Getting Aerobic

Why get Aerobic exercise: Aerobic exercise makes your muscles - including your heart muscle - stronger. It can also help you manage other heart disease risk factors such as:

• high blood pressure
• smoking 
• excess weight
• stress

What is Aerobic exercise: Any exercise that-- 

• is rhythmic and steady
• you can do without stopping
• uses large muscle groups
• raise your heart rate

How should you do it:

• Warm up (5 minutes)
• slowly raise your heart rate with mild exercise
• do slow, gentle stretching exercises
• Aerobic exercise (20 minutes)
• raise heart rate with more intensive exercise
• any activity will do
• do not exercise for long periods of time at a level where you cannot carry on a complete sentence
• Cool Down (5 minutes)
• slowly lower your heart rate
• stretch

If Drug Copays Have You Down, Check For A Coupon

I found the following story on the NPR iPhone App:
http://www.npr.org/blogs/health/2011/01/07/132740446/if-drug-copays-have-you-down-check-for-a-coupon?sc=17&f=1128

If Drug Copays Have You Down, Check For A Coupon
by Scott Hensley

- January 7, 2011

A few months back I went to the doctor to make sure some ribs I broke while biking were healing OK. And, like a lot of patients, I dropped the old line, "Oh, and there's one more thing I need to ask you about," just as we were wrapping up.

It was new doctors, and I needed a prescription for a daily brand-name medicine I've taken for years.

Well, the doctor not only wrote the prescription, she also gave me a card supplied by the drugmaker to help defray the copay. That last bit I wasn't expecting. But maybe I should have been.

There are coupons or subsidy cards to reduce copays for about half of the top 100 brand-name drugs sold in this country, according to a recent report from health analyst Richard Evans at Sector & Sovereign Research.

Some of the drugs with deals include cholesterol-fighter Lipitor and the heartburn pill Nexium and Aciphex, according to Evans' report.

By offering the help, drugmakers are able to neutralize, to some extent, steeper copays your insurance plan may have put in place to steer you to a preferred drug. That's often a generic or a brand-name medicine the plan gets at good price. The assistance is limited to people with private insurance.

A Kaiser Family Foundation survey of employer health plans last year found that the average copay for the first tier of drugs, usually generics was $11. From there, they went up to $28 in the second tier, $49 in the third tier (more details here). Copays in the lower tiers have gone up a lot in the past few years, too.

Even small differences in copays can have a big influence on people's choice of medicines. That's why insurers and employers have used them to encourage use of medicines that may cost them less.

There's been a lot of criticism of the cards for circumventing that system, as  the Wall Street Journal and NPR's Planet Money reported in 2009. Makers of brand-name drugs have said doctors and patients should make a choice of prescription drugs without being swayed by the costs.

Still, when it comes to the costliest drugs, the direct subsidies for patients bely big financial hits to employers and insurers. A winning strategy for drugmakers is "to price their drug as high as they possibly can and offer that copay assistance broadly" to protect patients, biotech analyst Joshua Schimmer told the New York Times earlier this week.

For me, I've tried a popular generic rival to the regular medicine I take, but it didn't work as well. I'd cough up the full copay, as I have in the past, for the usual medicine. But when i filled the new prescription and used the card I saved about $6, which I'll probably blow on a couple of fancy coffees. [Copyright 2011 National Public Radio]

To learn more about the NPR iPhone app, go to http://iphone.npr.org/recommendnprnews

Food, Inc.

I watched the movie Food, Inc. recently. It is a terrific account of the current state of the food industry here in the United States. The movie documents the highly mechanized food industry which is now controlled by just a handful of corporations. The films argues that these few corporations are mostly unregulated. It also argues that these corporations are greatly contributing to our growing obesity epidemic and exposing our population to food born illnesses.

The movie features interviews by experts Eric Schlosser and Michael Pollan. I would definitely recommend Pollan's Omnivore's Dilemma - its a terrific read. 

After watching the movie, I visited the official movie's website.

The website goes on to list educational information on important issues as well as lists 10 simple things you can do to change our food system.

I am very proud of our current government. In the past few weeks, 3 extremely important pieces of legislature has been or will be passed.

1. Meat, poultry to have nutrition labels by 2012
2. President to Sign Landmark Child Nutrition Bill
3. Obama to Sign Bill to Improve U.S. Food Safety

This is amazing. We now have:

• new legislation that gives the U.S. Food and Drug Administration unprecedented powers to keep the nation's food supply safe
• a bill which sets nutritional standards for all food sold in schools, and mandates an increase in the meal reimbursement rate for the first time in over three decades and also expands enrollment of already-qualified students in federal meal programs, provides funding for farm-to-school programs, and expands access to breakfast programs.
• labels will be mandatory on 40 popular cuts of meat and poultry products beginning in 2012, a measure that will make it easier for consumers to understand the content of the foods they buy

All three of these issues were specifically discussed in the movie.

This is terrific news for all Americans and will hopefully lead to a healthier and better informed consumer. 

Kidney Stones

I recently wrote an email to a friend who has been suffering from kidney stones. In it, I summarized what I knew about what to eat to try to avoid them. I thought it might be good to share it with my online followers. Here it is...

"Dear XXXX,

Debbie told me that you've been trying to eat healthy -- keeping in
mind your kidney stone.

Here's what I know about the healthiest way to eat for patients who have suffered a kidney stone.

We know that most stones contain calcium oxalate. Contrary to
conventional wisdom, a diet high in calcium is actually helpful. The
dietary calcium binds oxalate and then it is excreted when you poop. This helps reduce the binding of calcium and oxalate in the blood which in turn is filtered by the kidneys where/when stones are then formed.

Studies have shown that the Mediterranean diet is the healthiest way to eat for kidney stone formers (also the heart healthiest diet). This
diet consists of high intake of fruits and veggies, nuts and legumes, and low fat dairy and whole grains. The key to this diet is also low intake of sweetened beverages and red and processed meats. A high fat diet (meat and/or dairy) is the worst way to eat.

I hope this helps"

Snow shoveling and heart attacks - Is shoveling really dangerous to the heart????

Here is Fairfield County, CT, we are still digging out from The Blizzard of 2010 just like the rest of the TriState Area and New England.

 

I spent the blizzard on-call covering our local hospital for Interventional Cardiology - that means I was the "heart attack" expert on-call.

 

Monday morning, not one but two middle aged men can in with large heart attacks that began when the went outside to try and shovel snow.

 

What makes shoveling more dangerous than other average tasks around the house is the temperature. Your heart rate and blood pressure increase during strenuous activity. That, coupled with the body's natural reflex to constrict arteries and blood vessels when exposed to the cold, is a recipe for a heart attack. Research has also shown that many people hold their breath while shoveling, which can lead to a sudden change in hear rate.

 

Snow shoveling in itself can be done safely by individuals in good shape, but can be very dangerous for those individuals who lead a most sedentary lifesytle. Unfortunately, many individuals do not have a choice - they must get out and clear the driveway. In these individuals, the body is not prepared to deal with going from 0 to 100 (the couch to the driveway) in the above mentioned conditions. This places individuals at a uniquely highrisk.

 

My recommendations:

 

Certain individuals should consult their doctor before shoveling snow:

• People who have previously had a heart attack or other cardiovascular disease.
• People with a history of chest pain or angina.
• People with medical histories of high blood pressure, diabetes or high cholesterol levels.
• People who smoke or who have other cardiovascular risk factors.
• People who do not exercise regularly.

Please be careful

Plavix and Proton Pump Inhibitors

There has been much written in the press about a potential dangerous interaction between Plavix and a commonly used class of antacids called proton pump inhibitors. This class of medications includes drugs like: omeprazole (Prilosec), esomeprazole (Nexium), pantoprazole (Protonix) ...

It is true that testing of platelets in a test tube have show that using PPI's can decrease the potency of Plavix (potentially leading to more MIs), this has not been in many observational studies. Strangely and in a surprise to most Cardiologists, the FDA forced the makers of Plavix to warn their patients about this test tube interaction.


This potential interaction has only been tested in one randomized clinical trial. The COGENT randomized almost 4,000 patients and found NO increased signal for increased cardiovascular events. What it did show was a highly statistically significant decrease in gastrointestinal events (GI bleeding and ulcers) in the patients taking both omeprazole and Plavix.

I have been using Plavix in conjunction with PPI's for years. I have never seen an increase in MI's or other cardiovascular events in these patients. The COGENT trial supports what I have seen clinically -- while there may be an interaction in the test tube, the concomitant use of Plavix and a PPI is not only safe but also possible helpful.

Our Obesity Problem

I recently read to editorials on obesity. Both of these were written as thought pieces after the announcement of first new diet pill to be approved by the FDA in over ten years. I thought both were extremely poignant and I could not have written them better myself. I agree completely with their overwhelming sentiment that overcoming our obesity epidemic needs to be a concerted effort to change our eating habits and getting moving and not with a magic diet pill.

The first piece is an editorial from the most recent Lancet

New obesity pill: new hopes, old fears

On Dec 7, 2010, the US Food and Drug Administration (FDA) Endocrinologic and Metabolic Drugs Advisory Committee gave a positive recommendation for the use of Contrave in the treatment of obesity and weight management, signalling a potentially major shift in attitude towards the disorder. Contrave, if finally approved by the FDA on Jan 31, 2011, will be the first new weight-loss drug to be approved for 10 years. The drug is a combination of bupropion, an antidepressant used to help patients to quit smoking, and naltrexone, an opioid antagonist prescribed for alcohol and drug addiction, thought to affect the reward pathway (system in which behaviour is regulated by induction of pleasure).

The use of such a drug to tackle a complex problem like obesity is worrying, especially when the benefits seem modest (a decrease in bodyweight of 5%) compared with the potential risks. Albeit no serious side-effects were recorded in the four phase-3 trials for Contrave (one of which was published in this journal), there are indices of serious risks associated with bupropion, such as suicidal thoughts, seizures, and serious cardiovascular effects. The FDA committee and the drug's manufacturer, Orexigen, agreed that a large trial to assess the risk of major cardiac events associated with Contrave was needed, but that this study could wait until after the approval.

Research into obesity has been fraught with difficulty, with many drugs having been withdrawn from the market in the past for safety reasons. The flexibility shown by the FDA in its ruling on Contrave may be motivated by a desire to encourage pharmaceutical companies to commit more funding into obesity research, as rates of obesity continue to soar. More than a third of the US population is obese, and two-thirds are either obese or overweight. But this drug showed weight loss only when combined with lifestyle modification, and should not be seen as a magic bullet. Governments should address the obesity epidemic through a comprehensive approach, focusing on the underlying causes of obesity, and not promoting medication of a disorder that should be treated with modifications of lifestyle, diet, and exercise.

The second piece I read this morning on kevinmd.com

Is it the doctor's fault if an obese patient cannot lose weight?

By John Mandrola, MD

I need help.  In dealing with obesity as a medical problem, that is.

I am pretty solid at arrhythmia management, but as an obesity doctor, not so much.  If I was the teacher, and my obese patients were the students, I would surely be fired for poor student test performance. At least, if the core measure was the patient's BMI.

If a student does poorly on an achievement test, is it the student's or the teacher's fault? If the obese patient does not lose weight, is it the doctor's or the patient's fault?

Recently in the NEJM, I read about Arena pharmaceutical's attempt at creating the new "wonder pill" for obesity.  Lorcaserin is a novel serotonin re-uptake inhibitor which acts primarily in the brain centers that control hunger and satiety.  Theoretically, it provides a patient with the good sense not to eat too often, and as the skinny farmer advises, leave the table before you are stuffed.

Although, Locarserin had no major adverse effects, the weight loss was modest, up to 5-10% of body weight.  Thirty pounds is only the prologue for the 300 pound patient.

So, now we may have another pill for fatness.  Like we do for tiredness, and the low sex drive of male middle-agedness.

The study conclusion is worded with scientific precision.  The researchers say, in conjunction with behavioral modification, the drug was effective in weight loss  What people hear, though, and the drug manufacturer are really saying is: take this pill and be thin.

Cynicism is knocking at my door, and I am trying to ignore it.

It is clearly true that obesity is one of the developed world's most important medical problems.  Paradoxically, while the fury of modern medicine has lowered death rates from heart disease and cancer, the obesity epidemic continues unabated.  The more sophisticated we become as a society, the fatter we get.

As a doctor of the heart, it is crystal clear that lifestyle choices lie at the heart of health. No disease is more preventable by lifestyle choices than heart disease.  And these same lifestyle choices work on obesity as well.  Call it being on "the program."  Not a diet, the program is a simple concept: finding the groove of enough exercise, wise food choices and adequate rest.

I own only one belt.  It is thick leather.  At times, as I am human, the white-chocolate-chip brownies in the doctor's lounge get the best of me.  If this behavior persists with any regularity the belt feels tighter.  Thick leather belts do not stretch. The tighter belt says, pedal a little longer and cut smaller pieces of brownie. Doing so restores equilibrium.  But if I deny too much the result is grumpiness. The pattern is repetitive.

This simple formula is the problem.

However, the notion that obesity is simply an imbalance of the equation, calories-in, calories-burned, is not in vogue.  It seems, by saying to the patient, eat less (really, it is sadly amazing how few calories a sedentary middle-aged human needs) and move more, you are at risk of being perceived as judgmental, incurious and even aloof.

If on the other hand you talk about enhanced receptor sensitivities in hunger centers that may be inhibited by sophisticated chemicals, you are smart, and a sensitive doctor.  The obese patient may conclude that poor lifestyle choices are not their fault, rather a chemical imbalance in the brain.  (And maybe this will be proven so.)

I don't think we should persecute the obese. Malfeasance is bad for the heart.  Nor am I against novel pharmaceuticals or innovative surgery.  But taking a pill or having surgery (that someone else pays for) will always be easier than saying no to white-chocolate-chip brownies.

As we advance in medical technology, the simplicity of making a series of good choices should not be overshadowed by the science of receptor inhibition in the brain.

Surely, doctors should emphasize the program more.

John Mandrola is a cardiologist who blogs at Dr John M.