-loud funny.

Metrics in Healthcare

The New York Times has an interesting front page article on the impact of metrics and measurements in both healthcare and education.

Both are areas where quantified attempts to improve outcomes have been famously applied for years now (No Child Left Behind, Common Core, Electronic Medical Records, the Affordable Care Act a/k/a "ObamaCare") and it is possible to look at what the impact on these areas has been over the past years of widespread implementation.

The article does a good job of pointing out that some areas have seen improvement (lower infection rates in hospitals, improved attention to lower income public schools) and yet unanticipated downsides are also noted (doctor burnout rates of over 50%, loss of arts, music and physical education from school curricula).

Some of these are sort of predictable: if school testing is linked to funding and tests are largely on STEM (Science, Technology, Engineering, Mathematics), then of course arts and PE are going to be dropped because they're not on the test.

Some are less predictable: are poorly rated doctors and hospitals bad, or are they treating large populations of poor and/or seriously ill patients who aren't or can't be treated anywhere else?

It's particularly telling that MediCare has stopped a program that has linked payment to computer use by doctors, and that a ranking program by the program that inspects hospitals has been put on hold.

Avedis Donabedian, a professor at the University of Michigan’s School of Public Health, was a towering figure in the field of quality measurement. He developed what is known as Donabedian’s triad, which states that quality can be measured by looking at outcomes (how the subjects fared), processes (what was done) and structures (how the work was organized). In 2000, shortly before he died, he was asked about his view of quality. What this hard-nosed scientist answered is shocking at first, then somehow seems obvious.

“The secret of quality is love,” he said.

What do we know (or, not) about nutrition?

These links to Vox and Five Thirty Eight do a really nice job of showing how difficult it is to study nutrition and its effects on people's health, and also how difficult it is to sort out what you read about it.

The good news?

A healthy dietary pattern is higher in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meats; and low in sugar-sweetened foods and drinks and refined grains.
Additional strong evidence shows that it is not necessary to eliminate food groups or conform to a single dietary pattern to achieve healthy dietary patterns. Rather, individuals can combine foods in a variety of flexible ways to achieve healthy dietary patterns, and these strategies should be tailored to meet the individual’s health needs, dietary preferences and cultural traditions.

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...