The health care dilemma

For better or for worse, health care reform is here. With some of the debate over, and with Congress having debated the issues more on party lines than on the merit, we must ask ourselves: are we addressing the real issues?

Here is one man’s opinion:

It has been said by many that, despite its many deficiencies, the US has “the best health care in the world.” There is not much argument about the quality of care, certainly for those who can afford it. After all, people come to the US for medical care; they don’t usually leave the US to get better care elsewhere. But, surely there are tremendous deficiencies.

A large number of Americans are still without medical insurance. Others, who became unemployed in the recent economic downturn, may still have Cobra insurance, but when this runs out, they too may become uninsured.

Yet, if you need an urgent procedure (cardiac catheterization, an MRI), you are more likely to get it with much less delay in the US than in other industrialized countries, insured or uninsured (hospitals accepting Medicare will lose their funding otherwise).

There’s also no question that we have the most expensive healthcare system in the industrialized world.

Despite our presumed best health care and the enormous expense, longevity and infant mortality in the US lag behind many industrialized countries. We are #37 in longevity, sharing an “honorable ranking” with Cuba, and way behind Andorra, Canada, Israel, Norway, Germany and Jordan… A similar picture holds for infant mortality.

Why is there such disparity between “best, most expensive health care” and longevity?

I’ll briefly make the case that it’s lifestyles, not healthcare reform, that’s going to keep us healthier and make healthcare less expensive. There’s a whole lot more to health than health care reform.

Faulty lifestyles, mainly smoking, lack of physical activity and overeating, account for more than 40% of premature deaths in the US. They undoubtedly account for much more than 40% of the medical expense associated with faulty lifestyles. Combine this with the tendency of Americans to run to the doctor for minor issues not requiring care, such as simple colds or minor anxiety, and the willingness of the system to accommodate these demands, you have written the script for a healthcare system that is destined to bankruptcy. But there’s another aspect to lifestyles, not completely the fault of each person individually.

Much of the fault for our relatively poor health lies with industry, especially the food industry. It is not my intention to write a treatise about it here, but suffice it to say that in the last few decades Americans have been exposed to progressively increasing amounts of processed foods devoid of nutritional value, or outright dangerous, especially corn-derived sugar, salty canned foods, and bottled drinks (the plastic ones are generally worse).

So what’s the answer? Sure, there’s a lot to be corrected with the present health care system. Open competition for HMOs and commercial insurers, taking away limits on HMO payments (now restricted to no more than 65 cents on the premium dollar), decreasing the enormous obstacles the FDA places in new drug approvals, and many other measures will help. But all of this will be of limited value.

The biggest effort has to come in educating the public to change its lifestyles, and make sure that these changes are adopted by the young children. It could be very easy to make changes in the way food is processed in the US. If the demand for processed food is diminished, then the manufacturers will respond to market demands and make more acceptable foods available. If you give incentives to people who keep acceptable lifestyle (for example, reduce their insurance premium), the people will respond.

We can each contribute to the solution of the healthcare problem by taking the right steps and improving our lifestyles. With our actions, industry will respond, and we’ll help the economy, healthcare, and, most importantly, ourselves.

For Seniors, falling could be dangerous

Almost 30% of people over 65 fall each year. Ninety percent of all hip fractures are associated with falls. Approximately 300,000 hip fractures and more than 700,000 vertebral fractures occur each year, mostly in the elderly. The yearly direct cost for fall-related fractures was estimated at 20.2 billion dollars in 1994, and is estimated to reach over 32 billion dollars im 2020. Unintentional fall is the seventh leading cause of death among people over 65 years old. Falls are a primary reason why Seniors become home bound.

Work done at our own office (when Health Extenders was active), funded by us and the South Western Connecticut Agency on Aging 5 years ago, arrived at interesting results.

Our study showed that Seniors of non-minority groups experienced more falls than minority Seniors. Thirty two percent of the non-minority Seniors fell in the year before the study. Hispanics had fewer falls, 26%, and Afro-Americans had the lowest rate, 10%. Risk factors for falling included: muscle weakness; instability due to poor balance; agility and endurance; the use of certain medications, especially sedatives and muscle relaxants, and impairment of gait, vision and hearing.

The danger of falling increased with each risk factor, and with the number of previous falls.

The risk of sustaining a fracture after a fall is associated with two important factors: low bone mineral density (osteoporosis), and neuromuscular integrity. Generally, the higher the bone density, the higher the ability of bone to withstand the abnormal forces of a fall, and the lower the risk of a fracture. Neuromuscular integrity is associated with muscular strength, balance and agility, and with an ability to absorb the high force of a fall.

Appreciable increases in bone density occur when new muscle groups become active over time and the forces generated by these muscles increase with time. Vigorous walking, by itself, does not generally bring about a sufficient increase in bone density to decrease the risk of fractures from falling. Despite the general health benefits of regular exercise, the main benefit of a fall prevention program is derived from increasing muscle strength and coordination, and from decreasing the instability of gait.

Despite the gloomy-looking statistics, the good news is that most risks for falling and sustaining a serious fracture can be controlled. When guided by an experienced exercise physiologist and/or physical therapist, muscle strength and agility can be increased, and balance and coordination can be dramatically improved. Medications may be adjusted to reduce dizziness; other medications, designed to decrease bone loss, can be used to decrease the chance of a fracture in the event of a fall. When necessary, specially tailored hip padding can be worn to absorb the shock of falling and prevent a fracture. In addition, home safety is extremely important. Helpful tools include rails in bathrooms, special chairs to sit on while showering, and the use of a walker. Avoidance of loose carpet edges and unstable pieces of furniture is a must.

The tendency to fall increases with age, but fall prevention is effective at any age, and should be a part of good health habits of every Senior Citizen.

For additional information on fall prevention, you may contact our office.

Are you a chocolate lover?

I must admit that I'm one, and it's bitter sweet.

Cocoa, the good ingredient of chocolate has a great quality, it's high in antioxidants (flavonoids), even more so than green tea or red wine. But most chocolate you see on the store shelf contains refined sugar, a real problem for many individuals, and for healthcare as a whole.

And if you think that "no sugar added" chocolate is better, think twice.

Most sugar free, or even those labeled safe for people with diabetes, contain unacceptable sweeteners. The most common one is maltitol.

Maltilol is classified chemically as a "sugar alcohol." In reality it's neither one. But it has nearly as many calories as table sugar, and its glycemic index (a measure of its effect on blood glucose level) is almost the same as table sugar.

Some chocolates are made with more nutritionally acceptable sweeteners, such as erythritol (present in Truvia), which a very low glycemic index, and as far as the body is concerned, have no calories. Admittedly, it's hard to find them.

So you're a chocolate freak and you're worried about the sugar content of chocolate, what should you do (from personal experience, I know that telling you to stay away from chocolate isn't going to work...)?

Choose bitter-sweet chocolates, they have less sugar. If you can find erythritol, fructose or oligofructose sweetened chocolate, choose that. You may want to try home made hot chocolate made of unsweetened, fat free cocoa (available in many super markets), an erythritol sweetener (Truvia is OK), and  low fat milk - it may satisfy some of your chocolate craving.

Happy hunting. If you have good chocolate suggestions, let us know.

Short of Breath?

.
What is shortness of breath?

For most people "shortness of breath" or "having breathing difficulties" means a sensation of difficult or uncomfortable breathing, or a feeling of not getting enough air. Medically, this is referred to as dyspnea.

Does shortness of breath mean illness?

Shortness of breath can occur in both health and disease, and its significance varies accordingly. For example, when it occurs in a healthy person walking 100 feet at the top of a very high mountain, it may signify no disease. But if the same person had smoked a pack of cigarettes a day for 20 years, the same symptoms at lower altitude may be the first sign of progressive emphysema. In healthy individuals, shortness of breath may also occur at rest for no apparent physical reason.

Shortness of breath may be appropriate or inappropriate, real or perceived; and therefore, there is no standard lay person definition of shortness of breath. Physicians use the term dyspnea to describe "an abnormally uncomfortable awareness of breathing."

What causes dyspnea?

The issue of dyspnea comes up frequently when patients are seen in their physician's office for specific complaints, or for a periodic physical examination. It's the physician's task, not always an easy one, to determine whether the dyspnea is medically important, and to recommend a diagnostic plan and a course of therapy when needed.

Dyspnea can be acute, intermittent, or chronic, and can be caused by a heart or lung problem or physical de-conditioning; or it can be of psychogenic origin.

Common heart diseases causing dyspnea include coronary artery disease (the major cause of heart attacks), congestive heart failure, and conditions where heart valves malfunction. Lung problems include bronchial asthma, acute and chronic bronchitis, emphysema, and interstitial lung disease (diffuse scarring and stiffening of lung tissue). Exposure to allergens may precipitate an asthma attack, or dyspnea-producing post nasal drip; but the biggest undiagnosed culprit remains smoking.

Psychogenic dyspnea, precipitated by anxiety, panic or an irregular breathing pattern of frequent sighs ("sigh dyspnea"), is now diagnosed in increasing frequency. This is usually not dangerous, but it may be uncomfortable, and particularly hard to diagnose and treat.

Lack of conditioning is also a cause of dyspnea, especially seen in the "weekend warrior athlete." If you are short of breath playing basketball on Sunday afternoon, do you have a disease causing dyspnea, or is this lack of conditioning?

How is the diagnosis made?

Your account of the intensity, severity and frequency of dyspnea is very important.
This, combined with a physical examination and some basic testing, may rapidly establish the correct diagnosis.

Sometimes the diagnosis is elusive. Both asthma and heart disease can be "silent." Even lack of conditioning may be difficult to diagnose without meticulous testing. The diagnosis of psychogenic dyspnea, can be made on the basis of your symptoms, after medical causes of dyspnea have been ruled out.

For exercise-related dyspnea, we use cardio-pulmonary stress testing (CPST). This important, noninvasive test combines the familiar cardiac test with lung function testing during exercise (on a treadmill or exercise bicycle). With it, we can determine your level of cardiopulmonary fitness, and whether your shortness of breath is due to a heart problem, lung problem, de-conditioning, or "none of the above."

Treatment

Treatment of dyspnea, and its effectiveness, depends on the underlying cause. Frequently, medications are used, such as those needed to optimally control asthma, congestive heart disease and anxiety. Special lifestyle instructions may be given, such as smoking cessation and allergen avoidance. Reconditioning exercises and stress management may be advised, or you may be instructed in the proper performance of diaphragmatic breathing.

Working together with your physician, in the overwhelming majority of cases, shortness of breath can be controlled or completely resolved.

Most, if not all the tools necessary to establish the cause of dyspnea and treat dyspnea are available under one roof at our practice.

Prevent a heart attack

.
Heart attacks continue to be the number one killer in the US. Heart attacks are also one of the major strains on the national and personal health budgets. It is essential that you know your risks for the development of heart disease and take the necessary steps to decrease the chance of a premature heart attack.

Heart attacks, the major manifestation of coronary heart disease (or atherosclerosis, plaque), continues to be the leading cause of mortality in the US, and will continue to be so as longevity increases, and as the number of senior citizens increases. And, yes, many of us feel that we know what puts us at risk for a heart attack, and what we have to do in order to decrease that risk. But do we really know enough? And do we do enough?

Most of us know the detrimental role of smoking, diabetes, obesity, lack of exercise, and hypertension. Many of us also know of the role of cholesterol, including the “good cholesterol” (HDL) and the “bad cholesterol” (LDL), or even triglycerides. Certainly we know that it’s better to be born with “good genes.”

But what about the more recently recognized risks factors and tests to better detect a potential heart problem early, when there’s still time to delay or prevent a heart attack?

Look at one cholesterol related example: We now can look not only at the total LDL and HDL, but also at their respective subclasses (These are not routinely done unless your physician specifically asks for them). There are at least two important LDL patterns, “predominantly small particles LDL,” also known as B Pattern, and “predominantly large particles LDL,” known as A Pattern. Pattern B is the dangerous one, and it’s the one that can usually be managed by lowering dietary fat intake. In contrast, Pattern A individuals may not benefit, or even become worse with severe dietary fat restriction. Similarly, there are other subclasses and markers, each of which has its own significance and therapeutic implications.

Inflammation of the coronary arteries accelerates the formation of coronary plaque. Cardio-CRP is one such marker of inflammation, and helps identify those at risk of a first and subsequent heart attack, even when the cholesterol risk is low.

Newer blood tests, such as the extensive profile offered by the Berkeley HeartLab, (partially on the basis of technology developed at Berkeley Unversity) or the VAP profile (by Atherotech, Inc.) go much further into analyzing inflammatory markers, cholesterol subclasses, and the benefit effect of certain drugs in the management of cardiac risk factors.

Early detection of plaque formation has become easier too. We’re all familiar with the common treadmill stress test, stress ECHO’s, nuclear Thallium or MIBI test, or even cardiac catheterization. But newer tools have evolved. A modern “fast cardiac CT scan” in experienced hands can show calcium in existing plaque, and thus estimate the degree of atherosclerosis. Computerized coronary angiography, which is only minimally invasive, can even better assess the extent of plaque formation. A carotid ultrasound, with particular attention to inflammation (usually reported as “intimal thickening”) may be useful in risk assessment.

Many other developments are just below the horizon. However, an important problem hindering the use of many new techniques is coverage by the health insurance companies as well as Medicare. They traditionally take years before paying for some of these very important tests.

Regardless, we’ve come a long way in our ability to identify the risk of coronary heart disease, and to detect it early. At our practice, early detection and prevention is a cornerstone. Information is a powerful tool, become informed! We’re here to help you live a longer, healthier life…