The Doctor Weighs In

by Pat Salber

Here is a check list of health check-ups recommended to keep you healthy from youth to old age. I grabbed it from CNN.com. They, in turn, got it from the National Institutes of Health and the University of California, Berkeley.

There may be some differences of opinion about the details of some of these recommendations from preventive health experts, but by and large, this checklist offers good guidelines that you can discuss with your primary care physician.  Future posts will explore the scientific basis of these recommendations, but for now, regard these as a a reliable source of "general advice."

In your 20s:

• You should have two physical exams in your 20s. During the first exam, ask to have your cholesterol checked. Other blood tests are not needed in healthy people.

• Go to the dentist every year for an exam and cleaning

• If you have vision problems, have an eye exam every two years

• Have your blood pressure checked every year

• Men should perform a monthly self-exam to check for testicular cancer, the most common cause of cancer in males between the ages of 15 and 34

• Women should perform a monthly breast self-exam

• Women should have a yearly pelvic exam and Pap smear to check for cervical cancer. If your Pap smears are negative for three years in a row, the frequency may drop to every two or three years

• You should have a tetanus-diphtheria booster every 10 years.

In your 30s to 40s:

• Continue yearly visits to the dentist for cleaning

• Whether you’ve had vision problems or not, you should begin eye exams every two years. After the age of 45, start testing for glaucoma

• Continue keeping track of your blood pressure every year

• If your cholesterol remains normal, check it every five years

• Have a physical exam every one to five years

• Men should perform monthly testicular self-exams and women should perform monthly breast self-exams

• Women should have a yearly pelvic exam and Pap smear to check for cervical cancer. If your Pap smears are negative for three years in a row, the frequency may drop to every two or three years

• Women should have a yearly pelvic exam

• Women over the age of 40 should have a mammogram done every year to check for breast cancer. Earlier mammograms may be recommended for women at high risk for breast cancer

• Around age 45, everyone should be screened for diabetes every three years, or earlier if you are at high risk.

• You should have a tetanus-diphtheria booster every 10 years.

In your 50s:

• Continue yearly dental and blood pressure checkups as well as vision testing every two years

• If you cholesterol remains normal, check it every five years

• Have a physical exam every one to five years

• After age 50 men should have a yearly rectal exam to check for colorectal cancer and prostate cancer

• Have a stool guaiac test done every year and flexible sigmoidoscopy every three to five years to check for colorectal cancer. Periodic colonoscopies may be needed for those at high risk for colon cancer.

• You should receive a flu vaccine every year after the age of 50

• You should have a tetanus-diphtheria booster every 10 years • Men should perform a monthly testicular self-exam and women a monthly breast self-exam

• For women, a mammogram continues to be needed every year to check for breast cancer

• Continue to be screened for diabetes every three years

For 60s and above:

• Continue yearly dental and blood pressure checkups as well as vision testing every two years

• Have your hearing tested every year

• Check your cholesterol every three to five years, if it’s normal

• Begin yearly physical exams

• To check for cancer, every three to five years, everyone should have a sigmoidoscopy exam or every 10 years a colonoscopy

• Men should have a yearly rectal exam to check for colorectal cancer and prostate cancer

• Women should continue to perform monthly breast self-exams and have yearly mammograms, pelvic exams and Pap smears

• Men should perform a monthly testicular self-exam

• Get a flu shot every year

• After 65, get a pneumonia vaccine (good for 5 to 10 years).

• Get a tetanus diphtheria booster every 10 years

• Continue to be screened for diabetes every three years.

by Pat Salber, MD

In the early days of the clinical practice guidelines movement, doctors used to complain that it was “cookbook medicine.” As a pretty good cook, who still uses cookbooks, I say, great – when you follow the directions of experts, instead of “winging it,” you increase the odds of getting a good outcome.

So it should be not a surprise that a new study, in the July 23 issue of Archives of Internal Medicine, found that outcomes of hospitalized heart-failure patients are improved when hospital personnel follow clinical guidelines.

OPTIMIZE-HF (“Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure”) is a heart failure guidelines/quality improvement program adopted by the American Heart Association (and sponsored by drug maker GlaxoSmithKline). The program provides hospitals with tools to help improve the reliability of care, including standardized admission orders, discharge checklists, pocket cards, medical chart stickers, best-practice algorithms and critical pathways. It is currently being used by 259 hospitals across the US.

The study, led by Gregg Fonarow, MD from UCLA’s Department of Medicine, looked at data entered into an online OPTIMIZE-HF performance improvement registry. Admission, hospital, discharge care, and outcomes (death and hospital readmission rates) data on 48,612 heart failure patients were entered into the registry between March 2003 and December 2004. A subgroup of 5,791 patients were followed for an additional 60-90 days after they were discharged from the hospital.

The researchers found statistically significant improvements in three of four of the Joint Commission on Accreditation of Healthcare Organization's performance measures used to gauge the quality of heart failure care in hospitals. They included:

· Better patient discharge instructions. The rate of giving complete medical instructions to patients increased from 46.8 percent at the beginning of the study to 66.5 percent by the study's end.

· Smoking cessation counseling. Hospitals provided smoking cessation counseling to 75.6 percent of the patients at the end of the study, compared with 48.2 percent in the beginning.

· Left ventricular function assessment. Evaluating the heart's left ventricle systolic function rose from 89.3 percent to 92.1 percent.

A fourth measure, the rate of angiotensin-converting enzyme inhibitors (ACEIs) prescribed to eligible patients at discharge was 75.8% at baseline. This rate did not improve during the 2-year study.

There was a statistically significant reduction in the mean length of stay for these patients, going from 7.5 days at baseline to 6.2 days at the end of the study. In addition, were trends for reduction of in-hospital mortality, postdischarge death, and combined postdischarge death and rehospitalization, but they did not reach statistical significance.

So patients did better and hospital days were reduced (and so were costs presumably). What’s not to like? According to the lead author, Dr. Fonarow, as quoted in the Washington Post:

"If similar improvements had occurred at hospitals nationwide, this would translate to 40,000 less deaths and 1.4 million costly hospital days eliminated per year. Despite compelling scientific evidence and national guidelines for use of key life-prolonging agents and lifestyle changes, gaps exist in heart failure treatment. We hope more hospitals will adopt this validated model for enhancing heart-failure patient care."

Amen.

Ok, so I am tooting my own horn, but I want to share with you the latest review of the book I c0-authored together with Dr. Ellen Taliaferro, The Physician's Guide to Intimate Partner Violence and Abuse.  The book is published by Volcano Press, the leading publisher of books on family violence. 

The review appeared in the Permanente Journal's Spring 2007 issue.  It is written by Ruth Shaber, MD, an OB/Gyn at Kaiser Permanente's Daly City Medical Office in Northern California.  She is also the Director of Women's Health Services and Director of the Women's Health Research Institute for Kaiser Permanente Northern California. 

Here is her review:

"The facts are overwhelming. The Centers for Disease Control and Prevention (CDC) predicts that 5.3 million incidents of intimate partner violence (IPV) occur each year among US adult women and 3.2 million occur among men. Recent data from Group Health Cooperative demonstrates that about 46% of the female members have experienced physical, sexual, or emotional IPV in their lifetime, and data from the Kaiser Permanente Northern California Prevention Program estimates that in the previous year, at least 4% of women patients have experienced physical injury from an intimate partner--that is about 46,000 members in Northern California alone. The social and financial impact is enormous. The CDC estimates that the direct health care costs of IPV are over $4 billion a year. And, evidence has shown that IPV, along with its many comorbidities, is the number one cause of premature death, injury, and illness in women ages 15-­44 years.¹

It is difficult for even the most experienced clinician to recognize which of our
Ruth Shaber, MD patients are victims of IPV. The violence cuts across all socioeconomic and demographic categories. But we do know that routine screening of all patients is an effective way to identify victims and to offer them assistance. And we know that offering support and counseling to victims can improve the quality of their lives.

Now that we understand these facts, how can clinicians begin to care for patients who are victimized by this overwhelming social problem? The first step would be to open The Physician's Guide to Intimate Partner Violence and Abuse. This book is an essential tool for both experienced and new clinicians. It will help everyone better understand the impact of IPV and to start to comprehend the complicated issues that perpetuate the violence.

Patricia Salber, MD, and Ellen Taliaferro, MD, have compiled the definitive handbook for health care professionals. Their chapters, along with those of their expert contributors, help us navigate through the complicated web of social, psychological, and medical issues that lie underneath the surface of IPV. Many clinicians are intimidated by the thought of dealing with IPV: they are unfamiliar with the proper language to use to screen their patients and they dread the time when a patient will acknowledge the violence in their lives--for fear that they won't have the expertise or enough time to support them effectively. Fortunately, the authors help us realize the therapeutic value of simply asking the questions--even if our patients aren't able to make immediate changes in their lives. And they help clinicians better understand why immediate changes may be difficult and even dangerous. They provide simple tips for offering support and referral to identified victims. And they help explain the social dynamics and practical realities that limit the speed with which change will happen. The book also outlines effective strategies to set up IPV screening programs in our clinics.

A particularly interesting chapter entitled "What Do We Know About the Perpetrators of Intimate Partner Violence and Abuse" helps us understand the prevalence of alcoholism and personality disorders among perpetrators. There is also inspiring information about the effectiveness of batterer intervention programs--with some data suggesting a re-arrest rate as low as 8% among batterers who completed an intervention program. Some of the chapters will help you better understand information that you already knew or suspected about IPV. But some of the chapters--such as the one on Adverse Childhood Experiences and IPV--will turn everything you thought you knew about medicine upside down.

The book is an extremely well-organized resource. With its easy references, clear bullet points and excellent summary tables, it makes for fascinating reading all the way through--or an easy reference book to take off the shelf for a quick review. Wherever you are in your journey of understanding IPV, I highly recommend this book to take you further down the road.

Reference

1. Victoria Department of Human Services. The health costs of violence: measuring the burden of disease caused by intimate partner violence--A summary of findings (monograph on the Internet). Victorian Health Promotion Foundation 2004 Jun [cited 2006 Nov 13]. Available from: www.togetherwedobetter.vic.gov.au/resources/pdf/FinalReport_HealthCostsOfViolence.pdf.

Dr. Diana Fite, fully recovered after a stroke. From the NY Times 052807There is a pretty amazing story in the NY Times about an emergency physician, Dr. Diana Fite of Houston, who had a stroke while driving her car. She was able to call 911 on her cell phone and tell the ambulance drivers exactly where to take her so that she could get state of the art stroke treatment…Memorial Hermann Hospital. Because she was knowledgeable about hospitals in the Houston area, she wasn’t taken to the closest hospital, rather she was taken to the best hospital.

She was given a blood thinner, tPA, and the clot in the artery feeding her brain dissolved. She had a complete reversal of her stroke symptoms – a total paralysis of her right side.

This story is all the more remarkable to me because I have known Dr. Fite for years because of our work with the American College of Emergency Physicians (ACEP). Dr. Fite is only 53 years old. Had she not had a good recovery from her stroke, her career in Emergency Medicine would probably have been over.

My mother had a big stroke in her 70s. It was devastating. In a few moments, she went from being independent to a life of dependence. She could no longer walk and she could no longer perform many ordinary activities of daily living without help. It was depressing and she was depressed.  Her life was never the same again.

The most important point of the NY Times article is not Dr. Fite’s dramatic recovery from a serious stroke. Rather, it is her forthright discussion of her failure to take simple preventive steps to avoid getting the stroke in the first place. She had a five year history of high blood pressure that she ignored. She also had high cholesterol. No one likes to have to take medications every day for the rest of their lives, but the alternative, living forever with the consequences of stroke, are even more inconvenient.

So, I suggest you check out Gina Kolata’s stroke story in the times, including the video that outlines crucial facts about stroke. Other good resources on stroke and stroke prevention are listed below:

• Brain Basics: Preventing Stroke
• Brain Attack Foundation
• American Stroke Association

Pat Salber, MD

Living with diabetes can be tough. There is so much stuff to learn and so many things to do. It can be hard to keep track of everything. And, it can seem overwhelming, particularly around the time you are first diagnosed.

That’s why I am recommending if you have diabetes or if you know someone who has diabetes, get your hands on a great little book, "Know your Numbers, Outlive your Diabetes.” It is written by Richard Jackson, MD, a doc at the world famous Joslin Diabetes Center and Amy Tenderich, a professional journalist who also happens to have diabetes (check out her website: www.DiabetesMine.com).

Five Numbers to Know

This book points out that there are five essential tests everyone with diabetes should have:

• Hemoglobin A1c (often just called A1c). This is a measure of the average blood glucose levels over the previous two to three months
• Blood pressure
• A full lipid profile – not just a total cholesterol, but a full panel that determines LDL, HDL (often called good cholesterol), and triglycerides (blood fats that go up after we eat)
• Microalbumin: a test of whether diabetes has cause kidney damage
• A Retinal Eye Exam to asses whether there is any evidence of eye damage

The authors explain what these tests mean and how often you should get them. What I particularly like is that they stress that you need to be the owner of these numbers:

“These numbers belong to you, and knowing them is your right, as well as critical to your health – just like the numbers in your bank account.”

They even give you advice on how to get your hands on these numbers:

“It is your right to request them, so don’t feel intimidated about speaking up….A call to the office should suffice…” but they recommend, “make the call at a time when you have some other paperwork to do, and use a speakerphone so that you don’t get too frustrated trying to get through or waiting on the line.”  It seems like they may have had some first hand experience calling doctors' offices.

Don’t feel like you have to do everything at once

There is a chart in the book that the authors titled “Your Diabetes Health Account.” Using it, you can compare your numbers to the certain targets in order to determine how well you are doing. For example, if all of your numbers are at optimal targets, you can see that you have five “bags of money” in your diabetes account. These are your health assets. If your tests are past due or way out of whack, then you have health debts which should be paid off as soon as you can. By taking a close look at your diabetes health account, you can pinpoint your focus of what you need to do to get your health account back in balance.

They counsel, “Rather than depressing you, knowing your priorities should boost your confidence; you have learned exactly which health factors are most important for you right now and which may not need attention on an everyday basis."

Take Action

Once you learned your numbers and assessed your diabetes health account, it is time to take action. The book provides strategies for how to improve every one of the five essential factors. The tips provided are practical, but detailed enough to help even a novice diabetes-self-manager get started.

The first part of the book lays out the strategies for improvement and the second part dives deeper into the diabetes toolkit they are helping your prepare. Advice on diet and exercise are clear and easy to follow. For example, one strategy for portion control, an important element of a weight loss diet, is to share a meal. Pretty simple, huh? Or you can divide your food before you start to eat and have it put into a “doggie bag” before it automatically goes into your mouth to end up around your middle. Avoid buffets. We all know we eat too much at buffets…it is simply too easy to pile it on the plate.

Other good information

There are chapters on diabetes drugs and diabetes devices as well as information about low and high blood sugar. The chapters are well laid out with important information placed in boxes.

Sprinkled through the book are stories of real people living with diabetes, like Loretta, a kindly grandmother with type 2 diabetes who lost weight and brought her hemoglobin A1c into control or Marci, a “high-powered New York City account executive" who enlisted her husband to help her deal with “diabetes frustration.”

Empowerment

Yeah, I know, some of you hate the “empowerment” word. But that is what this book sets out to do. It arms you with information. It helps you understand your particular needs and challenges. And it provides guidance on how to go, one step at a time, from where you are now to where you want to be in terms of diabetes health.

So, there you go. If you have diabetes, if someone you care about has diabetes, or if you are a health professional working with people with diabetes, then buy (and read) this book. You will be glad you did.

Pat Salber, MD

Thanks to Skip McGinty for alerting me to this development: “Researchers Developing Automatic Oral Drug Dispenser”

According to a report by Reuters, the European Union is funding a project to develop a "cybertooth," a
Getting my cybertooth!cybernetic oral device that attaches to a tooth and automatically administers the appropriate dosage of medication as programmed by the patient's physician.

Supposedly the device is designed to help chronically ill people, including those with Alzheimer’s disease, who have physical and/or mental reasons why they miss their medication doses. I, for one, find even with my faculties more or less intact, that it is tough to remember to take those pills, particularly if you have to take them more than once a day. I am always forgetting the pill I am supposed to take in the evening even though I have used lots of little tricks to help me remember, like putting it in a bowl right next to my toothbrush. Hey, just give me a cybertooth and be done with it.

According to Ben Beiski, one of the developers of the device at the Assuta Medical Center in Tel Aviv, Israel, the device could contain up to several weeks of doses of most drugs and administer more than one type of medicine, The device also would transmit information to a remote receiver when it is about to become empty and needs to be replaced.

(from livingpictures.org)Now, we are going to have to wait a while to get our hands on this nifty device. So far it has only been tested in pigs. But those tests found that high levels of the drugs were administered and distributed evenly throughout the pigs’ blood. Beiski, a colleague, and scientists in Europe plan to conduct clinical trials of the device and hope to market it in three years.

Here's a note from a reader:

"Hi Pat-

A friend put me in touch with Maureen Whitehouse, a former model and now author of a new book, Soul-Full Eating. Maureen sent me a copy of her book to review. Now, it is a pretty book with a serenely beautiful cover photo – it’s a lettuce leaf (I think) and something that looks like a animal bone stuck in something that could be some sort of fruit. It is all a little blurry and abstract. But it does remind me of the décor of some of the nicer high-end spas I have frequented.

The subtitle of the book is “A (Delicious!) Path to Higher Conscious.” Oh, oh, I’m thinking … this may be a little too zen for me. I practice yoga because it is a great exercise and my main stretching activity. But I have never really been the meditating sort. I avoid the silent dinners at my annual visit at Rancho La Puerta … not being able to imagine how someone could pass up the chance to blab with the terrifically interesting people who attend that spa.

So, you can imagine my mind set when I started reading Soul-Full Eating. Each chapter starts with a quote. “Eat with love what’s grown with love, prepared with love, and served with love” is the basic principle of Soul-Full Eating. Hmmm.

Each chapter also has exercises to perform to help you understand the ideas presented in that chapter. The first chapter’s exercise was “Just for one day, do only what you genuinely love to do.” Yeah, right…but what about all of work I have to do. Who is going to write the post for The Doctor Weighs In?

Things aren’t going well for me and this book until I hit page 24. There, the author described a “mind-fullness” exercise that she uses in her True Beauty workshops. She describes how she walks into the workshop, and without saying a word, hands the participants three raisins.

Then she asks them to examine the raisins as though they had never seen a raisin before. They are to experience the raisin with what Zen Buddhists call “a beginner’s mind.” She tells the readers to get three raisins and do the exercise while reading this section.

So, I go to the kitchen and open the package of raisins that has been sitting, untouched, in my cupboard for several months (no, really several years, I think). I pick out three raisins and sit to read the section.

First, she tells us, examine one of the raisins carefully. Look at it closely and roll it in the palm of your hand. Lo and behold, the raisin I have picked out is actually two raisins stuck together. Had I just popped it in my mouth, I never would have known that. Next you lick the raisin. It is softer than it felt in my hand. At last, she tells you to put it in your mouth, but not chew it or swallow it, rather let your tongue explore it. Amazing, as I explore the raisin, it starts to get soft and feels like it is plumping up. It likes being in my mouth.

Now, she tells us, to slowly chew , but still not swallow. You are to chew that little raisin until it liquefies. That takes a long time. Meanwhile, you start to really taste the raisin. Ordinarily, if I eat raisins, I just pop a handful of those little sugar bombs in my mouth and swallow. I am not sure I ever really thought about the taste before.

The raisin tastes pretty darn good…earthy and sweet, but not too sweet. It is nice. I swallow the juice. It took about 3 minutes from touch to swallow…considerably longer than my usual “grab and swallow” raisin eating approach.

The author instructs us to repeat this exercise two more times. Each time consciously exploring the raisin and trying to find something new about it that you didn’t notice before. By the time I swallowed the third raisin, I realized how good it was to roll a raisin in your mouth with your tongue. And, how much flavor it has when allowed to slowly disintegrate and dissolve with during the long slow chewing process.

I must say, this exercise did get me in touch with my feelings about raisins in a way I have never experienced before. This, according to Maureen Whitehouse, is mind-full eating. I think I like it! I think I like this book. I think I’ll read the rest and will try to do what Maureen says --  that is to really be there when I eat.  Soul-Full Eating…a pretty good idea.

I must confess, I use Google to complete the NY Times Sunday crossword puzzle (please don't tell Will Shorz). And I regularly use Google instead of the phone book. I plan my vacations, do research for my blogs, and try to locate old friends using Google search. In fact, I use Google for just about everything, but I haven't been using Google to diagnose disease. Turns out, it is not too bad. Some of you may have heard about a doctor who astonished her colleagues by diagnosisng a rare condition

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Rick Botelho is a family doc who really cares about health promotion and disease prevention. He understands that many people have a strong desire to help family members improve their health habits. But all too often good intentions are perceived by the recipient as nagging or worse, a criticism of who they are as human beings. Rick has written a guidebook, Motivate Healthy Habits: Stepping Stones to Lasting change to help families make lasting improvements in their health habits. Here is a summary: Improving Your Family’s Health Habits: Change Yourself before Helping Others By Rick Botelho www.motivatehealthyhabits.com Does giving information and advice to family members help them to change their unhealthy habits work? Then, you’re the lucky one. Despite knowing what to do, most family members do not change their behavior. Giving information and advice addresses only surface change. Knowledge alone seldom changes behavior. For most people, behavior change is a challenge.

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The evidence is piling up that daily weighing is an important strategy for successful weight loss maintenance. I first wrote about the issue in a blog earlier this year titled "To weigh or not to weigh. That is the question." A review of the medical literature at that time suggested that frequent, usually daily, weighing helps dieters stay on track. A follow up blog, "You got it off - now, can you keep it off?" reviewed a study published by researchers from the Centers for Disease Control and Prevention. That study examined differences in habits between people who lost weight and were able to keep it off compared to people who either didn't lose weight or lost weight and regained it. Again, self-monitoring behaviors, including frequent weighing were determined to be key to success.

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The last time I lost twenty pounds, I had a very strong motivation. I was determined I would not be permanently memorialized as the fat lady in my son’s wedding pictures. So I dieted for 6 months – enduring hunger, nausea (I was on the Atkins diet), and bad breath. I also hired a personal trainer to whip me into shape. I did all of this for vanity – it is a powerful motivator. I hit my lowest weight in 20 years the week of the wedding. I look pretty darn good in the pictures. By the week after the wedding, the pounds were piling back on. I did not regain all of it. But I did regain most of it. Why? Because I could no longer force myself to have bacon and eggs without potatoes and toast for breakfast. And I let myself get too busy to exercise. No surprise, I was soon back to my pre-diet plump self. What a pity, after all that work.

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The internet has changed the way we do so many of life's routine activities. We shop on-line for clothes, food, birthday presents (thank heavens--no more going to the post office), insurance, dates, and new friends. The list of things we can do and get on the net just goes on and on. PEERtrainer has joined many other websites as a convenient, fun way to meet people with common interests and goals. It offers peer support and accountability for weight loss and fitness with 24/7 convenience, and if desired, anonymity. And the internet is changing the face of health care as well.

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Rick Botelho is a family doc who really cares about health promotion and disease prevention. Unlike a lot of doctors who glibly tell patients “loses weight” or “stop drinking,” Dr. Botelho really understands how hard it is to make lifestyle changes. He has written a guidebook, “My Healthy Habits” and a companion workbook, “My Healthy Habits Journal, to help individuals find the motivation to change. He advocates moving beyond “health information, advice and self-management supports,” to “motivational approaches to behavior change.” The book takes you through a step-by-step approach that is designed to move you from an unmotivated state to being ready to make the changes and then actually making the changes. The book uses check lists and journaling to help you understand your current readiness to change and to explore barriers to change, including emotional barriers. In his chapter on “Understanding Change,” Dr. Botelho describes the “Force for Change” model. The model is based on the idea that both internal and external factors are involved in determining whether we will make changes in our health habits. The internal factors include understanding where you are at on a scale of “readiness to change.” Readiness to change stages are as follows:

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Check out DiabetesPHD on the American Diabetes Association website. It is a risk assessment tool that uses Archimedes, a sophisticated computerized health modeling program to determine your risk of developing heart disease, stroke, and/or diabetes and its complications (kidney failure, eye problems, foot problems) over the next thirty years. The best thing about this program is it gives you a chance to see what happens to your risk if you lose weight, reduce your blood pressure or improve your cholesterol levels. You can also model the impact of taking certain medications or having better health habits (not smoking, taking an aspirin a day if you are over 40). It is pretty cool to watch the graphs of your risk improve in front of your eyes when you lop off 40 pounds or lower your cholesterol by 40 points.

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