By the numbers – my 2016

The end of 2016 – and every year – brings out the numbers – 10 best events, top news stories, greatest moments in sports, etc.  People have a natural need to quantify and rank things.  It gives us a sense of control over our lives – very important in a year that so much seemed beyond our control.  I am no different – living my life by the numbers.  I track my activity and sleep with a Fitbit, my runs with Runkeeper, occasionally track my calorie intake with Lose It! I track the number of patients I see every day, the articles I post on TheDiagnosisMD, number of hits it gets.  While the numbers are not the sum of all that is important in my life, it is an interesting lens with which to view it through!

Blog

  • 11 posts – missed my goal of 2 per month
  • Wrote 4/11 in January – meaning I went months without updating TheDiagnosisMD, other than via observations on Twitter and Facebook.
  • 824 people visited this blog in 2016 – less than in 2015 – perhaps an indicator of the lack of consistency last year!
  • In 2017, not only do I want to write more – I want to write consistently.

Activity

  • Tracked 4,463,882 steps – over 700,000 more than 2015 – NYC is a walking town for sure!
  • Ran 375 miles – 25 more than last year
  • Average distance per run 5.4 miles
  • Average pace of 8:56 per mile –  32 seconds per mile faster
  • I sleep an average of 6.5 hours per night – 12 minutes more per night than 2015

Work

  • Not going to attempt to count hours!
  • Became more involved in a leadership role in our practice and the Department of Medicine
  • Was co-investigator on a grant submission (decision pending) to develop a clinical research project and education program
  • Taught medical students and residents
  • 2940 face to face visits with patients

This last number strikes me as incredible – not for its absolute value, but the opportunity it represents.  2940 chances to make a difference in someone’s life.  2940 shared moments of success, failure, hope and fear as people cross my path.  My goal in 2017 is to make the most of these moments – for myself and my patients!

What are your goals for 2017?

The path to wellness begins with a proper diagnosis

Don’t wait for New Year’s – exercise now!

Wishing everyone a very Happy Thanksgiving – I’m thankful for the opportunity to continue sharing my thoughts on health with everyone!   I know the holiday season is here – because last night when I was walking my dog I saw the sidewalk Christmas tree vendors setting up!  I also knew a big meal awaited me this evening – so I went for a run this morning to prepare.

Starting an exercise program is a recommendation I make everyday – to patients, family and myself.  The answers are often the same – “I know I need to exercise, but I don’t have time”, “I have bad knees”, or even “I don’t know if it is safe for me to exercise.”

Everyone faces hurdles in developing a routine.  Change is hard.  We go through periods where we exercise regularly, then the pattern is broken.  Getting started again is much more difficult.  Besides getting back on track, there is muscle soreness and risk of injury when coming back too fast.  But what about heart risks?  There are stories of people having heart attacks during marathons and other races, or even professional athletes who have heart attacks despite being in presumably peak physical condition.

Regular exercise has repeatedly been shown to reduce the risk of heart disease, diabetes and stroke.  It has also been linked to lower rates of certain cancers.  However, in what may be one of the more profound ironies of life, the risk of a heart attack goes up when you first start to exercise – the older you are when starting and the more intense the activity – the greater the risk!

Statistically higher – but meaningful?

The good news is while the risk of a heart attack or dying when first exercising is increased compared to sitting on the couch – it is still exceedingly rare!  To be clear – if you already have heart disease these numbers don’t apply – I am referring to people who don’t have existing disease and are starting to exercise to keep it that way!  If you already have disease – exercise is essential for you, but you should speak to your physician about how to safely start (this is why cardiac rehabilitation programs after a heart attack are so important).

The risk of a fatal heart attack is literally 1 in a million  – this number comes from studies of people having heart attacks at the gym (over 22,000,000 hours of exercise evaluated) and half/full marathons – and most of the people in these settings had pre-existing heart disease.  That risk goes down with repetition – so the more you exercise the less likely you are to experience an exercise induced heart attack.

Start now – or pay later

The holiday season begins now.  Snacks start arriving in the office, there are holiday parties and dinners and more alcohol than usual – yet over a month before the inevitable New Year’s Resolution to exercise more!  Think about starting now.  Regular exercise now may not make you lose weight – but can limit the gain from all the festivities.  A habit started now will make a resolution unnecessary!

So follow common sense – start gradually and consistently, and increase the intensity of your activity as your body gets used to exercise.  Don’t let something very rare keep you from achieving your best health.  As Nietzsche said, “That which does not kill us, makes us stronger.

The path to wellness begins with a proper diagnosis”

It is important for me

It’s been a very busy month – and I noticed two things had gotten pushed back – my running and my writing.  Every weekend I’d say to myself, “I want to go for a run today” or “I should update my blog”…  And then life happens.  Work obligations, holidays, bad weather, family needs, or just being tired and unmotivated.  Next thing you know, it is the 3rd week of April, and I’ve only gone running twice this month.

I tell people every day they need to be more active.  Some take it to heart, others ignore it, but I suspect most end up where I’ve been this month – I know I should do it, but unable to turn that knowledge into action. This weekend was particularly busy, and I told myself yesterday that I should run this morning.  In psychology, this is known as the Prochaska Model of Transtheorectical Change.

As has been the pattern lately, I slept a little later than I planned.  Then I got my running stuff together.  I had coffee (even before a run, yes) to finish waking up, and then got a distracted by email and tidying up the things I didn’t finish last night.  Thinking about the things I wanted to do today, I started to convince myself I didn’t have time to run.  Just like last weekend.

In my mind I made excuses about putting my obligations first, and felt myself becoming resentful of the things in my way.  Rationalization is very easy, and I began to accept that another day would go by without a run.  Recognizing that 9am really wasn’t too late in the day to run, I said to myself – “It is important for me to run today.”  That change got me to open Runkeeper and start Spotify run (Funk n Soul playlist) on my phone and get outside!

That small change in my mental dialogue (a fancy way of saying talking to myself) made the difference.  It changed running from something I’d like to do, something optional, to something required – as important as the other obligations I was using as an excuse to not run.  That was the key for me to find the link between motivation and action.  Now to see if I can use that to help my patients do the same!

The path to wellness begins with a proper diagnosis

Tell Me What You Want

I am asking readers to tell me what you want.  Not in general, but at a health or wellness talk.  A few weeks ago I was asked to speak at a wellness seminar given at a company for its employees about heart health.  The talk was well received, and we had a good discussion after my presentation.

What struck me was how willing people were, in a room full of co-workers, to ask questions about their personal health.  In the office, we have safeguards to protect privacy at check-in, in the waiting room and at check out.  Yet in this conference room, with people they know listening, I was told about cholesterol results and other tests, treatments they were given, etc.  Granted, we were talking about heart disease, which may not seem as socially or professionally awkward as some other topics, but it still surprised me.

It also made me wonder – what did they want?  My professional interpretation and opinion of their situation, or validation that the choices they had made in their own care were “good choices”?

I did my best based on the information people gave me to address their concerns, while encouraging them to speak to their doctors.  Some had questions understanding what they were treating or how to interpret their results.  Others had decided to try a different therapy (often homeopathic) than what their doctor recommended and wanted my approval – so the answer to my initial question is “both”.

I found it to be a little uncomfortable being asked to approve someone’s decisions with limited information, especially if I didn’t “approve.”  However, the talk and Q&A are for the attendees, not me, so I did my best to give a recommendation and encourage discussion between the person and their doctor.

This is a copy of the talk I gave – I want to thank TheVisualMD for the image support in the talk.

My question to you – if you went to a talk like this what would you prefer?  A general Q&A or time at the end to make a mini-appointment to discuss your questions one on one with the speaker?  Tell me what you want!

The path to wellness begins with a proper diagnosis

Challenge Completed

So many people start the New Year stating what they wish to accomplish, without reflecting on the past year. So for my first post of 2015 I’d like to reflect back on the first year of TheDiagnosisMD.com – and a challenge I undertook.

In the first year of my blog, I posted 34 times – with over 3400 views from 76 countries! Reflecting on what I posted, and the responses I got will help me shape 2015.

My goal for 2015 with TheDiagnosisMD is to make it educational, useful and fun!

In January of 2014, I ran the PF Chang’s Rock n Roll Half Marathon, with my running partner, Dr. Craig Primack. After the race, he suggested we try to run one half marathon a month for 2014. I accepted the fitness challenge. Two weeks later, on a cold morning in Sedona, we ran our 2nd half marathon of the year. It was a fun race, but we had not trained for the hills in Sedona!

After another organized race in March, schedules and races became difficult to match up, so we mapped out several 13.1 mile courses near our homes, and, on December 20, 2014 we completed our 12th Half Marathon in 2014.

Training for this, I ran over 545 miles and 83.5 hours. I went through 4 pairs of running shoes, several minor injuries and 4 toenails. The injuries have healed, and 3 out of 4 toenails are normal again.

So what did I learn?

Consistent long distance running is great for cardiovascular endurance. I have no doubt that at any time I could go run 13 or so miles without worry. However, from an overall fitness perspective I’m the same as I was in January of 2014. Same weight and non-running strength!

When I knew I was running long distances on the weekend – I found it mentally difficult to go for a 3 or 4 mile run during the week – it didn’t seem worth it if I couldn’t run 6 miles – so I ended up stacking the runs and concentrating things on the weekends. So there was less balance to my overall activities.

I’ve always told my patients that moderation was the key to success for health. So it’s time for this physician to heal himself. My goal for 2015 is to be more balanced in my fitness and in life. Challenge accepted.

I look forward to writing more about the topics you are interested in – so let me know what you’d like to learn about!

Wishing you health and happiness in 2015.

The path to wellness begins with a proper diagnosis.

Steaks and Statins – weight gain and cholesterol management

Recently there have been several news stories with contradictory  health information; obesity has reached a peak, obesity is still rising.  Running leads to a longer life, but marathon runners don’t live longer.  Supplements don’t work, except when they do.

One of the latest stories is that people who take statins are gaining weight faster than those who don’t.    Have statins become a crutch or do statins cause weight gain?  Are we healthier now that we can have our steaks with a side of statins?

What did the study look at?

To assess the question of statins and weight gain the authors used a large database called the National Health and Nutrition Examination Survey (NHANES) which was a large study conducted from 1999-2010 that collected data on tens of thousands of Americans, looking at illnesses, medication use, diet, supplement use and other  items.

For this study, 28,000 people were evaluated:

  • those with high cholesterol and taking statins
  • those with high cholesterol and not on statins
  • those without high cholesterol and not on statins

They compared calorie and fat intake between statin users and nonusers in 1999-2000 and 2009-2010.  In 2010, statin users were eating almost 250 calories more a day than they did in 2000.  They were eating more fat, as well as having gained more weight than non-statin users.  However, statin users did have lower cholesterol.

What the study did not assess was if the rate of heart attacks changed in the groups – the study wasn’t designed to answer that question.  But is that the only question that matters?

The reason why it matters is that diabetes rates, linked to weight gain and obesity are still on the rise.  Are people being helped if they lower heart disease risk by taking statins but raise their risk of developing diabetes?

Possible explanations of the data

  • Doctor effect – are doctors advocating medication over healthy lifestyles?  It is easier and takes less time.
  • Patient effect – are patients interpreting taking statins as a free pass to keep the same lifestyle they had before medication?  Again taking a pill a day is easier than maintaining a healthy lifestyle.

The truth is probably a little bit of both.

How does this affect my practice?

I’m a strong proponent of preventing disease.  We prevent heart disease by not smoking, controlling blood pressure and reducing the Low Density Lipoproteins that clog our arteries with statins.  Central to this, and what I recommend with or without medication is lifestyle – a healthy and active one!  Doing so may avoid the need for medication or allow us to use a lower dose – reducing side effects!

What we don’t know from this study is if people had an increase in heart attacks despite their lower overall cholesterol levels – meaning the increase in calories, fat and weight offset the benefit of taking a statin.  Or, did the statin allow people to safely lead a more permissive lifestyle?  Can you have your steak if you have your statin too?

The study did show an increase in diabetes  – presumably related to the weight gain in the statin users.  They consumed about 250 calories a day more in 2010 than in 2000 – which can lead to almost 10 pounds a year in weight gain!

So when I discuss taking statins with my patients, I always frame it as a component of a plan to reduce the risk of heart disease.  If diet and exercise reduce risk enough, medication can be stopped and risk reassessed.  Even if lifestyle does not reduce risk enough to stop medication, it may minimize the need for dosage increases.

For those that do not alter their lifestyle, they run the risk of developing diabetes.  While statins will reduce some of the risk of heart disease, diabetes carries its own risks – kidney, nerve and eye damage – which statins won’t protect against.

My role as an Internist is to look at a person as  a whole – evaluate all their risks and how they relate to each other.  So this study serves as an example that we can treat a singular problem, but if that is our whole focus, we lose sight of the person and may not truly improve their health.

The path to wellness begins with a proper diagnosis

Exercise – The Power to Heal Yourself

 

exercise - the power to heal yourself
Visualizations are provided by www.theVisualMD.com

New Year’s is a time of resolution, renewal and rejuvenation.  People resolve to stop smoking, lose weight and exercise.  More gym memberships are sold in January than any other time of the year, and many go unused.  We all have this sense that we should exercise more – but have you ever wondered why that is such a universal sentiment?  What is it about exercise that makes it hard to maintain but remain so high on our wish lists?  What does exercise do for us?

Exercise impacts not only our muscles but almost every body function we have – it changes multiple hormone levels, insulin sensitivity, pain perception, hunger, sex drive and mood.  Exercise gives you the power to heal yourself.  Regular exercise promotes the following changes in the body:
  • increases the development of new blood vessels (can help in heart disease)
  • improves the functioning of multiple immune system aspects
  • decreases anxiety and depression
  • decreases inflammation
  • decreases pain in osteoarthritis
  • improves blood pressure
  • improves cholesterol
  • improves diabetes beyond weight loss
  • decreases the cravings for cigarettes
  • strengthens muscle fibers as well as promotes the development of more muscle tissue
  • improves digestion
  • stimulates the reward centers in the brain with substances called endorphins
  • and many other functions
These effects are separate from and in addition to the usual weight loss that accompanies exercise.

So what is exercise?

Exercise is any activity that maintains or improves physical fitness, health and wellness.  Studies have shown moderate activity will begin to show the benefits of exercise.  Moderate exercise is defined as 150 minutes per week (30 minutes/5 days per week) of brisk walking or similar activity.  The more intense your activity, the less total time you need – 75 minutes per week of intense activity will give similar benefits to the 150 minutes of moderate activity.
recent study in the journal Lancet  showed that in people with a high risk of heart disease and pre-diabetes decreased their risk of a heart attack by 10% just by increasing their walking by 2000 steps per day.   Another study in the British Medical Journal demonstrated that regular exercise was as effective as medication in preventing death from second heart attacks, rehabilitation from a stroke, improving heart failure and preventing diabetes.
The trick is maintaining the activity to continue reaping the benefits – if you don’t use it, you lose it.  Another way of looking at it is stated very well by Jim Rohn, an author and self development coach.  “Motivation is what gets you started, habit is what keeps you going.”

What do I recommend in my practice?

So, should everyone stop their medications if they exercise?  No, and certainly not without discussing your plans with your doctor.  Not every condition can be controlled with exercise, and not every medication can be safely stopped abruptly.  What I try to emphasize with my patients is that medication begins to correct a problem immediately – for example – lowering cardiovascular risk with a statin; adding an exercise program helps manage the long term risk.  We can then decide if immediate action is necessary, and set a goal – say losing a certain amount of weight.  When the goal is reached, stop the medication and reassess the condition.
By re-evaluating your diagnosis the effect of medication and the effect of your actions on your diagnosis can be measured, and your treatment plan revised.  You become an equal partner on your journey to wellness by revising your diagnosis!
Personally, I reconnected with running about 3 years ago. While there have been some ups and downs, I’ve managed to keep about 20 pounds off, and will be running my 7th half marathon next weekend. If you’d like to read about my own story on how I started maintaining a program, see this post – Exercise for a Cause, originally posted on TheVisualMD.com in 2011.

The path to wellness begins with a proper diagnosis