What I Believe (medical edition)

After 12 years of writing these Health Tips, resulting in around 600 total, this one will be my last. For those of you who read my tips regularly, you may recognize some repeated themes in today's message. These are a few of the most important "things that I believe" related to health and medical care:

1. Immunizations are one of the most important interventions in medical history.   Historically, infectious diseases have been one of the primary causes of death.  Worldwide, epidemics involving smallpox and influenza have been responsible for killing millions of people. In 1796, Edward Jenner developed a method to immunize people against smallpox by exposing them to a related virus called cowpox.  This process became known as vaccination from the Latin word "vacca" that means cow.  As a result of worldwide smallpox vaccinations, the World Health Organization announced in 1979 that smallpox was officially eradicated.  Vaccines work in cooperation with our immune system and could be considered to be one of the most "natural" means of preventing disease available.  Today, around 27 vaccines are available to prevent diseases caused by bacteria as well as viruses.  These include immunizations against tetanus, typhoid, Haemophilus Type b (Hib) bacteria, cholera, influenza, shingles, whooping cough, polio, Hepatitis A & B, measles, mumps, rubella, chickenpox and pneumococcal disease. There is no denying that vaccines are capable of causing side effects. The facts show, however, that the overwhelming majority of these are minor and transient.  In regard to the population as a whole, the benefits that immunizations have produced far exceed any recognized complication that they may have caused.
    
2. To add years to your life, consider the habits of groups of people known for living long and productive lives. These groups include Sardinians living on an island off the coast of western Italy, residents of the Okinawa Islands in Japan, and members of the Seventh-Day Adventist Church in California.  These groups of people have far less heart disease, cancer, and loss of intellectual ability with aging than most people in the world.  The common denominator among these groups appears to be a healthy lifestyle.  They remain physically active late into life, are primarily non-smokers, and their diet is based on fruits, vegetables and whole grains.  Other important factors thought to be related to longevity in these groups include regular social interaction, spiritual awareness, and having a purpose in life. The fact that Americans have the lowest life expectancy among the industrialized nations (Canada, the United Kingdom, France, Sweden, Germany, Italy, and Japan), indicates that access to the most technologically advanced medical system in the world does not necessarily insure long life.
    
3. Don't take antibiotics for a viral illness, such as the common cold.  Most people know that antibiotics are used to fight infections. Millions of lives have been saved by their ability to combat bacterial infections.  Many people are unaware, however, that antibiotics are not effective for all types of infections. Antibiotics are ineffective at shortening the duration or severity of a viral infection such as the common cold.  In fact, inappropriate use of antibiotics has been responsible for causing a number of serious problems including the development of antibiotic resistance, allergic reactions, and a serious type of diarrheal illness. Antibiotic resistance in particular is considered to be one of the world's most pressing public health problems. With inappropriate antibiotic usage, the resulting drug-resistant bacteria may not respond to treatment with previously effective antibiotics. This can lead to serious infections that require more expensive antibiotics including those that can only be delivered through an intravenous line.
    
4. Do some type of physical activity every day. Regular, moderate to vigorous physical activity is associated with substantially lower overall mortality compared to sedentary individuals.   Exercise has been shown to have positive effects on blood pressure, cholesterol level, blood sugar, body weight, mood, well-being, bone density, balance and energy level. Leisure-time physical activity is associated with a significantly lower risk of developing at least 13 types of cancer including those affecting the lungs, colon, breasts, liver, and head and neck.  For adults, the physical activity recommendations for general health promoted by the American Heart Association (AHA) are to do:
    
   • At least 30 minutes of moderate-intensity aerobic activity at least 5 days per week for a total of 150 minutes
     OR
      
   • At least 25 minutes of vigorous aerobic activity at least 3 days per week for a total of 75 minutes; or a combination of moderate- and vigorous-intensity aerobic activity
     
     
     AND
      
   • Moderate- to high-intensity muscle-strengthening activity at least 2 days per week for additional health benefits.
      
   Even people who hate to exercise should recognize that some activity is better than no activity.  You don't have to be a marathoner or spend hours in the gym to reap the benefits of exercise. You just need to figure out some way of getting your body moving each day. Once you start, you're likely to find that you want to do more and more challenging workouts.  Someday you may even discover that you actually enjoy exercising!
   

5. Don't smoke, period.  End of discussion.

Of course, I have far more opinions regarding health and medical care than mentioned above, but I'll leave it at that. In contrast with most of my Health Tips, I have not provided references to support the statements above.  This is just what I (and most likely a majority of people in health care as well) believe.  It has been an education and a pleasure to have provided this service to our subscribers.

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"Barking Dogs"--- painful conditions affecting the feet

It's no surprise that foot problems are common when you recognize that your feet bear the entire weight of the body with each step.  Congenital abnormalities, altered foot mechanics, excessive activity, and inappropriate footwear are responsible for most problems affecting the feet, such as: 

• Bunions
• Morton's neuroma
• Hammer toe
• Fallen arches, also known as flat feet or pes planus
• Plantar fasciitis

A bunion affects the joint between the foot and the big toe, known as the first metatarsophalangeal (MTP) joint).   Bony degeneration along with irritation of a "cushion" known as a bursa on the inside (medial aspect) of the joint, contribute to the discomfort associated with bunions. Bunions are often associated with a structural abnormality called hallux valgus in which the big toe is angled toward the other toes.  Wearing footwear that is too tight, squeezing the toes together, is one factor thought to be responsible for causing hallux valgus and bunions.  This is not the case in every instance, however, since bunions also develop in primitive cultures in which shoes are not worn.  Bunions tend to run in families, perhaps due to inherited faulty foot mechanics.

A number of non-surgical measures can help with bunion symptoms. The single most important measure is to remove pressure on the bunion by wearing shoes of appropriate width.  Shoes with pointed toes or high heels should be avoided.  In some cases, shoes can be stretched over the area of the bunion to reduce pressure. Pads made from felt, gel or foam are also available to cushion the bunion from the side of the shoe.  Some people may also benefit from the use of specially designed splints.  If the deformity or pain becomes severe, surgery to realign the toe and remove the bony bump (bunionectomy) may be necessary.

Morton's neuroma is a common cause for pain in the forefoot. A neuroma is a thickening of the tissue that surrounds the nerve in response to irritation, trauma, or excessive pressure. The most common location for a Morton's neuroma is between the 3rd and 4th toes.  The primary symptoms are burning pain in the ball of the foot and/or numbness of the toes that are supplied by the involved nerve.  The symptoms are typically worse with activity or when wearing constricting shoes.

The initial treatment is almost always non-surgical.  Some combination of the following measures may take care of the problem:

• A change in footwear toward wider shoes with lower heels and a cushioned sole.
• Anti-inflammatory medications.  Oral medications such as ibuprofen are tried first, but on occasion, a cortisone injection may be required.
• Special shoe inserts such as a metatarsal pad or arch support.

If conservative measures prove unsuccessful, surgery to remove a portion of the nerve or release the tissue around the nerve can provide relief.

Hammer toe is a deformity of the toe in which the end of the toe is bent downward, assuming a claw-like position. Hammer toe most commonly affects the second toe, although it can also affect the other toes. A corn on the top of a toe and a callus on the sole of the foot may develop, which makes walking painful. The condition may be congenital (present at birth), acquired by wearing short, narrow shoes or secondary to the development of hallux valgus (bunion). Properly-sized footwear or wide toe-box shoes usually provide comfort and can reduce aggravation of hammer toes. Mild hammer toe can also be treated with special splints. Severe hammer toe requires an operation to straighten the joint. The surgery usually involves cutting or transferring tendons or fusing the joints of the toe together.

A flat foot, also known as pes planus, is a condition where the arch or instep of the foot collapses during walking or running. This "fallen arch" can result from a number of causes including laxity of a tendon in the ankle (posterior tibial tendon), a complication of diabetes (Charcot foot), arthritis and injury.  When painful, most people will benefit from the use of arch supports. In some cases, custom-made arch supports called orthotics may be even more beneficial. People with flat feet, low arches, or overly flexible arches tend to overpronate which means that their foot rolls too far inward. Overpronation is a common cause of foot pain, particularly in runners. Most running shoe stores carry shoes for flat or overpronated feet that provide extra support on the inside (medial aspect) of the shoe. This type of shoe can even help non-athletes with pain associated with flat feet. Only rarely does surgical correction to improve alignment of flat feet become necessary.

Many people who think that they have a "stone bruise" beneath the heel actually have a problem known as plantar fasciitis. The plantar fascia is a very thick band of tissue that extends from the bottom of the heel toward the toes, forming part of the arch of the foot. Should the plantar fascia become inflamed, pain develops on the bottom of the heel. The most common symptom of plantar fasciitis is heel pain that occurs when taking the first few steps in the morning or after sitting for a period of time.  Risk factors for its development include problems with the arch of the foot (either flat feet or high arches), obesity, sudden weight gain, running, and a tight Achilles tendon. Initial treatment usually consists of heel stretching exercises, shoe inserts, night splints, and anti-inflammatory medications. Occasionally, a steroid injection will provide lasting relief of symptoms.  In a very few, non-surgical treatment fails and surgery to release the tight, inflamed fascia may be considered.

Sources for article:
Foot Injuries and Disorders from Medline Plus
Ailments of the Big Toe from the American Orthopaedic Foot and Ankle Society
Plantar Fasciitis and Bone Spurs from OrthoInfo

If you have any questions about foot problems, please log into your account and send us your question. We are here to help.

Kent Davidson MD - Health Tip Content Editor

Celiac Disease, a great masquerader

Celiac disease is an inherited digestive disorder of unknown cause that affects the small intestine. Other names for this condition are celiac sprue, nontropical sprue, and gluten-sensitive enteropathy. If someone in your immediate family has it, chances are about 10 percent that you may have it too. Once thought rare, celiac disease has recently been estimated to affect 1 of every 141 Americans.  Those who have celiac disease cannot tolerate a protein called gluten, which is present in wheat, rye, and barley. When a person with celiac disease eats foods containing gluten, an immune reaction occurs in the small intestine, resulting in damage to the surface of the small intestine and an inability to absorb certain nutrients from food.  Eventually, decreased absorption of nutrients can cause vitamin deficiencies which can lead to other illnesses affecting a number of organs.
 

Celiac disease symptoms may start in childhood or adulthood, with onset and severity influenced by the amount of gluten that is eaten.  Some of the ways that celiac disease can present include:

• An infant may have abdominal pain and diarrhea (even bloody diarrhea), and may fail to grow and gain weight.
• A young child may have abdominal pain with nausea and lack of appetite, anemia (not enough iron in the blood), mouth sores and allergic dermatitis (skin rash).
• Teenagers may hit puberty late and be short.
• Adults typically have abdominal pain, chronic diarrhea, weight loss and pale, foul-smelling stools.

Celiac disease may also present itself in less obvious ways, including irritability or depression, stomach upset, anemia, joint pain, muscle cramps, skin rash (dermatitis herpetiformis), mouth sores, osteoporosis, and tingling in the legs and feet (neuropathy).

Celiac disease appears to be an under-diagnosed condition and can be confused with other gastrointestinal problems such as irritable bowel syndrome, gastric ulcers, lactose intolerance, and parasite infections.  When suspected, a blood test (tTG-IgA test) can be performed to detect high
levels of antibodies responsible for the immune reaction.  If blood test results suggest celiac disease, a biopsy of the small intestine, performed during a procedure called upper GI endoscopy, can confirm the diagnosis.

There is no specific medicine or surgery to treat celiac disease. Instead it is "managed" through complete avoidance of gluten. Gluten-containing foods that must be avoided include:

• Breads or baked goods prepared from wheat, barley, or rye
• Cereals made from wheat, rye, or barley
• Pasta prepared from wheat, rye, barley, or semolina
• Salad dressings, gravies, sauces, and soups prepared with gluten-containing ingredients

Other less obvious sources of gluten include pre-packaged foods, lip balms, toothpastes, vitamin and nutrient supplements, and, rarely medications.

Following a gluten-free diet is a lifetime requirement for individuals with celiac disease. A gluten-free diet will stop symptoms and allow for healing of the intestinal damage. Gluten-free flour, bread, pasta, and other products are available, which makes this diet more tolerable. Improvements after starting a gluten-free diet may be especially dramatic in children.

It is very important to recognize celiac disease since, if left untreated, it can result in a number of serious conditions including malnutrition, osteoporosis, and nerve damage. Celiac disease has even been associated with a higher risk of developing colon cancer and intestinal lymphoma.

Sources for article: 
Celiac Disease from the The National Institute of Diabetes and Digestive and Kidney Diseases
What is Celiac Disease? from the Celiac Disease Foundation

If you have any questions about Celiac disease, please log into your account and send us your question. We are here to help.

Kent Davidson MD - Health Tip Content Editor

Cardio Exercise vs. Weight Lifting - Which is better for my health?

Back in the early 70's, Kenneth Cooper, M.D popularized the term "aerobics", which referred to the types of exercise that focused on cardiorespiratory fitness. This spurred on the jogging, cycling and walking craze which continues today. Aerobic exercise, also known as "cardiovascular" or "cardio" exercise, utilizes major muscles such as those in the arms and legs walking while increasing heart and respiratory rate. Examples of this type of exercise include jogging, aerobic dancing, rowing and bicycling. Since then Dr. Cooper's Aerobics Center and numerous other researchers have confirmed the health benefits of aerobic exercise which range from increased longevity to reduction in the risk of developing certain types of cancer and heart disease.  At the outset of the aerobics boom, resistance training or weight lifting was thought of as a means to building muscle mass, increasing strength or enhancing sports performance, but it took a back seat in terms of promoting general health. Over the past several years, this previously held perception is being reevaluated, with clear benefits being reported with resistance training in the literature.  This has led to a great deal of confusion among many people who want to do what is best for their health.   Additionally, for those with busy schedules, it is important to be able to get the "most bang for the buck" in terms of their time commitment to exercise.  In today's health tip, I'll try to point out some of the confirmed benefits of aerobic (cardio) and resistance exercise and also dispel some of myths surrounding each.


Effect on hypertension
Studies have shown that regular cardio exercise can reduce systolic blood pressure (the top number) anywhere from 4 to 9 mm (points).  The greatest benefit appears to come from a moderate-intensity exercise as compared to higher intensity workouts.  Some studies have also shown sustained improvement, although not as great as with cardio activity, in people participating in a resistance training program.  When lifting weights, systolic and diastolic blood pressures can actually increase temporarily, indicating the need for caution among individuals with uncontrolled hypertension or heart disease.  Resistance training does not, however, lead to the development of hypertension.

Effect on blood lipids
For some time it has been known that cardio exercise can increase the level of "good cholesterol" (HDL cholesterol) and lower blood triglycerides in those with elevated levels.  More recently it has been found that resistance training can bring about similar results.  It appears that the resistance programs that use lower weights with higher repetitions are the ones that are best at improving lipid profiles.  Combining aerobics with resistance training appears to be the optimal way to address elevated blood lipids.

Effect of oxygen uptake
In numerous studies, aerobic exercise has been confirmed to improve maximum oxygen uptake (VO2 max).  In sedentary persons, an improvement in VO2 max of 10-20% will occur with a minimum of 20 minutes of moderate-intensity aerobic exercise done at least 3 days a week.  Exercising at higher intensities will improve VO2 max even more. Typical resistance training programs that utilize "sets" of weight lifting with rest periods between have not demonstrated this same degree of improvement in VO2 max.  "Circuit training" programs, however, in which the individual moves rapidly between resistance exercises with minimal rest, have been shown to produce modest improvement in VO2 max.  These programs may be performed with exercise machines, hand-held weights, elastic resistance, calisthenics or any combination.

Effect on calorie burning
Exercise is an essential component of an effective weight loss program.  Aerobic activity alone, keeping caloric intake at the same level, causes weight loss primarily by "burning" body fat.  With diet alone, reduction in weight may occur, but this can be at the expense of lean body tissue (muscle).  A number off studies have shown that sustained weight loss is more likely when a reduced calorie diet is coupled with a regular exercise program. Resistance training programs (particularly those using circuit methods) have shown improvements in body weight and fat mass comparable to aerobic programs.

Effect on strength
This is one area where resistance training clearly stands out.  By pitting muscles against resistance, such as  a barbell or weight machine, the muscle cells eventually become larger and stronger.  When beginning resistance training, the initial increase in strength is due to a phenomenon called "neural adaptation." This means that the nerves servicing the muscles "fire" more frequently and more muscle fibers are recruited to perform the contraction.  Through neural adaptation, you become stronger, but the muscles remain the same size. With continued resistance training, the muscle cells eventually increase in size (hypertrophy).  While aerobic exercise does work the larger muscles of the arms and legs, its primary benefit is to improve heart and lung function.
 
Final thoughts
This Health Tip only touches on the many benefits of these two types of exercise.  The "take home" message is that there are clear and undeniable reasons to incorporate exercise into your life.  An ideal program should include elements of each type.  The American College of Sports Medicine recommends that all Americans should try to receive "30-60 minutes of moderate-intensity exercise (five days per week) or 20-60 minutes of vigorous-intensity exercise (three days per week) and perform strength training on two non-consecutive days each week."  From the above discussion, it is clear that there are complimentary benefits from participation in both types of exercise.

Sources for article:
Hypertension and weight training: secrets for success from The Cooper Institute
Exercises to Control Your Cholesterol from WebMD
How much am I burning? From Mayo Clinic
ACSM Issues New Recommendations on Quantity and Quality of Exercise from the American College of Sports Medicine

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Along Came a Spider...

Black widow spider (Latrodectus mactans)   The female black widow spider is a shiny, inky black spider that measures (including its legs) anywhere from one-half to one inch in length.  The male is much smaller and does not cause envenomation in humans.  The most distinguishing characteristic is a red to orange-colored marking on the underside of its abdomen in the shape of an hourglass.  Black widow spiders are found throughout the U.S. and prefer to live in undisturbed areas such as woodpiles, sheds, crawl spaces, basements and garages.  The venom of a black widow is a type of neurotoxin, meaning it attacks the nervous system. The bite is said to feel like a pinprick and sometimes the two fang marks can be seen.  Within a few hours, though, intense pain at the site of the bite begins. Systemic (affecting the entire body) symptoms of black widow envenomation include nausea, restlessness, sweating, increased blood pressure, severe abdominal pain, muscle spasms and fever. 

Brown recluse spider (Loxosceles reclusa) The brown recluse is named for its habit of hiding in dark locations such as attics, closets, and woodpiles.  Their range is primarily in the Midwest and South Central United States.  They are sometimes called "fiddle back" spiders due to a violin-shaped marking on their backs (cephalothorax).  This spider is golden brown in color and its size ranges from one-quarter to three-quarters inches in length. The bite produces a mild stinging, followed by local redness and intense pain within eight hours. The wound may take on a bull's-eye appearance, with a center blister surrounded by an angry-looking red ring and then a blanched (white) ring. Tissue at the site of the bite and the surrounding area dies and eventually sheds. Systemic symptoms include fever, chills, nausea, vomiting, and muscle aches.

What to do if bitten by a spider.  If it can be done safely, identification or collection of the spider can assist the doctor in managing the bite. First-aid measures for black widow or brown recluse bites include cleaning the wound, applying cool compresses and taking a mild pain reliever, such as acetaminophen (Tylenol).  Since the extent or seriousness of the envenomation may not be apparent shortly after the bite, it is a good idea to seek medical attention.  Development of systemic symptoms clearly warrants medical evaluation.
Most black widow spider bites do not cause serious complications and can be managed with pain medications, benzodiazepines (e.g. Valium) for muscle spasms and, administration of tetanus prophylaxis.

For more severe symptoms, such as increasingly severe pain, dangerously high blood pressure, and generalized muscle spasms, black widow antivenom is available. This should only be administered under the careful supervision of a physician since severe allergic reactions, including anaphylaxis, have occurred.
Rather than being toxic to the nervous system, the venom of the brown recluse primarily causes tissue destruction at the site of the bite.  With careful wound care, sometimes including treatment with antibiotics, most of these bites heal without complications. Often, weeks of treatment are necessary until the skin is completely healed.  Occasionally, because of severe tissue damage, surgical debridement or skin grafting may be required.

In spite of the general perception that spiders are dangerous, they are actually quite beneficial in controlling insects.  Most envenomations occur as a defensive measure when humans encroach upon the spider's habitat.  Spider-related fatalities are rare, usually only occurring in small children, the severely ill, or in the elderly. In fact, most people who go to the doctor because of a "spider bite" actually have some other skin problem.  Particularly in the areas of the country that venomous spiders are not known to live, a more likely explanation for a "spider bite" is a methicillin-resistant Staphylococcus aureus (MRSA) skin infection.

Sources for article:

Black widow spider from Medline Plus
Spider bites: First aid from Mayo Foundation for Medical Education and Research
Black Widow Spider Bite from WebMD
Brown Recluse Spider Bite from eMedicineHealth

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