Is It Bad Patient Behavior Or Poor Doctor-Patient Communication?

It seem like everyone these days is focused on changing some aspect of patient health behavior. You know — getting patients to get a mammogram or PSA test, exercise more, take medications as prescribed, or simply becoming more engaged in their healthcare. If only we could change unhealthy patient health behaviors, the world would be a better place.

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I agree with the sentiment, but I think that patients and their health behavior often get a a??bad rapa?? from healthcare professionals. I would even go so far as to say that much (not all) of what we attribute to poor patient behavior is more correctly attributable to ineffective doctor communications with patients.

In my last post I talked about the link between strong physician advocacy, e.g., I recommend, and desirable health outcomes, i.e., patients getting more preventive screening.

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Herea??s what I mean. Mammography studies have consistently shown that screening mammograms rates would be much high if more physicians a??strongly recommendeda?? that women get screened, e.g., a??I recommenda?? you get a mammogram. In studies where physicians advocated for screening, mammography screening rates were always higher compared to physicians that did not advocate for them. The same phenomenon can be found in studies dealing with exercise, weight loss, colorectal cancer screening, HVP immunization, and patient participation in clinical trials.

In cases where physicians unequivocally recommended to patients that they do XYZ, patients were much more likely to do it — or at least they were much more likely to try. I am not naive enough to believe that an unequivocal recommendation from a physician is a a??cure alla?? for the most recalcitrant patients. Factors such as level of patient trust in the physician and patienta??s agreement with the physiciana??s diagnosis are mediating factors. Depression and fatigue from dealing with chronic conditions also play a role. But the evidence clearly suggests that a good many patients probably would respond positively to a strong recommendation from their physician.

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Herea??s an anecdotal experience describe by a physician comment on my last blog post:

“I agree that doctor-patient communication is critically important. My 50 year-old best friend shuns doctors, but told me he is getting a colonoscopy because his doctor strongly recommended it.”

Herea??s the basis for my thinking. Many patients operate on the principle that if my doctor thinks something is important they will tell me. On this point patients can be quite literal. I have seen studies in which obese patients do not see themselves as a??obese.a?? Their self-perception is validated every time their doctor fails to tell the patient that they have a serious weight problem and that they need to lose 20 pounds in no uncertain terms. If I have such a big weight problems, why hasna??t my doctor said anything?

Think back to your recent trips to the doctor. If you are like me, you may be hard pressed to think of a single instance in which your physicians ever said the words a??I recommenda?? to you.

The only such instance I can recall was when my wifea??s oncologist (stage 4 lung cancer) said: “I recommend that you start the chemo treatment immediately — tomorrow wouldna??t be too soon.” My wife did what her doctor recommended and she is alive today some??six years later.

REFERENCES:

Carroll, J., et al. “Clinician-Patient Communication About Physical Activity in an Underserved Population.” Journal of the American Board of Family Medicine. 2008;21:118a??127.

Taylor, V., et al. “Colorectal Cancer Screening Among African Americans: The Importance of Physician Recommendation.” Journal National Medical Association. 2003;95:806-812.

Brown, T., et al. “Predictors of Cardiac Rehabilitation Referral in Coronary Artery Disease Patients.” Journal of the American College of Cardiology. Vo. 54, 2009.

Albrecht, T., et al. “Influence of Clinical Communication on Patientsa?? Decision.” Clinical Oncology. 26:2666-2673. 2008.

                       

A Chia Pet For Diabetes?

Like swallows returning to San Juan Capistrano in the spring, Chia Pets begin appearing every December on late-night television and in the gift aisles of many stores. (Full disclaimer: I bought one for the Yankee Swap at Harvard Health Publicationa??s annual Christmas party.) Water these ceramic figures and they sprout a green a??fura?? from seeds embedded on the surface. Silly? Sure, thata??s why they are such a hit. What you might not know is that the seeds may someday be a real gift for people with diabetes.

Chia seeds come from a plant formally known as Salvia hispanica, which is a member of the mint family. It gets its common name from the Aztec word a??chian,a?? meaning oily, because the herba??s small, black seeds are rich in oils. It was a staple food for the Aztecs, and legend has it that their runners relied on chia seeds for fuel as they carried messages one hundred or more miles in a day. Chia seeds contain more healthy omega-3 fats and fiber than flax or other grain seeds. They are also a good source of protein and antioxidants.

Some preliminary research indicates that chia seeds could a?? I stress the a??coulda?? a?? help people with diabetes control their blood sugar and protect their hearts. Studies in animals show that a chia-rich diet lowers harmful LDL cholesterol and triglycerides while increasing beneficial HDL cholesterol. And a white-seeded variant of chia, called Salba, helped diabetic volunteers control their blood sugar, as well as their blood pressure and new markers of cardiac risk, such as C-reactive protein. The results were published in the journal Diabetes Care.

Before you rush out to buy Salba, which is sold online and in health food stores, keep in mind that it worked only slightly better than wheat bran (which is less expensive and easier to find). In addition, the study was small (20 volunteers), lasted for just 12 weeks, and the results havena??t yet been replicated.

The real message of this work is that cutting back on highly-refined grains (white bread, white rice, etc.) and embracing more whole grains (whole-wheat bread, brown rice, oatmeal, quinoa, chia, and more) is good for people with diabetes and almost everyone else. Numerous studies show that eating more whole grains and foods made from them and cutting back on highly refined grains is an excellent way to fight heart disease, diabetes, and other chronic conditions. Coupling that with the stress reduction you get from watching a Chia Peta??s fur grow could really make a difference!

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A New Twist On Food Allergies In Kids

The current New Yorker unfolds an engaging story on childhood food allergies. As related by Dr. Jerome Groopman, therea??s a shift in how some doctors think about how these conditions ??are best managed and, even better — might be prevented. The article feeds into recent discussion that medical science, and even dogma, too-often turns out to be incorrect.

Groopman interviews Dr. Hugh Sampson, director of the Jae Food Allergy Institute at Mount Sinai Medical Center in New York:

a?|a??This increase in the incidence of food allergy is real,a?? Sampson said when we spoke recently. He cannot say what is causing the increase, but he now thinks the conventional approach to preventing food allergies is misconceived. For most of his career, he believed, like most allergists, that children are far less likely to become allergic to problematic foods if they are not exposed to them as infants. But now Sampson and other specialists believe that early exposure may actually help prevent food allergies.a??

I recommend the full read if you can get it: Groopman probes potential causes of discordant food allergy rates in children of different geographic regions. I learned a number of details on how some doctors in the U.S. use protein-breakdown methods to desensitize children to food allergies, how in Israel newly-speaking infants are said to ask eagerly for Bamba, a manufactured, peanut-containing snack (which, for the record, I dona??t particularly endorse), and how in some cultures parents chew their young childrena??s food in a manner that might that might facilitate breakdown of complex proteins by enzymes in saliva.

All interesting. Of course ita??s hard to know exactly whata??s true in this, and the causes of allergies are likely to vary among children. Therea??s a randomized LEAP study (Learning Early About Peanut Allergy) in the U.K. that may provide some hard evidence on this, one way or another.

                       

A New Twist On Food Allergies In Kids

The current New Yorker unfolds an engaging story on childhood food allergies. As related by Dr. Jerome Groopman, therea??s a shift in how some doctors think about how these conditions ??are best managed and, even better — might be prevented. The article feeds into recent discussion that medical science, and even dogma, too-often turns out to be incorrect.

Groopman interviews Dr. Hugh Sampson, director of the Jae Food Allergy Institute at Mount Sinai Medical Center in New York:

a?|a??This increase in the incidence of food allergy is real,a?? Sampson said when we spoke recently. He cannot say what is causing the increase, but he now thinks the conventional approach to preventing food allergies is misconceived. For most of his career, he believed, like most allergists, that children are far less likely to become allergic to problematic foods if they are not exposed to them as infants. But now Sampson and other specialists believe that early exposure may actually help prevent food allergies.a??

I recommend the full read if you can get it: Groopman probes potential causes of discordant food allergy rates in children of different geographic regions. I learned a number of details on how some doctors in the U.S. use protein-breakdown methods to desensitize children to food allergies, how in Israel newly-speaking infants are said to ask eagerly for Bamba, a manufactured, peanut-containing snack (which, for the record, I dona??t particularly endorse), and how in some cultures parents chew their young childrena??s food in a manner that might that might facilitate breakdown of complex proteins by enzymes in saliva.

All interesting. Of course ita??s hard to know exactly whata??s true in this, and the causes of allergies are likely to vary among children. Therea??s a randomized LEAP study (Learning Early About Peanut Allergy) in the U.K. that may provide some hard evidence on this, one way or another.

                       

App-Tracking The Flu

As a part of the TheraFlu campaign, Novartis has developed free Android, Blackberry and iPhone applications for tracking flu outbreaks in the U.S. These days it’s become inevitable to develop free apps on all platforms in order to promote your product. From Novartis:

Keep up-to-date on the most active cold and flu reports around the country. The WheresFlua?￠ app follows sickness incidence levels from week to week and keeps track of the current top 5 affected cities in the nation. The WheresFlua?￠ app will find your current location and provide you with results for that area. Or you can enter a ZIP code to get information for that area.

If you’re wondering how it actually works and how it differs from Google Flu Trends, here it is:

WheresFlua?￠ measures weekly activity for cold and flu based upon real-time reports of symptoms from SDI FAN?? (a source used by the Centers for Disease Control and Prevention). As the longest-running respiratory tracking program in the US, SDI FAN?? covers illness levels in 135 regions across the country utilizing panel-member reporting along with patient-specific data. Advanced tracking uses illness status levels to predict change in the affected population for the nine US Census Regions.

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a??Just In Casea?? Heart Tests: Can They Do More Harm Than Good?

Herea??s an important equation that all of us — doctors include — should know about healthcare, but dona??t:

More a?? Better

a??More does not equal bettera?? applies to diagnostic procedures, screening tests meant to identify problems before they appear, medications, dietary supplements, and just about every aspect of medicine.

That scenario is spelled out in alarming detail in the Archives of Internal Medicine. Clinicians at the Cleveland Clinic describe the case of a 52-year-old woman who went to her community hospital because she had been having chest pain for two days. She wasna??t having symptoms of a heart attack, such as shortness of breath, unexplained nausea, or a cold sweat, and her electrocardiogram and other tests were fine. The womana??s doctors concluded that her chest pain was probably due to a muscle she had pulled or strained during her recently begun exercise program to lose weight.

To a??reassure hera?? that she wasna??t having a heart attack, the emergency department team recommended she have a CT scan of her heart. This noninvasive procedure can spot narrowings in coronary arteries and other problems that can interfere with blood flow to the heart. When it showed a suspicious area in her left anterior descending artery (a key artery nourishing the heart), she underwent a coronary angiogram. This involves inserting a thin wire called a catheter into a blood vessel in the groin and deftly maneuvering it into the heart. Once in place, equipment on the catheter is used to make pictures of blood flow through the coronary arteries.

During the angiogram, the womana??s aorta was torn. Emergency bypass surgery was needed to fix this tear. The bypass graft failed, and she had several wire-mesh stents implanted to hold open the graft. A blood clot formed inside one of the stents, causing a heart attack and complete heart failure. She ultimately needed a heart transplant.

Such an unfortunate chain of events is rare. But it highlights the fact that things can, and do, go wrong in medicine — in every other aspect of life and business. No test, no procedure, no drug or dietary supplement is 100 percent??safe.

Readers of the Harvard Heart Letter often write asking if they should have an exercise stress test or a coronary calcium test or a scan of their carotid arteries a??just in case,a?? even though they feel fine and are in generally good health. In theory, such information could warn about an impending heart attack or stroke. The answer from cardiologists on the newslettera??s editorial board is a resounding a??No.a?? Why? Because the chances of causing harm — physical, emotional, or financial — often far exceed the limited diagnostic information and advice for management the test provides.

Tests and procedures are justified when there are solid, evidence-based reasons for performing them, when the anticipated benefits exceed the likelihood of risk, and when their results will clearly change how a persona??s care is managed. Reassurance and a??just in casea?? dona??t fill the bill.

- PJ Skerrett, Editor, Harvard Heart Letter

                        h

A Second Opinion Is Good, But A Third Or Fourth?

A few years ago I started writing a book on what it was like to be a cancer patient and an oncologist. This morning I came upon this section on second opinions:

Is It OK To Get A Second Opinion?

Definitely. And therea??s no need to be secretive about it, or to worry about hurting the doctora??s feelings. Second opinions are routine in fields like oncology, and are often covered by insurance. Be up-front: Any decent oncologist can understand a cancer patienta??s need to find a doctor whoa??s right for them, with whom theya??re comfortable making important decisions. And in difficult cases, some specialists appreciate the chance to discuss the situation with another expert. So a second opinion can be beneficial to patients and physicians alike.

When things can get out of hand, though, is when patients start a??doctor shopping.a????For example, Ia??ve cared for some patients with leukemia whoa??ve been to see over 10 oncol?-o?-gists. If youa??re acutely sick, this sort of approach to illness can be coun?-ter?-pro?-ductive — it can delay needed therapy. From the physiciana??s per?-spective, ita??s alien?-ating: Who wants to invest her time, intel?-lectual effort, and feelings for a??patient whoa??s unlikely to follow up? Besides, oncology is the sort of field where each con?-sulting doctor may have a??dis?-tinct opinion. (If you see??10 oncol?-o?-gists, you may get??10 opinions.) Beyond a??certain point, it may not help to get more input, but instead will cloud the??issue.

As things stand, oncol?-o?-gists often discuss dif?-ficult cases with their col?-leagues. This happens at aca?-demic centers and hos?-pitals, where tumor boards meet reg?-u?-larly to review the diag?-nosis and man?-agement of each cancer case, and infor?-mally in private prac?-tices, where physi?-cians are likely to discuss certain aspects of treatment with their partners. For patients with very rare con?-di?-tions, some oncol?-o?-gists will call experts in the field whom they may know through national meetings, journals, and other resources. What this means for patients is that through one con?-sultant, they may be getting input of more than one expert, although they may not be??aware.

So I??rec?-ommend that patients with cancer, or any other serious or rare con?-dition for that matter, get a??second or third opinion about the best way to manage their illness. But at some point youa??ve got to select one among those spe?-cialists, even if shea??s not perfect, and stick with her at least for awhile, until you have a??good reason to switch or move on. Otherwise, youa??re unlikely to have a??doctor who cares when youa??re really sick and, later, about your long-term well-being.

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Doctors And Aging: 5 Things To Help Good Doctors Stay Good Longer

I asked my age-matched colleague the other day: a??Do you think we’ll know when it happens to us?a?? He responded: a??I know. I worry about that, too…a lot. Ia??m getting out before it happens to me.a??

We were talking about our fears of being labeled as an a??olda?? doctor.?? Not just old in years — our children and bifocals remind of us of that — but old in our mindset. We fear becoming one of the dinosaur doctors who get known for their excessive attachment to old dogma, premature dismissiveness of novel new approaches, fear of social media, and of course the tell-tail (pathognomonic) sign of agedness, ranting mindlessly in front of Fox news about healthcare reform in the doctora??s lounge.

This transition can happen fast.??One moment a doctor might be in their sweet spot — a period of time where the nearness of training meets with the treasure of experience in a capable mind, body and spirit.?? Sadly, and obviously this period is finite. Ita??s limited by aging. Getting older happens to all of us, but the pertinent fact for medical practice is that, like all humans, doctors age at different velocities.

The topic of how best to deal with aging doctors came up after this provocative piece in the New York Times highlighted a couple egregious cases of bad care at the hands of doctors who should have been retired.??Kevin Phoa??s follow-up piece emphasized the relevance of this topic when he suggested that more than one in three U.S. doctors are over 65 years old, and that unlike pilots they are a??grandfathereda?? into not being required to take re-certification exams. That policy is hard to defend.

Since I’m writing this post with the aid of reading glasses, how to handle aging doctors hits me pretty hard.??Ita??s a quandary.??For instance, I know a cardiologist in his early sixties who behaves like a chief resident — quoting journal articles, presenting interesting cases and even voluntarily re-certifying (he was grandfathered).??Herea??s a doctor with both 25 years experience and knowledge of the cutting edge.??The quality of his doctoring speaks loudly against any arbitrary age cutoffs.??But then there are the outrageous cases cited in the Times piece.

Ia??d like to think therea??s a way to extend the sweet spot of doctoring. Perhaps the answer is obvious: The same things that make healthy people healthy might make good doctors stay good longer. Things like:

1. Staying physically fit.??Sleeping well, eating well, and exercising regularly have all been shown to improve mentation and dexterity.??Quick thinking and nimbleness both make for better electrophysiologists.

2. Staying mentally engaged. I feel like a better doctor after returning from a medical meeting.??Likewise, I certainly feel more informed after researching a journal article for a blog entry.??(Immediate disclaimer:?? I am not saying bloggers make better doctors — some might argue the opposite.)

3. Staying emotionally engaged.??In other words, caring.??Healthy people seem to have a cause thata??s important to their self-esteem.??The best doctors I know hang a lot of their self-esteem on their doctoring peg.??But not too much — no peg is that strong.

4. Staying balanced. Healthy people exude balance.??They may focus on one thing primarily, but keep other interests, too — things like spending time with family, reading fiction, watching movies, riding a bike, or volunteering their time.

5. Staying open-minded.??This doesna??t come naturally to aging doctors. (First off, they are mostly republican.) Sure, much of what worked in the past stays timeless, but not always.??For instance, if I wasna??t open-minded, three of my afternoon patients may still have AF symptoms, and a few more would still be taking a drug that poisons rodents.

Let the quality people try and measure these five traits with checklists and spreadsheets.

JMM

                       

Whispering: Is It Bad For Your Vocal Cords?

Is whispering bad for your vocal cords? For most people, the answer is yes according to research publicized in a recent??New York Times article.

In the mentioned study, out of a group of 100 patients, 69 percent??exhibited increased supraglottic hyperfunction with whispered voice (i.e. it was bad for the voice.) Eighteen percent??had no change and 13??percent??had less severe hyperfunction.

As such, though whispering is not bad for everybody, it is for most people and as such, the safest thing to do if the vocal cords are damaged whether by infection or trauma is to rest your voice. If you have to talk, do not whisper, but rather talk in a soft voice.

The best way to think about injured vocal cords is to talk in an analogy. Laryngitis is like a badly sprained ankle. In this scenario, talking is like walking and screaming is like running. So just like you would rest the sprained ankle and not walk on it in order for it to recover as quickly as possible, you should refrain from talking in order for the laryngitis to recover as quickly as possible. Where does whispering fall in this analogy? Probably equivalent to running on a sprained ankle.

Read more about voice problems here.

REFERENCE: “Laryngeal hyperfunction during whispering: reality or myth?” J Voice. 2006 Mar;20(1):121-7.

                       

Fungus: An Unwanted Yoga Partner

Yoga is good for your mind and body, including your skin. Yoga mats, on the other hand, might not be. Using someone elsea??s yoga mat for an hour could lead to an infection.

Fungal infections are common and appear as athletea??s foot, toenail fungus, and ringworm. Unfortunately, the fungus can survive on surfaces like mats long after the infected person has left. Although most people blame the gym locker room when they develop athletea??s foot, you can catch the fungus from a variety of places anytime you walk barefoot.

Fortunately, even if the fungus comes into contact with your skin, it doesna??t always lead to infection. Dry, cracked skin, or soft, wet skin disrupt your primary defense against the fungus — the densely packed barrier of skin cells, oils and proteins on your healthy skina??s surface. Here are??five ways to prevent taking a fungus home with you from your next yoga class:

1. Bring your own mat. At least you know what you have.

2. Use an alcohol sanitizer on your hands and feet after your class. Sanitizers with at least 60 percent??alcohol are excellent at drying up the fungus and killing it long before it has a chance to infect you.

3. Clean your yoga mat. Use a solution of??one part vinegar to??three parts water and scrubbing will act as a fungicide. You can add a few drops of essential oils to the wash so that your neighbor doesna??t think that vinegar smell from your mat is coming from you.

4. Take a shower after class. Be sure to scrub your hands and feet with soap and water. Fungus sitting on the surface of your skin can easily be washed off.

5. Keep your skin healthy. Damaged, cracked, or moist skin is vulnerable skin. Dry your feet well and use antiperspirant on them if you have trouble keeping them dry. Moisturize daily to preserve a protective barrier of healthy skin which will keep infections out.

                       

There’s Still Time For A Flu Shot

Ita??s not too late to protect yourself and your family from the flu. Influenza??is about to enter its??peak season??in the United States. Now is the time to be vigilant in protecting against and preventing the spread of flu. Washing your hands, staying home from work or school, and covering your cough can be incredible steps.

But the most effective way to prevent influenza is to get vaccinated. If you havena??t had a flu shot, get one this week. Your child can be immunized if over??six months of age, and remember that many children under age??nine will need a second dose (booster shot).??Find out??how to determine if your child needs a second dose.

1o Things To Know About Influenza

1. Influenza peaks in February and March in the United States. Look at the CDC data that reflects ongoing influenza activity.

2. Vaccination is the best way to protect you, your family, and your community from the flu.

3. Children under age??five are at higher risk from complications from the flu. Children under age??two are at even higher risk. Children with asthma and other underlying medical conditions are at higher risk as well.

4. Pregnant women are at exceptionally high risk from influenza and complications from the infection due to changes in their immune, cardiac, and pulmonary (lungs) systems. While pregnant women make up only 1 percent??of the U.S. population, they accounted for 5 percent??of the countrya??s deaths from H1N1 (swine flu) in 2009. All pregnant women are recommended to get a flu shot. However, we know that only about 30 percent??of moms are immunized at the time of delivery. The bonus of protecting themselves? New research shows how vaccinating pregnant women protects babies. When moms protect themselves by getting flu shot, they also prevent spreading flu to their babies. Babies born to vaccinated moms have a lower risk of flu (and hospitalization) under??six months of age when they are too young to get the flu vaccine.

5. The best way to protect a newborn baby from the flu is to have all caregivers (parents, grandparents, nannies) get the flu shot.

6. People can spread the flu to others before they even now theya??re sick. People also spread the infection after they have had it — they can continue to spread flu for??five to??seven days??in mucus via sneezing??and coughing. The best way to protect yourself is to get a flu shot, and second to that: Wash you hands, cover your cough, and stay home from school or work when sick with??cold and flu??symptoms.

7. Each year 20,000 children under age??five are hospitalized with flu or complications of the flu.??Eleven children died from influenza during the week of January 30 through Feb 5th, 2011??in the United states.

8. Although flu is reported as widespread in 37 states, nearly all areas have circulating flu right now. See the most recent CDC data on influenza around the country.

9. Overall flu vaccination rates are less than 50 percent??for people under 65 years of age. To best protect our communities, vaccination coverage rates should be about 90 percent. Wea??re not there. Immunizing yourself and your family protects those who are too sick (or too young) to get the flu shot and are also at higher risk of complications.

10. Flu shots for children under age??three do not have thimerosal. FluMist (intranasal flu vaccine) doesna??t have thimeroal. Read the National Network for Immunization Information (NNii) page on mercury in vaccines. I dona??t believe you need to find a thimerosal flu shot.

                        y

A Map App For Wheelchair Users

Getting around a city can be hard when you’re in a wheelchair because some places simply aren’t designed for wheels. Wheelmap is an iPhone app for wheelchair users which tells you about the accessibility of nearby restaurants, cafes, clubs, museums, and other locations.

Locations are color-coded on a map to show how accessible they are. The current location, but also any place around the world, can be viewed. Maps are based on OpenStreetMap data, and accessibility data about locations can be modified and sent back to the servers by users from within the app. There is also a corresponding website showing the same information online.

As with any other crowd-sourced initiative, success depends on the number of contributors, but we have good hopes for this one to succeed.??Because the app was created by a German, coverage is most extensive in Germany, particularly Berlin, but other large cities worldwide are starting to catch up.

More from AP: German iPhone app guides handicapped around cities…

iTunes link: Wheelmap…

Homepage: Wheelmap…

                       

What Is Telebaby?

There are more and more premature babies, and the situation for their parents is dramatic. They would love to be with their newborn 24 hours a day, but in most cases they obviously can’t.

At the Dutch UMC Ultrecht, they’ve launched a project under the name Telebaby, in which cameras were installed at the incubators and parents can watch their child live 24 hours a day — even through a mobile device.

The system is password protected, of course, so only the parents can access the specific video channels. Isna??t it great? A very human but not that expensive idea — a really Dutch approach.

                       

May We All Die So Well

Everyone liked him. Though his later years (the only ones in which I knew him) took away his ability to do most things, and though he was in great pain every day, it was easy to see the mischief in his eyes. The subtle humor was still there, coming out of a man who was weak, in pain, dying.

She lived for him. She was always telling me of his pain, frustrated with the fact that he didna??t tell me enough. She was anxious about each complaint of his, wondering if this was the one that would take him away from her. Many of her problems were driven by this anxiety and fears, and she spent many hours in my office giving witness to them through her tears.

As his health failed, I wondered about her future.??He was the center of her life, the source of her energy, joy, purpose. How could she manage life without him? How could she, who had so much lived off of the care of this wonderful man, find meaning and purpose in a life without his calming presence?

Then he died.

I saw her in the office recently, and was amazed at the look in her eyes. It wasna??t the empty, lonely look I was expecting. It wasna??t the worried, helpless look that I had seen so many times. It was peaceful, content.

a??You look good,a?? I said, wondering at what I saw.

a??I miss him a lot,a?? she said — something that really didna??t need saying.

a??You looka?|content, much better than I expected,a?? I responded.

a??I feel content. I miss him so terribly, but I am so blessed that I could be with him when he died.a??

When his health failed, I called hospice to take away much of the worry and fear.??I wasna??t sure how well shea??d accept that help, but she did, and his death came fairly rapidly.

a??He died in my arms,a?? she continued. “For the last two hours of his life, he just lay in my arms. He didna??t say anything to me, but I am sure he knew. I just held him.a??

a??Ia??m glad you could do that. I want people to die with their loved ones around them. Ita??s a sacred thing, something very intimate.a??

a??Yes, it is,a?? she said, looking up at me and smiling. “All of those years we spent together, and I got to be with him until the very end. He was mine, and I took care of him. Now when I think about how he died, I get meaning and purpose.a??

I thought about this as she left the office.??Ia??ve seen many people die, and have helped many through the grieving process. I have witnessed the loneliness, the pain, the loss, and have done what I can to comfort.??But this woman took comfort in something unexpected: She took comfort in her husbanda??s death. The story ended up in such a fulfilling way that the pain of loss was eclipsed by the joy of a life with her husband.??The way he died made all of the love and all of the shared life close in a way that wasna??t tragic, it was climactic.

That is what it is to die well. Death is inevitable, but it is almost always seen as tragic. Yet his death was a culmination of all his life had been. His memorial service, she told me, was filled with people telling of his wonderful demeanor, his wry humor, and his caring heart. So to her, the story ended up in a most satisfying way.??The intensity of the loss only serves to emphasize the glory of the life.

May we all die so well.

                        m

An Animated Look At The Future Of Healthcare

Mrs. Happy and I just returned from Disney World for our Happy family vacation. (It was either that or a Parkinson’s Cruise.) While at Disney’s Epcot Center, Mama and Papa??Happy discovered what the future of healthcare in America will look like, and it has nothing to do with insurance.

You’ve all seen that giant Epcot ball.??Inside that ball is a slow-moving ride??that takes??you through thousands of years of history. At the end you choose your own future. I present to you this video showing the future of healthcare in America, courtesy of the Epcot Spaceship Earth and Mama and Papa Happy:

A couple words of mention. They still think there will be doctors in the future, unless their reference to doctors was reference to future nurse practitioners known as Dr. Nurse. That’s quite possible.??Maybe that’s why the future of healthcare has nothing to do with medical care or insurance and has everything to do with healthy lifestyle.??You don’t need to be a nurse for that, you just have to accept the truth of healthy living.??And you don’t need a medical school education or even nursing education requirements to make that happen.

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The 12 STIs Of Christmas

My yearly Christmas favorite reposted, courtesy of the British National Health Service (BNHS):

(Click on the??title image to watch)

I have seen several searches of this blog for the??BNHS and wondered why. The answer: The site no longer carries the wonderful show, for reasons unknown to me. As for the searches, I guess the Christmas season has people thinking about sexually-transmitted infections (STIs) set to a Christmas tune.

Merry Christmas!

                       

Painkiller Safety

Perhaps as many as one in every??five American adults will get a prescription for a painkiller this year, and many more will buy over-the-counter medicines without a prescription.??These??drugs can do wonders a?? getting rid of pain can seem like a miracle a?? but sometimes therea??s a high??price to be paid.

Remember the heavily marketed??COX-2 inhibitors???Rofecoxib, sold as Vioxx, and valdecoxib, sold as Bextra, were taken off the market in 2004 and 2005, respectively, after studies linked them to an increased risk of heart attack and stroke.

The??nonsteroidal??anti-inflammatory drugs (NSAIDs), like aspirin, ibuprofen (sold as Advil and Motrin), and naproxen (sold as Aleve) seem like safe??bets.??But??taken over long periods, they have??potentially dangerous gastrointestinal side effects, including ulcers and bleeding. Kidney and liver damage??are possible, too. More recently, some of the NSAIDs??have??been linked to an increased risk of cardiovascular disease.??Low doses of aspirin (usually??defined as 81 mg) is an exception and is??often prescribed??to lower the risk of heart and stroke.

Even acetaminophen, which is often viewed as the safest pain drug and a low-risk??alternative to the NSAIDs because it doesna??t have their gastrointestinal side effects,??comes with a caution about high doses??possibly causing liver failure.

Then there are powerful??opioid painkillers, which??include codeine,??morphine, methadone, and other drugs that are much better known by their brand names. These include Oxycontin,??a sustained-release form of oxycodone;??Percocet, a combination of??oxycodone and acetaminophen (acetaminophen is the active ingredient in Tylenol); and??Vicodin,??a combination of??hydrocodone and acetaminophen.

The??number of prescriptions being written for the opioid drugs has skyrocketed in the last 10 years or so,??partly because doctors are encouraged to treat chronic pain these days and partly because the problems with the non-opioid?? painkillers have become more evident.

Of course, the??opioid painkillers are not without their problems. People??misuse them??to get high. The risk of addiction is real. And??even when used as prescribed for pain, larger and larger doses may be needed to achieve the??same effect.??Deaths from??overdoses of opioids have been?? increasing at an alarming rate.

And in November,??an opioid called??propoxyphene (sold as Darvocet and, when combined with acetaminophen,??as Darvon)??was taken off the market after the??FDA??advised doctors to stop??prescribing the drug because it can??cause??fatal heart arrhythmias.

Making side-by-side comparisons

Two studies published in the Archives of Internal Medicine last week help put the safety??problems??of many of the?? painkillers in perspective by making some??side-by-side comparisons.??One of the studies??compared the safety of??NSAIDs with??the safety of COX-2 inhibitors and the opioid painkillers when they are prescribed for osteoarthritis and rheumatoid arthritis.??The other??study compared the safety profiles of five??opioids (codeine, hydrocodone, oxycodone, propoxyphene,??tramadol) when they were prescribed for pain not related to cancer.

Researchers at Harvard-affiliated Brigham and Womena??s Hospital conducted both studies. The raw??data for their analysis came from??pharamaceutical assistance programs for low-income adults in New Jersey and Pennsylvania in the late 1990s and early 2000s. The researchers??used an interesting??statistical technique called propensity scoring, which??tries??to make??the comparison groups developed from??observational data the same,?? just as the comparison groups??would be in a??randomized clinical trial, the gold standard for medical research.??Both studies??were paid for by??a grant from the Developing Evidence to Inform Decisions about Effectiveness program run by the??Agency for Healthcare Research and Quality, a federal government??agency.

In many??ways, the results from the study comparing NSAIDs,??COX-2 inhibitors, and opioids??arena??t all that surprising. They show that in most respects, the NSAIDs are as safe, and??probably??safer, than the COX-2 inhibitors.??The notable??exception is??gastrointestinal bleeds, and thata??s not going to turn many heads??because a??sparing the guta?? had been??the??chief selling point for the COX-2 inhibitors.

Also to be expected:??the opioids are riskier in almost??all categories??than the??NSAIDs and COX-2 inhibitors.

Still, it was??a surprise??that the opioids are??associated??with a higher risk for??cardiovascular events (heart attacks, strokes, out-of-hospital cardiac death) than the NSAIDs and COX-2 inhibitors, according to Dr. Daniel H. Solomon, the lead author.??Reviewers and some senior colleagues were??skeptical, he says??(keep in mind the paper was under review before Darvocet and Darvon were taken off the market).

Dr. Solomon says the??next step is??to??re-analyze??the??data to see whether??specific??opioids might be related to??specific kinds of??arrhythmias or??other sorts of heart problems.

Another novel finding was that opioid users were much more likely to break a bone than people taking NSAIDs or COX-2 inhibitors.??An opioida??fracture link has been reported before. Opioids increase the risk of falling and may also weaken bones by altering hormone levels. But??the fracture risk??among opioid users??was much higher than the risk??seen in prior studies.

Codeine not so safe

As for the??second study comparing the five opioid drugs, the??biggest surprise there was that codeine emerged??looking much??riskier than the other four drugs with respect to cardiovascular events and all-cause mortality.

Thata??s unexpected??because doctors tend to view codeine as a milder, safer opioid. An??editorial in the??Archives about the??study talks about??codeine??being??a a??middle-ground treatmenta?? between all the various non-opioid painkillers and the??more powerful??opioids.??It??continues:

The untested but widespread assumption that codeine is safer from an addiction standpoint because of its lower potency may need to give way to these data demonstrating increased risk of cardiovascular events and all-cause mortality. If codeine is of middling efficacy for pain and is more risky than other opioids, there would be little reason to use it.

Of course, as the editorial points out, it will take??more research to figure out whether that is really the case.

A more complete conversation needed

So where does this leave us?

Certainly that much more wary of opioid painkillers,??and perhaps of codeine in particular. The??FDA has been moving toward??requiring special training for doctors who prescibe extended-release and long-acting opioids because of abuse and overdose??problems. These results??add??side effects and safety??considerations to??the argument that ita??s time to rein in the runaway use??of opioid painkillers.

Dr. Solomon said the broader theme of the research is to re-evalate painkillers as a group and across various safety problems. Often, he says, researchers and doctors have been a bit myopic, focusing on one drug and one side effect or safety problem at a time. a??The conversation about the side effects from painkillers needs to be more complete,a?? he says.

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The Energy Drink

By??Scott Gavura, BScPhm, MBA, RPh??for Science-Based Medicine

My stimulant of choice is coffee. I started drinking it in first-year university, and never looked back. A tiny four-cup coffee maker became my reliable companion right through graduate school.

But since I stopped needing to drink a pot at a time, an entirely new category of products has appeared — the energy drink. Targeting students, athletes, and others seeking a mental or physical boost, energy drinks are now an enormous industry: From the first U.S. product sale in 1997, the market size was $4.8 billion by 2008, and continues to grow. (1)

My precious coffee effectively has a single therapeutic ingredient, caffeine. Its pharmacology is well documented, and the physiologic effects are understood. The safety data isna??t too shabby either: ita??s probably not harmful and possibly is even beneficial. (Ia??m talking about oral consumption — no coffee enemas. Please.) In comparison, energy drinks are a bewildering category of products with an array of ingredients including caffeine, amino acids, vitamins, and other a??naturala?? substances and assorted a??nutraceuticals,a?? usually in a sugar-laden vehicle (though sugar-free versions exist). Given many products contain chemicals with pharmacologic effects, understanding the risks, signs of adverse events, and potential implications on drug therapy, are important.

So are energy drinks just candied caffeine delivery systems? Or are these syrupy supplements skirting drug regulations?

The Message

The ads are seductive. Who doesna??t want more energy? Who doesna??t want their mind and body a??vitalized?” And dona??t we have time-starved lifestyles? Initially envisioned for athletes, energy drinks are now marketed mainly towards teens and young adults, where uptake has been dramatic. Cross-promotion with extreme sporting events, and creating names like a??Full Throttle,a?? a??Rockstar,a?? and even?? a??Cocainea?? burnish the a??extremea?? image. The market is now segmented further with products targeted at women, vegetarians, diabetics, celiacs, and more. However you identify yourself, therea??s probably an energy drink developed with you in mind.

The Ingredients

Evaluating claims of efficacy and safety are complicated by the multiple formulations and versions of the products. Most energy drinks contain these ingredients:

Ginseng is often claimed to have remarkable properties, from preventing colds to acting as an immune a??boostera??, but therea??s actually little evidence to suggest it has any of these effects. Studies looking specifically at performance effects have not been impressive. (2) Furthermore, the doses that have been studied significantly exceed the amounts that are found in energy drinks. At low doses ginseng seems safe, but therea??s not a lot of long-term data to reassure us. (3)

Taurine is an amino acid that is is plentiful in our diets, and can also be endogenously manufactured. Ita??s involved in an array of physiologic functions. Whata??s not clear is if exogenous taurine supplements have any meaningful effect on subjective or objectively measures of a??energya?? or performance. There are limited data evaluating taurine in combination with caffeine, but high quality evidence is lacking. Taurine does seem to be reasonably well tolerated, however, with few adverse events reported or expected. (3)

Glucuronolactone is another natural ingredient of food for which therea??s no evidence of deficiency, nor any evidence that supplementation improves energy level. Consumption at the levels present in energy drinks is considered safe.

Bitter Orange is the peel or oil from Seville oranges. It became a popular ingredient in supplements after ephedra was pulled from the U.S. market. A natural source of epinephrine-like compounds, it shares the same adverse effect profile, with links to serious events such as syncope, heart attacks, colitis, and stroke. Therea??s no persuasive evidence demonstrating bitter orange provides any energy boost, particularly at the low levels present in energy drinks. However, given bitter orange is usually combined with other stimulants, the true pharmacologic profile, and consequent adverse effects, may not be clear. (3)

Caffeine and guarana (a natural source of caffeine) are the most relevant ingredients in energy drinks. Caffeine has a variety of physiologic effects, and while it appears to have value improving endurance and reducing fatigue during sustained physical exercise, its role as a cognition booster seems much more tenuous. It also seems to improve the effectiveness of analgesics, and may possibly have its own analgesic properties. In general caffeine has a reasonable safety profile at moderate doses. (3)

While total amount of caffeine in an energy drink may not be listed, as natural sources may not be included in the nutritional information, coffee has more caffeine than many energy drinks. A 16 oz a??grandea?? coffee at Starbucks has 320mg of caffeine; the 20oz a??ventia?? has 400mg. (For Tim Hortons lovers, therea??s about half that much caffeine in your double-double). In comparison, a Red Bull has 151mg/16 oz, Monster Khaos has 150mg/16oz, and Rockstar Punched has 160mg/16oz. And a 573mL can of Coca Cola (19oz) has a piddly 62mg. If you accept that caffeine is worth consuming, then energy drinks are clearly not the best source. Even factoring in the caffeine from guarana, coffees still appears to be the caffeine king. (CSPI has a nice compilation of the caffeine content of different beverages.)Besides, therea??s always Nodoz.

Vitamins are in many of the energy drinks: especially combinations of the B vitamins, like cyanocobalamin (B12), niacinamide (B3), pantothenic acid (B5) and pyridoxine (B6). Vitamin C is also common. In the absence of a deficiency, there isna??t any persuasive evidence to suggest that supplementation has meaningful effects on a??energy,a?? however defined. (3) Even long term use of the B vitamins doesna??t look promising for cognition.

Sugar is the major sweetener in energy drinks, though sugar-free versions exist. Speaking strictly in terms of chemistry, as a carbohydrate, sugar is the only actual energy in an energy drink. (The a??calorie free energy drinka?? ads make me laugh out loud.) The sugar content of most products seems largely similar to colas and other soft drinks. So if you want to carb-load, therea??s no particular advantage to the energy drinks — sugar is sugar, and calories are calories.

Risks

Side effects related to energy drinks appear to be largely due to the caffeine content. Thresholds are difficult to predict, given that tolerances to caffeine can vary. In general, the amounts of taurine, guarana, and other components are felt to be below the level necessary to cause noticeable adverse effects.(2) While there have been serious adverse events reported with energy drinks including seizures and sudden death, clear causation has not been established.

Probably the biggest concern related to energy drinks is their consumptions by youths and adolescents, where caffeinea??s effects are less well understood. Sugar and caffeine consumption are probably best minimized in this population, yet ita??s clear that this is the target consumer.

The combination of energy drinks with alcohol — they are popular mixers — has been linked to a suppression of the traditional intoxication effects.Therea??s controversy over the sale of the deliberate combinations of the two ingredients, and some regulators have taken action to stop the sales of some products.

Regulation

Regulation of energy drinks varies by country. From an international perspective, the United States has one of the least regulated marketplaces. (1) Caffeine limits that apply to cola drinks do not apply to energy drinks. In Canada, some energy drinks are federally approved as natural health products. For example,?? the authorized recommended use for Red Bull is:

Developed for periods of increased mental and physical exertion, helps temporarily restore mental alertness or wakefulness when experiencing fatigue or drowsiness.

The product has a specific caution not to consume more than 500mL (2 cans) per day, and that it is not recommended for children, pregnant, or breastfeeding women.

Given their noveltly in the market, and their growing popularity, expect regulatory approaches to vary around the world. Products like Red Bull have been subject to regulatory restrictions and even bans in some European countries.

Conclusion

Neither innocuous nor toxic, energy drinks seem safe for adults when consumed in moderation. Therea??s no convincing evidence to back up the cognitive or athletic performance enhancement claims attached to the category, or to specific products. Despite the impressive lists of ingredients and slick marketing, these products are essentially caffeine delivery vehicles, most of which come loaded with sugar. The incremental risk from the other ingredients isna??t well understood, but is probably small when consumed occasionally.

So go ahead and enjoy your Red Bull. But when that liquid candy stops appealing to you, Ia??ve got some shade-grown, bird-friendly, passive-organic, fair-trade, home-roasted coffee for you to try.

REFERENCES:

1. Heckman, M., Sherry, K., & De Mejia, E. (2010). Energy Drinks: An Assessment of Their Market Size, Consumer Demographics, Ingredient Profile, Functionality, and Regulations in the United States Comprehensive Reviews in Food Science and Food Safety, 9 (3), 303-317 DOI: 10.1111/j.1541-4337.2010.00111.x

2. Clauson, K., Shields, K., McQueen, C., & Persad, N. (2008). Safety issues associated with commercially available energy drinks Journal of the American Pharmacists Association, 48 (3) DOI: 10.1331/JAPhA.2008.07055

3. Natural Medicines Comprehensive Database. Subscription required to view.

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Shoveling Snow? How To Protect Your Heart

After shoveling the heavy, 18-inch layer of snow that fell overnight on my sidewalk and driveway, my back hurt, my left shoulder ached, and I was tired. Was my body warning me I was having a heart attack, or were these just the aftermath of a morning spent toiling with a shovel? Now that Ia??m of an AARP age, ita??s a question I shouldna??t ignore.

Snow shoveling is a known trigger for heart attacks. Emergency rooms in the snowbelt gear up for extra cases when enough of the white stuff has fallen to force folks out of their homes armed with shovels or snow blowers.??

Whata??s the connection? Many people who shovel snow rarely exercise. Picking up a shovel and moving hundreds of pounds of snow, particularly after doing nothing physical for several months, can put a big strain on the heart. Pushing a heavy snowblower can do the same thing. Cold weather is another contributor because it can boost blood pressure, interrupt blood flow to part of the heart, and make blood more likely to form clots.

When a clot forms inside a coronary artery (a vessel that nourishes the heart), it can completely block blood flow to part of the heart. Cut off from their supply of life-sustaining oxygen and nutrients, heart muscle cells begin to shut down, and then die. This is what doctors call a myocardial infarction or acute coronary syndrome. The rest of us call it a heart attack.

The so-called classic signs of a heart attack are a squeezing pain in the chest, shortness of breath, pain that radiates up to the left shoulder and down the left arm, or a cold sweat. Other signs that are equally common include jaw pain, lower back pain, unexplained fatigue or nausea, and anxiety.

I figured I was tired because I had been shoveling for three hours, my left shoulder hurt because of the way I was tossing snow, and my back hurt from all the bending and lifting. I felt confident about my self-diagnosis, but would have changed it in an instant if something else started bugging me. (Click here to read a??Chest pain: A heart attack or something else?a?? from the May 2010 Harvard Heart Letter.)

If you need to clear away snow, keep in mind that this activity can be more strenuous than exercising full throttle on a treadmill. Thata??s no problem if you are healthy and fit. But it can be dangerous if you arena??t. As I mentioned in the December 2010 issue of the Heart Letter, a study from the University of Virginia Medical Center suggests that anyone who has received an artery-opening stent in the preceding year or so might want to be especially careful about clearing snow.

Here are some tips for safe shoveling:

• Warm up your muscles before starting.


• Shovel many light loads instead of fewer heavy ones.


• Take frequent breaks.


• Drink plenty of water.


• Dona??t feel that you need to clear every speck of snow from your property.


• Head indoors right away if your chest starts hurting, you feel lightheaded or short of breath, your heart starts racing, or some other physical change makes you nervous. If you think you are having a heart attack, call 911 or your local emergency number.

If you are out of shape or worried about your heart, hire a teenage neighbor. He or she could use the money, and probably the exercise.

- P.J. Skerrett, Editor, Harvard Health Letter

                       

New Dietary Guidelines Give Little New Guidance

There isna??t much new in the latest iteration of the “Dietary Guidelines for Americans.” Three years in the making, the 2010 guidelines (released a tad late, on January 31, 2011) offer the usual advice about eating less of the bad stuff (salt; saturated fat, trans fats, and cholesterol; and refined grains) and more of the good stuff (fruits and vegetables; whole grains; seafood, beans, and other lean protein; and unsaturated fats). Ia??ve listed the 23 main recommendations below. You can also find them on the “Dietary Guidelines” website.

The guidelines do break some new ground. They state loudly and clearly that overweight and obesity are a leading nutrition problem in the United States, and that a healthy diet can help people achieve a healthy weight. They also ratchet down sodium intake to 1,500 milligrams per day (about two-thirds of a teaspoon of salt) for African Americans and people with high blood pressure or risk factors for it, such as kidney disease or diabetes. But the guidelines also leave the recommendation for sodium at 2,300 milligrams a day for everyone else, a move that the American Heart Association and others call a??a step backward.a??

Vague language spoils the message

One big problem with the guidelines is that they continue to use the same nebulous language that has made previous versions poor road maps for the average person wanting to adopt a healthier diet.

Herea??s an example: The new guidelines urge Americans to eat less a??solid fat.a?? What, exactly, does that mean — stop spooning up lard or Crisco? No. Solid fat is a catchphrase for red meat, butter, cheese, ice cream, and other full-fat dairy foods. But the guidelines cana??t say that, since they are partly created by the U.S. Department of Agriculture USDA), the agency charged with promoting the products of American farmers and ranchers, which includes red meat and dairy products. a??Added sugarsa?? is another circumlocution, a stand-in for sugar-sweetened sodas, many breakfast cereals, and other foods that provide huge doses of sugar and few, or no, nutrients.

Cautious thumbs up

Several Harvard-affiliated nutrition experts approved of the new guidelines with some reservations:

Dr. Walter Willett, chairman of the department of nutrition at Harvard School of Public Health, called the guidelines an incremental step in the right direction. a??But they dona??t give Americans the concrete steps they need to make healthy choices about food,a?? he cautioned. (You can read more on the guidelines from Dr. Willett and his colleagues at The Nutrition Source.)

Dr. David Ludwig, a nutrition and child obesity expert at Harvard-affiliated Childrena??s Hospital Boston, praised the new guidelines for emphasizing food choices and dietary patterns — rather than focusing on isolated nutrients — and for promoting a healthful ratio of fats, carbohydrates, and protein in the diet. He did have some quibbles with the 35 percent??upper limit on fat in the diet and the guidelines assertion that the glycemic index of food??– essentially, the effect food has on blood sugar levels — isna??t useful for managing weight.

Dr. George L. Blackburn, a nutrition and obesity expert at Harvard-affiliated Beth Israel Deaconess Medical Center, complimented the USDA and the Department of Health and Human Services for providing evidence-based dietary recommendations that focus on obesity.

Kathy McManus, a registered dietitian who directs the department of nutrition at Harvard-affiliated Brigham and Womena??s Hospital, said the specific recommendations for sodium reduction are important. a??This will be a challenge,a?? she said, a??but we need to begin getting out the message and working with the food industry to support decreasing the amount of sodium in products.a??

Bottom line

These experts are right in pointing to the positives of the “2010 Dietary Guidelines for Americans,” which are supposed to help us decide what we should — and shouldna??t — eat. The new recommendations??also provide evidence-based nutritional guidance for federal food programs like school lunches and food assistance. To truly help Americans choose healthier diets, though, the guidelines need to use plain language and offer unambiguous direction. Maybe theya??ll get it right in the next update five years from now.

In the meantime, you can get straight talk on diet and nutrition from “Healthy Eating: A guide to the new nutrition,” a special health report from Harvard Health Publications.

**********

Recommendations included in the “Dietary Guidelines for Americans”

The guidelines divide 23 recommendations into four categories:

1) Balancing calories to manage weight

• Prevent and/or reduce overweight and obesity through improved eating and physical activity behaviors.


• Control total calorie intake to manage body weight. For people who are overweight or obese, this will mean consuming fewer calories from foods and beverages.


• Increase physical activity and reduce time spent in sedentary behaviors.


• Maintain appropriate calorie balance during each stage of life — childhood, adolescence, adulthood, pregnancy and breastfeeding, and older age.

2) Foods and food components to reduce

• Reduce daily sodium intake to less than 2,300 milligrams (mg) and further reduce intake to 1,500 mg among persons who are 51 and older and those of any age who are African American or have hypertension, diabetes, or chronic kidney disease. The 1,500 mg recommendation applies to about half of the U.S. population, including children, and the majority of adults.


• Consume less than 10 percent of calories from saturated fatty acids by replacing them with monounsaturated and polyunsaturated fatty acids.


• Consume less than 300 mg per day of dietary cholesterol.


• Keep trans fatty acid consumption as low as possible by limiting foods that contain synthetic sources of trans fats, such as partially hydrogenated oils, and by limiting other solid fats.


• Reduce the intake of calories from solid fats and added sugars.


• Limit the consumption of foods that contain refined grains, especially refined grain foods that contain solid fats, added sugars, and sodium.


• If alcohol is consumed, it should be consumed in moderation — up to one drink per day for women and two drinks per day for men — and only by adults of legal drinking age.

3) Foods and nutrients to increase

• Individuals should meet the following recommendations as part of a healthy eating pattern while staying within their calorie needs.


• Increase vegetable and fruit intake.


• Eat a variety of vegetables, especially dark-green and red and orange vegetables and beans and peas.


• Consume at least half of all grains as whole grains. Increase whole-grain intake by replacing refined grains with whole grains.


• Increase intake of fat-free or low-fat milk and milk products, such as milk, yogurt, cheese, or fortified soy beverages.


• Choose a variety of protein foods, which include seafood, lean meat and poultry, eggs, beans and peas, soy products, and unsalted nuts and seeds.


• Increase the amount and variety of seafood consumed by choosing seafood in place of some meat and poultry.


• Replace protein foods that are higher in solid fats with choices that are lower in solid fats and calories and/or are sources of oils.


• Use oils to replace solid fats where possible.


• Choose foods that provide more potassium, dietary fiber, calcium, and vitamin D, which are nutrients of concern in American diets. These foods include vegetables, fruits, whole grains, and milk and milk products.

??4) Building healthy eating patterns

• Select an eating pattern that meets nutrient needs over time at an appropriate calorie level.


• Account for all foods and beverages consumed and assess how they fit within a total healthy eating pattern.


• Follow food safety recommendations when preparing and eating foods to reduce the risk of foodborne illnesses.

- P.J. Skerrett, Editor, Harvard Heart Letter

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