Senior Citizens Can Walk Off Meal Related Spikes in Their Blood Sugar

Elderly Couple Walking on Beach v1 - Steve Reznick, M.D.As a physician, it is extremely difficult to motivate older adults to exercise – especially those that do not like to sweat.  At the same time we are always trying to find ways to treat or prevent illness without adding additional pills, medicines or chemicals to a person’s life.  To address these concerns, Loretta DiPetro, PhD of the George Washington University School of Public Health and Health Services in Washington, D.C. presented data in the online journal of Diabetes Care presented from her studies on the effects of post dinner walking on blood sugar.

She followed 10 healthy but obese adult onset diabetics who were sedentary and disliked exercise.  None of the study participants were taking diabetic blood sugar altering medications. The mean age was 69 years old and all were considered Class I obese.  She asked them to take a 15 minute walk after dinner at 3 mph on a treadmill. She compared the glucose response at this speed to a 45 minute walk after breakfast or a 45 minute walk after lunch.  She followed their fasting blood sugars and post dinner glucose levels.  Her results showed that the 15 minute post dinner meal walk was the only exercise period to significantly lower the blood sugar three hours after a meal. The 15 minute walk helped improve 24 hour overall blood sugar control as well.  All the walks helped lower blood sugar but only the 15 minute post dinner walk lowered the sugar at a statistically significant level.

It is well known that exercise of the large muscle groups helps improve glucose metabolism and the body’s sensitivity and response to insulin.  We usually lower the prescribed insulin dosage of actively competing athletes before they compete because their usual dose lowers blood sugar much lower when combined with exercise. This study used that knowledge to assist older, sedentary individuals to improve their glucose control. 

 The message is simple – take a 15 minute walk after dinner. Your life depends on it.


Mediterranean Diet Improves Cognition

Grilled Fish Entree in BarcelonaDiets come and go as do recommendations for healthy living and eating. Once again the traditional Mediterranean Diet was found to be a superior way of living to a traditional low fat diet in individuals who were high risk for the development of cardiovascular disease. The study published in the May edition of the journal Neurology, Neurosurgery & Psychiatry 2013, May 13 is known as PREDIMED (Prevention with Diet Mediterranean) looked at 552 participants in a high risk population. These were men ( ages 55-80) and women ( ages 60-80) free of cardiovascular disease at study entry but high risk due to the presence of either type 2 diabetes or at least 3 of the following major risk factors: current smoking, high blood pressure, elevated lipids, obesity or strong family history of premature cardiovascular disease. The study was performed in Spain and used the Mini-Mental State Examination (MMSE) and Clock Drawing Test (CDT) to assess cognitive function after 6.5 years of nutritional intervention. The participants were randomly divided with the researchers blinded to which group they were in. One group practiced a Mediterranean Diet with Extra Virgin Oil and mixed nuts. The other group was placed on a low fat diet generally recommended for individuals with cardiovascular disease.

At 6.5 years the practitioners of the Mediterranean diet scored significantly higher on the cognition studies. The authors concluded that an intervention with a Mediterranean dietary pattern enhanced cognition compared with a low fat diet. The authors believe that even at an advanced age and with major risk factors for cardiovascular disease, a simple lifestyle modification improved brain health.

We have seen results of studies that show that a Mediterranean style diet improves your chances of avoiding heart attacks and strokes. Now we have a study which suggests that if you follow a Mediterranean type diet you will reduce your risks of developing dementia. Isn’t it time that we start educating our citizens and patients about the benefits of such a program and how to shop, prepare and live with this type of lifestyle?

Hope for HIV Prevention and Treatment

HIV is a disease that has evolved during our lifetime. As a clinician, during my years of training I saw men and women present to the Jackson Memorial Hospital emergency room with a strange overwhelming lung infection and a shutdown of the body’s immune response to infection. Even with aggressive treatment they failed and succumbed to the disease quickly. We had no idea what the process was back in the early 1970’s and were privileged to be around to see pioneers like Margaret Fischl, MD at the University of Miami Miller School of Medicine, begin to take on this dreaded disease in a population no one else would care for.

Hard work and millions of dollars in expense for research coupled with courageous patients has led to announcements like the one released by Michael Martin , MD of the Center for Disease Control that a drug called tenofovir, administered to high risk intravenous narcotic users, significantly reduced the risk of catching the disease. One pill a day In the 2400 volunteers, from 17 drug treatment centers in Thailand, taking one dose of tenofovir per day reduced the risk by almost half. The results were so striking amongst IV drug users that the author recommended beginning a once a day tenofovir program as a pre-exposure prophylaxis in all the high risk groups. He defined the high risk groups as men who have sex with men, heterosexual individuals and heterosexual couples where one person is HIV positive and the other HIV negative.  The drug was surprisingly well tolerated with only 8% of the patients experiencing episodes of nausea.

The purpose of discussing this article is to fan the hope among all individuals, providers and citizens, who have seen the ravages of this disease and did not believe a treatment, prevention or cure would occur in our lifetime. The presence of newer medications for prevention should not allow any of us to let our guard down and eliminate using the tried and true methods that prevent transmission of the disease.  Practicing safe sex by using condoms, avoiding sharing needles when injecting medication and being aware that when you are sexually active you are exposing yourself to your partner’s entire sexual past history will still need to be the cornerstone of prevention.


Electrical Stimulation May Improve Sleep Apnea

Sleep Apnea v2Patrick Strollo Jr., MD of the University of Pittsburgh Medical Center presented preliminary data on the use of a surgically implanted neurostimulator to improve sleep apnea symptoms. The device was implanted to stimulate the hypoglossal nerve. The participants in the study were 124 patients who could not tolerate the CPAP mask treatment or who were never before treated. After implantation they were treated and followed for one year. The participants were mostly men (83%) in their mid-fifties (mean age 54.5 years old), Caucasian and overweight (mean BMI 28.4 kg/m2). Thirty eight percent of the participants had hypertension, 9% were diabetic, and 5% had COPD. Interestingly, 18% had undergone previous surgery on the uvula called uvulopalatopharyngoplasty which was felt to be an effective alternative to wearing a CPAP mask for sleep.

At 12 months all the parameters to assess the effects of sleep apnea had improved dramatically. Interestingly enough, some of the study participants were allowed to continue treatment while others were randomized to stop the neurostimulation. Those who stopped the treatment were followed and their scores regressed.

Like all treatments there were some adverse effects such as tongue pain and mild to moderate infection in 1%.

This is very preliminary data. The study must be presented to a peer review journal, evaluated and published before this treatment becomes acceptable. We recognize sleep apnea as a dangerous disease that leads to pulmonary hypertension and right heart failure if not treated. CPAP masks work well but are cumbersome, awkward and difficult to travel with. The epidemic of sleep apnea is being fueled by a worldwide epidemic of obesity. The current preliminary work at the University of Pittsburgh holds out hope for a future solution that may be easier to live with.

Sunscreen Works!

Sunscreen - FDA v2For decades, dermatologists and health care professionals have been urging patients to use sunscreen to protect against sun damage and skin cancer. What has been lacking is excellent research to prove the point.

The June 4th edition of the Annals of Internal Medicine Volume 158 #11 contains the results of just such a study. The study originated in Australia in a collaborative study of the University of Queensland and the Manchester Academic Health Sciences Centre in the United Kingdom under the authorship of Maria Hughes, Gail Williams, Peter Baker and Dele Green – all PhD’s. Nine hundred and three adults, younger than 55 years old, were randomized into one of four groups. One group used a broad spectrum sunscreen daily and 30 mg of Beta Carotene. The second group used sunscreen and a placebo, the third group had a choice of using sunscreen and beta carotene when they felt they needed to and; the fourth group had a choice of using sunscreen and a placebo.  All four groups were then followed between 1992 and 1997 for changes in their skin.

The findings:

·         ~ At 4 ½ years, the daily sunscreen group showed no detectable increase in skin aging.

·         ~ Skin aging was 24% less in the daily sunscreen group compared to the discretionary sunscreen group.

·         ~ Beta Carotene had absolutely no effect on retarding skin aging.

Despite some questions about the methodology, the study clearly showed that, in middle aged men and women, daily use of sun screen prevented skin aging.

As we head into summer it’s important to take this research to heart and use sunscreen of SPF applied to sun exposed areas before you go out.  Depending on how long you are exposed to the sun, you will need to reapply the sunscreen to continue receiving the protection you require.

The Beat Goes On

Graduates Lifting MortarboardsLast month, I attended the University of Miami Miller School of Medicine graduation for the class of 2013. It had special meaning for me since this was the last group of students, at the University of Miami Miller School of Medicine/ Charles M Schmidt Florida Atlantic University (FAU) joint venture, to pass through my tutelage prior to the Boca Raton program becoming solely an FAU program.

One of the graduates visited my office weekly for two years and then once per quarter the following year.   He came to me as a first year student to learn how to take a history and do a physical exam after being out in the world working for a few years, post-college, as a psychiatric nurse.  He was extremely nervous about being able to remember how to study and succeed at test taking with the younger more academic students.  He brought a mature determined attitude to his mission and was now finishing at the top of the class. 

Also among the graduates was my niece who liked the small class size of the program, the early introduction of patient contact and the ability to develop strong relationships with the faculty. Despite being a mature 23 year-old future pediatric emergency room physician , at 56 inches and 85 lbs. she still got “carded” when she ordered white wine at a post ceremony celebration. 

Then there was “Mike” a young enthusiastic African American student who I met for the first time last year while “chaperoning” a community service health screening in an impoverished section of Fort Lauderdale. My first year student is his best friend and he sent Mike over to me because his mentor was not present.  “I have this middle aged woman with a butterfly rash and all the signs and symptoms of lupus. I have never seen lupus before so how do I help her.”  Mike was correct in his diagnosis and then became her supporter and advocate in helping her gain access to medical care and follow up. 

At the post ceremony reception we met Adam, the son of a colleague, who gave my wife a big hug because she was his teacher in 3 year-old preschool and he remembered her because she taught him to love education and learning.

The President of the University of Miami, and former Secretary of Health and Human Services, Donna Shalala, presided over the ceremonies and reminded the new physicians of what an exciting time this was to be entering the field of medicine.  These young physicians will be at the forefront of the changes in health care delivery in medicine.  They have been given the best of training over four years in evidence based medicine and all the latest technology without forgetting the importance of the personal touch and humanism.  The caring and compassion for others putting the patients’ needs first was the theme hammered home all night by the talented and accomplished faculty and guest speakers. 

I left the ceremonies with a new sense of optimism looking at a diverse but already accomplished group of young physicians.  I feel comfortable they will steer patient care in the correct direction and I feel fortunate that I was able to play a very small role in their nurturing and education.

Prolotherapy for Osteoarthritis of the Knee

Knee X-rayThe National Institute of Health Division of Alternative and Complimentary Medicine has said that if a treatment works, and its results can be reproduced, then it is not alternative therapy.  Such a wise mantra is at the heart of a study published in the May/June issue of the Annals of Family Medicine and recently reviewed in MedPage.

David Rabago, MD, of the University of Wisconsin in Madison and his associates looked at whether prolotherapy is beneficial for those patients suffering from arthritis of the knee. Prolotherapy involves the injection of sugar water or dextrose into joints for the relief of pain. It has been used in different joints for over 75 years but most of the research studies available on its use suffer from poor scientific design and reproducibility.

This study involved 90 adults with knee arthritis in one or both knees for at least five years.  The mean age of the enrollees was 57 years with 2/3 of the enrollees being women and ¾ overweight or obese.  The enrollees were separated into groups. One group received dextrose injections, another received saline or salt water, and a non-injection exercise group. The injections were given at weeks 1, 5, 9, 13 and 17. 

Prolotherapy required them to make multiple punctures around the knee at various tendon and ligament sites. 22.5 mL of either concentrated dextrose or saline placebo were injected into the knees followed by an intra-articular injection of 6mL of additional fluid.   A third arm of the study included patients given no injections but instructed in a home exercise physical therapy program. 

In the dextrose group, 17 patients received injections in only one knee and 13 had treatment in both knees. In the placebo saline group, 15 had a single knee treated while 13 had both knees treated.   During the study, 14 patients in each group used oral non-steroidal inflammatory drugs to relieve pain and discomfort.  All patients receiving injections reported mild to moderate pain after the procedure and up to 2/3 used oral oxycodone before or after the procedure.

The patients used the Western Ontario McMaster University Osteoarthritis Index to score their pain, function and stiffness. There was a significant difference in the improvement of those receiving the dextrose injections as compared to those receiving saline injections. Ninety-one percent of those receiving the dextrose injections said they would recommend the treatment to others.

This was a preliminary study which showed the effectiveness of an alternative therapy in treating a common and chronic condition. It is clear that these findings necessitate a larger study which can look at the correct dosage to inject and to explore how the sugar injections actually work. It appears to be a relatively inexpensive way to relieve chronic pain and is worthy of further study!

pH Testing For GERD May Save Money

HeartburnHeartburn and dyspepsia are common conditions exacerbated by being overweight, eating too much, eating certain types of foods (red sauces, berries, alcohol, fatty foods, caffeinated beverages, chocolate) reclining after eating, wearing constrictive clothing at the belt line and a host of other items. The heartburn is supposed to be due to the reflux of acidic digestive juices from the stomach into the gullet or esophagus. There is no true physical barrier between the stomach and the lower esophagus like a trap door but there are a group of muscles known as the lower esophageal sphincter. These muscles are supposed to recognize that the stomach contains food and acidic digestive juices and contract and prevent the stomach contents from kicking back up the esophagus and producing heartburn symptoms.

The treatments of choice are; avoiding those foods that produce the heartburn, wearing less constrictive clothing and, medications. The gold standard of medications is the PPI’s or proton pump inhibitors. These would be medicines like Prilosec, Nexium, and Prevacid. The product inserts suggests we take these medications for eight weeks and no longer. Most patients continue to take the medications long after the recommended eight weeks.

In an interview in MedPage, the online journal of the University Of Pennsylvania School Of Medicine, David Kleiman, MD of Weill Cornell Medical College in New York City proposes that at eight weeks patients be given a pH test or what used to be called the “Bernstein Test”.

With the pH test, a thin plastic tube is inserted through the nose and placed so the tip is at the lower portion of the esophagus adjacent to the stomach. You then sample and test the fluid for acidity by measuring its pH. The test costs under $700 and is fairly accurate and safe.

According to Dr. Kleiman, he examined patients with GERD who continued to take PPI’s beyond eight weeks and almost 1/3 of them did not have any signs of acidic material refluxing into the esophagus. When looking at the lower dose PPI’s sold over the counter, versus the prescription items, the average weekly cost of PPI’s varies from $29 to $107. This translates to a cost of between $2000 and $7,300 a year on medicines not needed.

While the idea of inserting a tube to measure acidity as a way to distinguish who should continue PPI’s has its merits, the practical question is “How available is the test and who is doing it?”.

It is always a good idea to discontinue medications you do not need – especially expensive ones. The availability of the testing in local communities may preclude this approach.

Fitness in Mid-life Leads to Less Illness in Later Life

Woman with DumbbellsAt doctor/patient visits, physicians stress the importance of developing and following a healthy lifestyle. That healthy lifestyle includes eating correctly and in moderation, controlling your weight, going for periodic benchmarking checkups and getting regular and consistent exercise. An untold number of research studies have supported these recommendations.  Medpage, the online medical journal of the University Of Pennsylvania School Of Medicine printed two reviews of studies which confirm the findings.

Ambrish Pandey, MD, of the prestigious University of Texas Southwestern Medical Center in Dallas, Texas with his colleagues presented data that links fitness in your fifties with a reduced risk of cardiovascular heart failure in later life.  They looked at 9,050 men and women with an average age of 48 and followed them for a period of eight years. They evaluated their fitness at entry into the study and eight years later. They followed patients for 60,635 patient years.  

Their findings were quite simple. Those people who exercised regularly and improved their fitness over time had less heart disease and heart failure. They proved that your risk of cardiovascular disease in your sixties and seventies was modifiable based on your fitness level and effort to improve it and sustain it.

Susan Lakoski, MD, of the University of Vermont in Burlington looked at fitness in men in their fifties and concluded that “physical fitness reduces the risk of lung and colorectal cancer”.  She pointed out that if fit men developed cancer they tended to have a higher survival rate than unfit men. Interestingly, her study suggested that weight was NOT the issue.  Overweight men who were fit did well, while unfit lean men did not do as well.

It is refreshing to have data to back up the recommendations we make to our patients – find some form of exercise they enjoy and keep doing it, frequently and repeatedly if you wish to have fewer health issues to deal with as you age.

Evaluation of Blood in the Urine (Hematuria)

Speciman BottlesI recently had a long discussion with a diabetic patient about the drug Actos. This very effective and relatively safe diabetic drug has now been implicated as increasing the risk of bladder cancer. While the FDA has not removed the drug from the market, it has been removed from the market in Germany.  My patient wondered if he could continue using Actos but send his urine off for testing and evaluation regularly to detect any indication bladder cancer early. I said I preferred switching medications. 

Chance would have it that the April 11, 2013 edition of Journal Watch addressed the question indirectly.  They looked at whether or not it was safe to send urine off for cytology to look for cancerous cells in the evaluation of blood in the urine. Urine cytology, like the Pap smear, looks at cells in the urine from the bladder and tries to diagnose bladder abnormalities and cancers by identifying abnormal cells. The traditional evaluation of blood in the urine includes doing x-ray and imaging studies as well as performing an invasive procedure called a cystoscope (under anesthesia a fiber optic device is inserted into the bladder through the urethra and advanced into the upper collecting tracts.).

In a study performed in the United Kingdom at a teaching hospital, researchers reviewed the records of patients with blood in the urine. Sixty-five percent of the patients had visible bleeding while 35% had only microscopic bleeding. They all underwent imaging of the upper tract, cystoscopy and urine cytology.

A full evaluation of imaging, cystoscopy and cytology was performed on 2,507 patients. Fourteen percent of the patients were ultimately diagnosed with transitional cell cancers of the bladder. The sensitivity and specificity of abnormal cytology were 45% and 89% making cytology not “good enough” to serve as a first line test for patients with unexplained blood in the urine. More than half the patients with bladder cancers had negative cytology and about 105 of patients with negative cytology had bladder cancers.

The study supports the recommendations of the American Urologic Association’s guidelines that recommend against using urine cytology in the initial evaluation of patients with microhematuria.