Heat Related Illness

It is summer time and the heat and humidity are higher than at any other time of the year.   We spend more time in the outdoors so we must learn to protect ourselves against the unique illnesses caused by this increased exposure.  Heat related illness occurs when your body cannot keep itself cool. As the air temperature rises, your body cools off by sweating.  Sweating occurs when liquid on your skin surface evaporates. On hot humid days, the evaporation of moisture is slowed down by the increased moisture in the air. When sweating cannot cool you down your body temperature rises and you may become ill.

Some people are at greater risk to develop heat related illness than others. This includes infants and young children, people 65 years of age or older, people with mental illness taking medications, the physically ill; especially those with heart disease, high blood pressure and lung disease.  Individuals who have suffered from heat exhaustion or heat stroke in the past have an increased risk of developing recurrent heat illnesses.

When your body overheats due to very hot weather and or exercise in the heat, you are susceptible to heat exhaustion. Patients experience heavy sweating, non-specific weakness and or confusion, dizziness, nausea, headache, rapid heartbeat and dark very concentrated urine.

If you experience these symptoms in the heat you need to get out of the heat quickly. Find an air conditioned building and rest in it. If you cannot find an air conditioned building then get into the shade and out of the sun. Start drinking cool liquids (avoid caffeine and alcohol which exacerbate fluid loss and heat related disease). Take a cool shower or bath or apply cool water to your skin. Remove any tight constricting clothing.  If you do not feel better within 30 minutes you must contact your physician or seek emergency help.

Untreated or inadequately treated heat exhaustion can progress to heatstroke. Heatstroke occurs when the internal body temperature rises to 104 degrees Fahrenheit or higher. Heatstroke is far more serious than heat exhaustion it can cause damage to your internal organs and brain and it can kill you.  Patients with heatstroke are running a fever of 104 degree F or higher. They complain of severe headaches with a dizzy or light headed feeling. Their skin is flushed or red in appearance and they are NOT sweating.  Many will be experiencing severe and painful muscle cramps accompanied by nausea and vomiting. Their heartbeats are rapid, their blood pressure low. They are often extremely agitated, anxious and disoriented with some experiencing tonic clinic epileptic type seizures.

Heatstroke is a medical emergency and you must call 911 immediately. While you are waiting for help to arrive remove their clothing after taking the patient to an air conditioned or shady place. Wet the skin with water and fan the skin if possible. If you have access to ice or ice packs place them on the patient’s neck, back, groin and armpits while waiting for help.

Heat illness is preventable. When the heat index is over 90 and you must go outside wear lightweight, light-colored, loose fitting clothing. Wear a hat or use an umbrella.  Apply sunscreen SPF 30 or greater 15-20 minutes BEFORE going outside. Drink plenty of water before you go out and 2-4 glasses of cool water each hour you are outside working in the heat. Avoid alcohol and caffeine including soda with caffeine.  Take frequent breaks every 20 minutes and drink water or sports drink even if you do not feel thirsty. Try to schedule your outside work for before 10 a.m. or after 6 p.m. to avoid peak sun exposure.

If you are being treated for chronic medical conditions ask your doctor how to prevent heat illness.  Patients taking antihistamines, some blood pressure medications (beta-blockers and vasoconstrictors), diet pills, anti depressants and antipsychotics impair your ability to control your internal body temperature. Water pills to prevent excessive fluid lead to dehydration. Anti-epilepsy and anti-seizure medicines impair your body’s ability to regulate internal temperatures as well.

Heat illness is preventable if you take the precautions outlined above.

Dark Chocolate: Cardiovascular Prevention

A study from Australia predicts that if 10,000 men with big bellies and the “metabolic syndrome” (abdominal obesity, diabetes, hyperlipidemia , hypertension)  ate 100 grams of  dark chocolate daily, it would prevent 70 non-fatal and 15 fatal heart attacks per year.  The total yearly cost of the chocolate is less than $50 per patient.   Recent studies have shown that dark chocolate can reduce high blood pressure and lower lipids.  This study was based on a model that predicted the effects of dark chocolate lasting for 10 years when, in fact, true research studies have not lasted that long.

This is a promising avenue of research involving a food substance that most of us enjoy.  For my patients, almost any food in moderation produces success.

Additional Study Discusses Relationship Between ACTOS and Bladder Cancer

Laurent Azoulay, PhD, of McGill University in Montreal presented data linking ACTOS with the development of bladder cancer.  His research specifically implicated ACTOS rather than implicating the class of drugs ACTOS belongs to. His group specifically did not see this effect when looking at Avandia (rosiglitazone).  Avandia has been removed from the US market because of its cardiac toxic effects.

Azoulay and associates looked at 115,727 patients given prescriptions for these antidiabetic medicines in the United Kingdom primary care data base between 1988 and 2009.  The mean age of participants was 64 years old and they were followed for over 4 years.  Patients who had been given a prescription for the thiazolidinediones tended to be more obese, smoked and have worse control of their diabetes.  These are all risk factors for the development of bladder cancer.

ACTOS has been removed from the market in some European countries. The FDA did not restrict it in a recent review.

With the new data it will become necessary to suggest alternatives to ACTOS to my diabetic patients until the matter is completely clarified.

Big Belly May Increase the Risk of Sudden Death

The United States is experiencing an epidemic of obesity.  Baby Boomers were accustomed to discussing weight in terms of ideal body weight and height weight charts.  Susbsequent generations have become used to the Body Mass Index (BMI) and percentage of body fat.

In a study out of the University of Minnesota and the VA Medical Center of Minneapolis, researchers now encourage us to look at the ratio between our waists and our hips as the most accurate predictive tool for sudden cardiac death.  Sudden cardiac death is defined as a death that occurred within one hour of the onset of symptoms when witnessed or within 24 hours of being seen alive when the death was not witnessed.

Their study included 15,156 participants from the Atherosclerosis Risk in Communities Study which enrolled persons between 45 and 64 years old.  For women with a waist to hip ratio of 0.97 or higher and men with a ratio of 1.01 or higher there was 40% greater chance of sudden cardiac death. While all measures of obesity, including body mass index and waist circumference, could be associated with an increased risk of cardiac disease, only elevated waist hip ratio correlated with an increased risk for sudden cardiac death.

Selcuk Adabag, MD a main researcher in the study made it clear that obesity is “a root cause of problems.”  Physicians need to be paying particular attention to weight gain especially in individuals with a big belly and apple shape and they need to actively work to reduce it. Dr. Selcuk was not sure why belly fat led to sudden death but speculated that belly fat may produce unique inflammatory markers which could lead to heart muscle fibrosis and then arrhythmias and sudden death.

In my practice we are weighing individuals as well as checking heights and body mass index at each visit. This is designed to establish risk of developing severe diseases and preventing them.  We continue to work with our patients to reduce their risk factors.

FDA Approves Delays in Labeling Sunscreen Products

Under intense lobbying from the cosmetic and personal care industries, the Food and Drug Administration has wilted and granted sunscreen manufacturers an extra six months to clarify the efficacy of their products in terms of how they are labeled. Originally it was hoped that the new labeling would be in effect for the 2012 summer season with correct labeling required by June 17, 2012.  That has been pushed back to December 17, 2012.

It is widely known that sunscreens with an SPF of 15 or less do not provide total sun protection. The new labeling system was supposed to carry warnings so that consumers do not think they are getting more sun protection than they actually are.

Under the new regulations, manufacturers may no longer refer to their products as “sun block,” “waterproof,” “sweat proof,” or providing “ all day protection”.  If the product is SP15 or greater they may say that the product protects against sunburn, early signs of aging and skin cancer. Sunscreens that meet the FDA’s guidelines and protect against both ultraviolet A and B rays will be allowed to say they are “broad spectrum”.

The FDA claims the extra time was granted to allow testing of each product to determine if the product can justify its packaging claims. The delay was felt to be preferable to pulling products from the shelf in the summer sun exposure season.

Statins Reduce Risks, Even in the Lowest Risk Groups

Current guidelines for the use of statins in the USA (Lipitor, Zocor, Crestor, Atoravastatin, Simvastatin, Pravastatin, etc.) call for only treating individuals who have a ten-year risk of major vascular event of at least 20%.

European researchers including Borislava Mihaylova, MSc DPhil, and colleagues on the Cholesterol Treatment and Trialists Collaborators team writing in the Lancet question whether the guidelines should be changed to treat individuals with even lower risks. Their large Meta analysis suggests that statins provide substantial benefits for primary prevention – especially in patients with a 5-10% ten year risk of a major vascular event. They looked at data from 27 trials including over 175,000 participants. When they took into account cost and side effects of statins, such as muscle pain and inflammation, rhabdomyolysis, diabetes and hemorrhagic stroke, they concluded that the benefits still far outweighed the risks. They think that the clear-cut affect on lower risk individuals coupled with the fact that almost 50% of vascular events occur in patients without previous cardiovascular disease necessitates the broadening of USA guidelines for treatment of patients. The researchers go on to hypothesize that as more generic statins enter the market, cost concerns will become far less of a factor in the decision to treat or not treat.

They noted that for each 1 mmol/L reduction in LDL cholesterol, there was a 21% reduction in the relative risk of major vascular events, and all cause death, irrespective of age, baseline LDL or previous cardiovascular disease.

This research makes it clear that there is great value in assessing the statistical cardiovascular risk of each individual and being more aggressive in the use of statins than current national guidelines call for.  Incorporating risk tools such as the Framingham Risk assessment plus looking at newer techniques such as the measurement of carotid artery intimal thickness may be appropriate in the decision to choose a statin or not.

Drinking Coffee, Lower Mortality

Over the years, the consumption of coffee and its relationship to your health has been controversial.  In my medical school, internship, and training years in the late 1970‘s, it was thought that consuming more than five caffeinated beverages per day was associated with an increased risk of pancreatic cancer. That relationship has since been disproved.

The May 17th issue of the New England Journal of Medicine published a study on coffee drinking that will certainly make coffee drinkers more comfortable with a consuming a “cup of Joe.” They looked at a National Institute of Health – AARP study that began 1995 and includes almost 230,000 men and 173,000 women. They found that coffee drinking was associated with many negative behaviors including cigarette smoking, less exercise, eating more red meat, and eating less fresh fruits and vegetables.  Upon initially looking at the data, coffee drinking was associated with an increased mortality. However, when researches removed the negative behaviors from the data, and looked at the people who drank coffee but didn’t smoke and exercised; they found a significant drop in the mortality of coffee drinkers. Over 13 years, men who drank 4-5 cups of coffee per day had a risk reduction of 12% while women had a risk reduction of 16%.

The risk reduction was considered “modest” by Neal Freedman, PhD of the National Cancer Institute.  Lona Sandon, RD (registered dietitian) of the UT Southwestern Medical Center in Dallas said, “Based on this study alone I would not tell people to start drinking more coffee to lower their risk of death.”   She felt individuals should “stop smoking, be more physically active, and eat fruits, veggies, whole grains and healthy fats…. A little coffee doesn’t appear to hurt.”  Cheryl Williams, RD, of Emory Heart and Vascular Center in Atlanta commented that “if you are not a coffee drinker, this study is not a good enough reason to start.”

The study seemed to show that with consumption of 4-5 cups of coffee per day your risk of death due to cardiovascular disease, respiratory disease, injuries and accidents, diabetes and infections decreased. Coffee consumption did not appear to protect against cancer-related deaths. The design of the study does not allow us the luxury of saying drinking coffee is the “cause” of an “effect” of lowered overall mortality, but does certainly hint at it.

What is clear is that coffee drinking does not appear to have an adverse effect on already healthy lifestyles, but will not protect an individual from the detrimental effects of smoking, poor dietary choices and inactivity.