Archive for July, 2013

Billboard Advertising of Physicians and Hospitals

July 28, 2013

http://www.nytimes.com/2013/07/28/sunday-review/the-hype-over-hospital-rankings.html After reading this in today’s NY Times, I thought it would be worthwhile to reblog this post.

Our Greatest Wealth Is Health

Blog  #52        Andrew Siegel, M.D.

 Image

The image above is a billboard that I photographed on Route 4 in New Jersey, advertising kidney transplantation at St. Barnabas Hospital.  Now people, come on—if any of us ever need a kidney transplant, are we really going to pick our transplantation center based upon a billboard ad situated above a gas station and a Dunkin’ Donuts?

As I continued driving east on Route 4, I couldn’t help but see—or shall I say, be assaulted by—a huge electronic billboard, its flickering colored pixels advertising the merits of one of the local hospitals.  The subject matter changed every few seconds, the slide show shifting to the faces of local physicians, some of whom I know and others whom I don’t know.

I don’t care for any type of billboard insulting my visual field, much preferring nature, trees, and mountains as background, although there is not…

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Dehydration

July 20, 2013

Andrew Siegel, M.D. Blog #113

As I sit here writing, it is 100 degrees Fahrenheit in the New York metropolitan area. We are in the thick of an absolute hellish heat wave, as we have been for the past several weeks. I prefer the heat to winter frigidity, but current weather conditions make it very unpleasant to be outside and, more importantly, these temperatures can be downright dangerous to one’s health, causing an entire host of very unpleasant symptoms that if not attended to can result in heat stroke and even death.

I became dehydrated last weekend, a miserable incident that has happened a few times in my lifetime. It happened after cycling with my sister, her friend and a few of my friends. It was 95 degrees Fahrenheit and near 100% humidity. I picked up Michael in my wife’s hybrid SUV and with our two bikes on the rack headed to Fort Lee, parking near the George Washington Bridge. I consumed a bottle of water in the car while driving, because I knew it was going to be a scorcher, and had two full bottles on my bike of iced water and iced coconut water. Our group rode 45 or so very hilly miles that day. We did the Palisades Interstate Park starting at Fort Lee and then headed up north and exited the park to enter 9W. We cycled past the Tappan Zee Bridge and ended up at Nyack Beach State Park. We put in nearly 3 hours of cycling time, with a bunch of rest stops, totaling about 5 hours of outdoor exposure time. I really thought I could keep up with my water losses, but I was clearly in the wrong.

We initially stopped for a breather near the police station in Alpine after a tough climb and the entire group was already drenched. Our next break was at the Community Market in Piermont for a water refill and a short recess. We turned around at Nyack Beach State Park and two of our group departed for home, but four of us stopped at the Runcible Spoon for a smoothie, a carbohydrate recharge, another water replenishment, and a nice break. Thereafter, our foursome maintained a well-executed pacing line for the remainder of the return trip, which was predominantly on Piermont Road, with a final rest stop before descending the hills of Tenafly. At this stop, all of us felt “not quite right.” My sister experienced chills and nausea; I felt incredibly hot and my pulse was racing away and our two friends were entirely relieved to be out of the saddle and the sun for a few minutes. During the final ascent, both of my quads experienced simultaneous cramps, but our group ultimately made it back intact. I ripped off my sweat-weighted cycling jersey and turned the AC in the SUV to max. As I drove home I felt light-headed and experienced a strange visual occurrence in which everything that was white in color appeared glaringly and strangely bright to me—kind of the way heaven is portrayed in movies!

When I arrived home, I felt out of sorts; I was exhausted and my heart was still racing and all I wanted to do was to lie down—I truly felt as if a truck had hit me! I couldn’t seem to find the keys to the SUV to return to my wife, hunted in vain for them, but ultimately discovered them tucked into the front waist of my cycling shorts—clearly I was not playing with a full deck!

I had a mid-afternoon lunch, drank almost two more bottles of water and mustered up the energy to shower. I headed to the couch, where I proceeded to read the Sunday paper. I developed an awful headache and took a few Motrin with some more water. My family was supposed to go out for dinner that evening, but I felt so sluggish that I just wasn’t up for it. After having take-in Chinese food for dinner (certain to rebalance my sodium deficit!) I spent the evening on the couch, watching “The Borgias” and “Prison Break.” By 9PM I realized that I hadn’t urinated in 12 hours. When I did, the urine was dark and concentrated. Ultimately, after a pretty decent night’s sleep, I was back to normal in every respect. However, in retrospect, I recognized that I had suffered with dehydration, a very dangerous problem that has the potential to kill human beings.

Dehydration is a state in which there is excessive loss of body water and therefore a disturbance in our metabolic processes and functions. As a result of excessive fluid loss, there is decreased blood volume (hypovolemia) and consequently, lower blood pressure and a faster heart rate with less delivery of oxygen and other nutrients to our tissues, and less removal of waste products. Under these circumstances, it is common to experience “orthostatic” changes—feeling light-headed and dizzy when arising from a supine or sitting position. Often one experiences a dry mouth and profound and sometimes insatiable thirst. It is typical to feel nauseated, sleepy, lethargic, fatigued and generally awful, not dissimilar to the sensation of being hung over. Mental confusion and even delirium are real possibilities. One’s urine becomes very dark and concentrated as the kidneys make every effort to reabsorb water back into the body. Urine production therefore becomes minimal. Skin can lose its healthy consistency, becoming dry, shriveled and much less elastic. Sweating and tearing can cease and body weight can drop significantly. 60% of our body weight is water, of which two-thirds is within cells and one-third in our blood and interstitial fluid (fluid between our cells). For a 70 kg man, that amounts to 42 kg of water. It doesn’t take too much in the way of fluid losses to throw one over the brink into dehydration. The long and the short of it is that dehydration can and will negatively affect every cell, tissue and organ in the body.

Dehydration can severely impact one’s athletic performance. Endurance athletes such as marathon runners and cyclists are particularly susceptible because of the amount of time they spend exercising and the extent of sweating that comes with the territory. Dehydration is cumulative, such that a fluid deficit from a previous day’s effort carries over to the next day. Exercising in high altitude areas increases the degree of the risk. The greater the temperature, the greater the risk, and the same goes for humidity, since sweat cannot evaporate as efficiently under severely humid conditions as it can under dry ambient conditions.

Tips To Avoid Dehydration
• Don’t be a fool like me and spend hours doing a strenuous endurance event when it is ridiculously hot and humid out. In the circumstances of really high temperature and humidity, go to the gym or for a swim to get your exercise dose.
• Hydrate, hydrate, hydrate…the best endpoint is urine approaching the color of water; if it looks like apple cider it is a sign of dehydration. Drink abundantly before, during, and after exertional activities.
• Wear light gear that wicks the sweat from your body and that promotes evaporation.
• Avoid strenuous exercise at the peak heat of the day—early morning or late afternoon are preferred times.
• The young and the elderly are at higher risk, so this population should hydrate to an even greater extent.
• Be particularly careful about dehydration if you take a diuretic or drink a lot of caffeine or alcohol, since you will be particularly prone from the dehydrating effect of these substances.

Bottom Line: Always be cognizant of weather conditions when undertaking any type of outdoor activity. Remember, Mother Nature rules supreme and is not something to take lightly…serious, or even deadly, consequences can be the result.

Andrew Siegel, M.D.
Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: http://www.promiscuouseating.com
Available on Amazon in paperback or Kindle edition
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“Hurt” Your Hunger

July 13, 2013

       Andrew Siegel, MD Blog #112

Hunger is one of our most basic and primal urges and a fundamental part of our hard-wired engineering in order to ensure adequate intake of calories, energy, and nutrition for the purpose of survival of the individual.  It is one of nature’s clever “bait and switch” mechanisms: we think we are satisfying an urge, but we are really fueling up to stoke our metabolic processes and provide fodder for cellular growth and maintenance.

Hunger is functionally based upon chemicals including hormones and neurotransmitters—for example, ghrehlin (appetite stimulating), and leptin (appetite inhibiting).  Additionally, our circadian biorhythm plays an important role as our brain’s body clock drives the cycle of hunger which is typically at its lowest at 8 AM in the morning and peaks at 8 PM at night.  This cycle can lead to a tendency to gain weight by not eating when you need it (breakfast) and eating when you don’t need to (evening after dinner).  Furthermore, emotional factors—particularly stress—can impact our “hunger” in a major way.  Our environment—which can expose us to the sight, sound, and smell of food, television commercials and other triggers—also has a significant influence on our hunger, causing us to suddenly desire food when moments before we had no appetite whatsoever.

It is important to make the distinction between physiological hunger and emotional hunger.  Physiological hunger is the instinctual drive to seek food versus emotional hunger, which is psychological and largely influenced by environmental exposure to food triggers as well as to our emotional state of mind.  If you haven’t eaten for hours and are famished and have a stomach that is producing a symphony of growling sounds, it is a pretty clear-cut case of physiological hunger. However, if you have just eaten dinner and are sitting on the couch relaxing in front of the television and become “hungry,” typically for a very specific food item, it usually bespeaks emotional hunger.

Interestingly, our physiological hunger drives us to consume a fixed weight of food every day, regardless of calories/nutrient content; therefore, low-caloric density foods—those that contain abundant water content—rule. For this reason, it is good to “preload” before a meal by eating low density foods such as salad, soup, a piece of fruit, cut-up raw veggies or drinking a glass of water to help curb caloric intake.

Fatigue eating is a very common phenomenon, which has a physiological basis.  This is why a good night’s sleep goes a very long way in helping to maintain a healthy weight. It is important to not succumb to the temptation to eat yourself awake—see my blog on FATigue eating: https://healthdoc13.wordpress.com/2011/03/28/fatigue-eating/.

The nutritional content of our meals is of fundamental importance in quelling our hunger. Specifically, eating protein as well as some healthy fats can go a long way in diminishing our hunger. A diet that is balanced in terms of carbohydrates, proteins and healthy fats can keep one satisfied until the next meal.  So, try to have some protein for breakfast as well as for an afternoon snack— it does wonders in terms of maintaining high levels of our satiety hormones to keep hunger at bay.  Carbohydrates without protein or fat provide only a short-lived suppression of hunger.

Stress is a particularly toxic emotion in terms of driving “hunger.”   It is best to try to avoid “eating” stress away and instead trying to “exercise” it away.   Exercise has numerous positive effects, including the enhancement of the brain’s executive function to help inhibit temptations and impulses—see my blog on Exercise To Exorcise: https://healthdoc13.wordpress.com/2011/11/13/exercise-to-exorcise/. Like fatigue, there is a clear-cut physiological basis for stress- induced eating.  Stress causes the release of a number of hormones and chemicals including cortisol, which can profoundly influence us to eat, often fatty, salty, and sugary foods—see my blog on The Mind-Body Connection and How It Relates To Our Eating Behaviors: https://healthdoc13.wordpress.com/2011/12/31/the-mind-body-connection-how-it-relates-to-our-eating-behaviors/.

Bottom Line: Exercising “mindfulness” is a vitally important asset in the struggle to maintain a healthy weight. It is a good idea before putting any food item into one’s mouth to consider what you are eating, why you are eating, when you are eating and where you are eating.  If what is a bad what, why is for non-physiological reasons, when is late at night and where is in front of the TV or in the car while driving, it is worth considering an alternative activity to occupy and amuse yourself in lieu of eating. Am I saying it is bad to sit in front of the television and have a snack?  Not at all…but if you are really not hungry and just desire entertainment and diversion, it is best not to down a large bag of chips mindlessly. Consumption should be accompanied by conscientious choices.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

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My Blood Pressure Ordeal

July 6, 2013

Andrew Siegel, MD  Blog #111

I consider myself to be a very fit person—for the most part, I eat a very healthy diet with abundant fruits and vegetable and avoid processed, fast and junk foods, don’t smoke, drink alcohol very moderately, and exercise religiously and aggressively.  I’m 5’9” tall and weigh 155 lbs., so I’m not carrying around much body fat.  Nonetheless, in spite of my healthy lifestyle, I was diagnosed with hypertension this year.  I am a strong believer in the mind-body connection and initially attributed my blood pressure issue to the incorporation of electronic medical records into my urology practice, a frustrating and tedious experience that has added hours of time to my workday and much grief and hassle to my life.  That stated, it is difficult to hide from one’s genetics—I have a bunch of family members with high blood pressure, including my younger sister who is a vegetarian and avid cyclist and runner who truly could not be any leaner or in any better physical shape.  But it really irks me that I know many obese and sedentary individuals who do not have blood pressure iss

Earlier this year, I was in Florida with my brother, cousin, and brother’s friend for an extended weekend golf and tennis excursion. We went to the Publix supermarket where we chanced upon one of those free blood pressure machines that you stick your arm in and presto, in a few moments you have a blood pressure reading.   Suffice it to say that among the four of us, I lost the blood pressure contest!   I wrote it off to the stressful week that I had had, but at a visit to my dentist several weeks later, the elevated blood pressure was confirmed.  Suffice it to say that I was not pleased with this news.

You are probably aware that high pressure within the arterial walls (hypertension) contributes to many serious ailments including the following: coronary artery disease; aneurysms; stroke; congestive heart failure; and kidney disease.  These cardiovascular diseases are the leading causes of death in the USA. So it behooves anyone with high blood pressure to get it treated, pronto.

I saw my internist and was prescribed medication called Diovan, which I started immediately.  It controlled my blood pressure nicely, but I experienced some side effects, so I returned to my doctor and I recommended to him a trial of a different class of medication called a beta-blocker.   This is typically not a first-line drug for hypertension and is often used for people with cardiac problems.   It works by decreasing the heart rate and contractility (the ability of the heart muscle to squeeze out blood).   This class of medication generally has a calming effect and I thought that because of my rather “energetic” style and persona, it might have a beneficial effect beyond managing the high blood pressure. Beta-blockers are sometimes used by people before public speaking, work on tremors of the hand, and have a general blunting/“take off the edge” effect.  I have some early morning insomnia and thought that this might help with that as well.

The medication was effective in normalizing my blood pressure.   However, it did “knock” me down a few notches.  I experienced fatigue in the late afternoon that was new to me.  More disturbing was that it was more difficult for me to exercise when it required major exertion.   When working out, I became short of breath and tired much more readily than previously. I’m a recreational cyclist and have always enjoyed bike riding since my earliest days of childhood.  I observed that I was having trouble keeping up with my cycling buddies and that hills—previously one of my strengths—were suddenly particularly difficult.  Understand that I’m going to be 58 years old on my next birthday, so I thought that my age might have finally caught up with me a bit, but I also questioned what role the beta blocker was playing.

My old heart rate monitor that I typically use when I cycle was not working properly so I headed out to Campmor and picked up a new one.  It is basically a chest strap that detects one’s heart rate that is displayed on a wristwatch. It is a very helpful device when cycling that helps one stay in the proper zone of heart rates to assure the appropriate level of exertion.   For example, I know that my maximum heart rate is 160 and a level of 125–140 is a comfortable heart rate for an endurance ride. When I start heading above 145, I begin experiencing shortness of breath and need to tamp down the exertion if I want to maintain the endurance.  I learned all of this when I attended Chris Carmichael hill cycling camp, located in Asheville North Carolina where I went a number of years ago with my cycling buddies to learn the proper techniques of attacking hills.

So I put on my new heart monitor and went out on a hilly ride.  Much to my surprise, my maximum heart rate was now 125, being 160 under normal circumstances.   At 115, I started experiencing shortness of breath; 110 was a comfortable rate.  I was astonished by the profound effect the beta-blocker had my heart rate.

Understand that beta-blockers do not just work on heart rate but also on contractility.  The term “stroke volume” refers to the amount of blood that the heart pumps out with one beat. Beta-blockers reduce both heart rate and stroke volume.   The ability to succeed in aerobic sports such as cycling and running is contingent upon satisfactory cardiac output to provide oxygen and nutrients to our cells. Cardiac output is the product of heart rate and stroke volume. So, cardiac output goes way down on a beta-blocker and clearly explains my sub-normal performance with highly exertion physical sports.

I saw my internist yet again, stopped the beta-blocker, and started an alternative medication—the same one that my sister is on—that has no cardiac effects. I went on a bike ride in Fort Lee Park and Route 9W with my sister and friends and noticed a dramatic subjective improvement in my cycling performance, more in line with my typical cycling functioning of previous years.  This was just one day after getting the beta-blocker out of my system. Objectively, my maximum heart rate was 140, much improved over the 125 on the beta-blocker, but still not up to the 160 that was typical for me.  On my next ride, my maximum heart rate was back to normal and my cycling performance was fully back to days of old.  I was back!  I’m very happy to say that age is not catching up with me—yet.

Bottom Line: The morals of the story are several: 

1.    High blood pressure usually causes no symptoms whatsoever and must be sought after, so get your blood pressure checked periodically even if you’re feeling great

2.    Do not assume that because you are in great physical shape, exercise regularly, are not overweight, are a non-smoker and have a healthy diet, that you are immune from high blood pressure, which is often genetic despite a very healthy lifestyle

3.    Be wary of beta-blockers if you are an endurance exercise enthusiast.   Apparently what I experienced does not happen to everybody, but it was quite profound with me.  

4.    Don’t tell your doctor what to prescribe you even if you are a doctor!  Physician—do not treat thyself; let your internist provide their sage input regarding management of medical problems.

 

 

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.