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LIVING HEALTHIER

LIVING HEALTHIER AND LONGER – WHAT WORKS, WHAT DOESN’T


AND
This educational text is made available to you thanks LONGER –
to the generous contributions of these donors:
WHAT WORKS,
The Chamberlain Foundation WHAT DOESN’T NO SMOKING
IMMUNIZATIONS
Parkview Medical Center POTASSIUM
SUNSHINE
The Pueblo Chieftain Provided by: NO TOBACCO PRODUCTS
SOCIAL CONTACTS
Pueblo City-County Health Department NORMAL TRIGLYCERIDES
NO ILLICIT DRUGS
Ryals’ Family Foundation CALCIUM
VITAMIN D
St. Mary-Corwin Medical Center MULTIPLE VITAMIN
ALCOHOL MODERATION
University of Colorado School of Medicine CANCER SCREENING
FISH AND GRAINS
GOOD HDL CHOLESTEROL
LOW LDL CHOLESTEROL
FRUITS AND VEGETABLES
EXERCISE DAILY
IDEAL BLOOD PRESSURE
HEALTHY DIET
IDEAL BODY WEIGHT
NO SMOKING

ByCarl
By CarlE.E.Bartecchi,
Bartecchi,M.D.
M.D.
RobertW.
Robert W.Schrier,
Schrier,M.D.
M.D.
Forward
Foreword bybyRichard
RichardD.D.
Lamm
Lamm
Living Healthier

and

Longer –

What Works,
What Doesn’t

This educational text is made available to you thanks to


the generous contributions of these donors:
The Chamberlain Foundation
Parkview Medical Center
The Pueblo Chieftain
Pueblo City-County Health Department
Ryals’ Family Foundation
St. Mary-Corwin Medical Center
University of Colorado School of Medicine
Living Healthier

and

Longer –

What Works,
What Doesn’t

Carl E. Bartecchi, M.D.

and

Robert W. Schrier, M.D.

Foreword by Richard D. Lamm

Quotations sourced by
Barbara Lindley Schrier
MFTP PUBLICATIONS
Pueblo, Colorado

Copyright© 2008, Carl E. Bartecchi, M.D. and


Robert W. Schrier, M.D.

The medical information in this book is solely from the au-


thors, their medical Information resources and their colleagues,
and not from any of the organizations that funded the printing
and distribution of the book. The authors have not received any
funding or support from pharmaceutical firms, for-profit health
organizations or publishers.

The information in this text is made available to all individuals


seeking to live healthier and thus live longer. Individuals are
free to copy and or download this information for their own
personal use. They are also free to distribute this information to
friends and family members. No part of this publication, in any
form, can be sold by any party without the written permission
of the authors.
THIS BOOK OR CHAPTERS CAN BE DOWNLOADED AT:
healthierlongerlife.org

Printed in the United States of America


To our wives, Kay and Barbara, who continue to help us live
longer, healthier, and happier lives.
TABLE OF CONTENTS
Foreword .................................................................................... 1
Preface ....................................................................................... 3
Acknowledgements..................................................................... 5
Introduction . ............................................................................... 6

DISEASES
1. Coronary Artery Disease..................................................... 10
2. High Blood Pressure........................................................... 20
3. Stroke.................................................................................. 27
4. Cancer................................................................................. 33
5. Diabetes: We are learning more about management.......... 44
6. Bone Disease...................................................................... 50
7. Dementia............................................................................. 58
8. Infections/HIV and the AIDS Epidemic................................ 63

OTHER PROBLEMS
9. Sex...................................................................................... 70
10. Injuries/Accidents/Domestic Violence.................................. 76
11. The Bad (Polypharmacy) and the Ugly (Cocaine,
Methamphetamines, Marijuana).......................................... 81

RISK FACTORS
12. Smoking.............................................................................. 87
13. Good and Bad Cholesterol.................................................. 98
14. Obesity.............................................................................. 106
15. Alcohol............................................................................... 117
16. Stress and Depression...................................................... 124
DISEASE PREVENTION/HEALTH AIDS
17. Immunizations................................................................... 132
18. Diet.................................................................................... 136
19. Exercise............................................................................. 149
20. Sleep................................................................................. 156
21. Vitamins and Supplements................................................ 163
22. Aspirin............................................................................... 171

GENERAL INFORMATION
23. Aging................................................................................. 175
24. The Physician.................................................................... 179
25. The Patient........................................................................ 184
26. Alternative Medicine: Alternative to What????.................. 188

CONCLUSION
27. In Summary....................................................................... 206
28. What Works – What Doesn’t.............................................. 208
29. About the Authors.............................................................. 220
30. Would you like more information?..................................... 221
Living Healthier and Longer –  What Works, What Doesn’t

FOREWORD
Proust once observed that “the real voyage of discovery is not
in seeking new lands but seeing with new eyes.” Carl Bartecchi
and Robert Schrier direct us to look at health with new eyes.
Health, they suggest, is both an art and a science; and it takes
an understanding of both to live a longer and healthier life. This is
important to both individuals and public policy.
A nation’s health has more to do with its lifestyle and habits than
the quality of its health care system. Without casting aspersions on
the brilliance of U.S. medicine (which has saved one desperately
important to me), we know clearly that your best doctor is yourself.
We can avoid many more diseases than we can cure. Our habits
are more important than our hospitals. The authors know the most
valuable thing they can do for the public is to educate people on
what they can do for themselves. They recognize that “medicine”
and “health” are related but are not Siamese twins.
National polls confirm that “health” is one of the American
public’s most important priorities. But how does one achieve a long
and healthy life? The authors inform us of a wide variety of simple
things we can do for ourselves. These are obvious but still too
often overlooked.
Victor Fuchs has written:
The greatest current potential for improving the health of
the American people is to be found in what they do and don’t do
to and for themselves. Individual decisions about diet, exercise,
and smoking are of critical importance; and collective decisions
affecting pollution and other aspects of the environment are
also relevant.
As a public policy maker, I feel that my patient is society. It is
important to distinguish between a doctor’s role and a public policy
maker’s. Public policy must, by definition, ask macro questions,
such as “How do we keep a society healthy?” and “How do we
invest limited funds to buy the most health?”
I started asking these questions when I was in the Colorado
legislature. I could not understand why there was (and is) an inverse
correlation in the developed world between health spending and
health.
The U.S., Canada, and Germany spend the most on health
care; yet they have (generally) the worst health statistics. Japan


Living Healthier and Longer –  What Works, What Doesn’t

spends the least and has the best. I was told that the Japanese
recognized that getting people jobs and increasing living standards
will buy far more health for a country than having a health care
system.
The U.S. Department of Health and Human Services estimates
that, of the 30 years that have been added to human life expectancy
this century, only 5 of those years are due to clinical medicine.
We all must learn better what we can do for ourselves. With all
their medical training, the authors still remind us that our health
depends more on ourselves than on them.
Medicine is a profession, but health policy is a public policy
choice. Our government pays more than 40 percent of health
care costs. Health care costs are bankrupting more and more
businesses and are dampening needed wage increases. Medicare
is fast heading toward bankruptcy. Our aging bodies can thus
bankrupt our children. Inquiring minds increasingly ask “How do
we keep a society healthy?”
This argument is timeless. The ancient Greeks had 2 theories
concerning health: one symbolized by the goddess Hygeia and the
other by the god Aesculapius. Hygeia was the guardian of health,
but her role was to symbolize the belief that people would stay in
good health if they lived according to reason. She represented
moderation in lifestyles, not treatment of the sick. Aesculapius, in
contrast, was concerned with identifying the cause of disease and
the treatment of the sick.
These divergent views of health have never been resolved
and remain a key issue today, one that will grow during the next
10 years. Dr. Bartecchi and Dr. Schrier brilliantly bridge these 2
aspects of health. Both are scholars in allopathic medicine; yet
both recognize that we currently do not inform the public enough
on how people can take care of their own health. Their book is
filled with useful and practical suggestions on how individuals,
families, and societies can best maintain health.
The authors, thus, have risen above the excellence of their own
specialties and have looked at the big picture. They are concerned
with both medicine and health and have given us a practical guide
to use in our daily lives.
Richard Lamm
Governor of Colorado
1975-1987

Living Healthier and Longer –  What Works, What Doesn’t

PREFACE
It has been 8 years since the publication of our book – The
Science and Art of Living a Longer and Healthier Life. The book
proved popular, in an otherwise crowded market of personal-
health related books. Readers of the original book have pressed
the authors for an updated version. Some might ask how much
could have changed in 8 years to justify another book on the
subject. Many of the basic principles of maintaining good health
and extending lives have remained unchanged. However, many
concepts have changed, been modified, updated or even cast
aside.
In the fields of health maintenance and disease prevention,
information is always changing. New studies, when well done,
may negate older information. That’s the beauty of conventional
medicine. It moves forward with new scientific discoveries. It
isn’t sidetracked or delayed trying to explain or justify outdated,
unscientific concepts, be they centuries or months old. Confusion
may arise on some points. Even medical schools and medical
centers might provide therapies that are not recognized as
scientifically plausible. They justify this by “giving patients what
they want or even demand” (or will pay for). Such centers are
often under great pressures from supporting foundations, wealthy
donors or sympathetic board members. Sometimes, a medical
center will compromise (or be compromised) by such financial
pressures by offering to do “research” on scientifically suspect
therapies. Such “research” may be quite profitable for the center
and the researchers. They forget, however, that supporters of these
suspect therapies portray any such activity at a legitimate medical
center as support for their scientifically questionable therapy.
Not only have many health and therapeutic concepts
changed, been modified or simply tossed aside, but several new
considerations and therapeutic approaches have appeared that
deserve inclusion in this new book, a book devoted to providing
readers with documented strategies that can allow them to live a
healthier and longer life.
Today, we are reaping the benefits from many large-scale,
randomized, placebo-controlled, double-blinded clinical trials
published in sophisticated, peer-reviewed medical journals. These


Living Healthier and Longer –  What Works, What Doesn’t

studies have provided new evidence-based insights into several


difficult health problem areas. As physicians and educators, we
demand proof and support for the concepts and recommendations
that we pass on to our patients in order to help counter
undocumented information that constantly bombards the public
via radio, television, newspapers, magazines and the Internet.
Conflicting data that the public is asked to decipher is confusing
and lessens the public’s confidence in our health care systems
and its providers. This book helps resolve some of the apparent
contradictions as to how to live a healthier and longer life.
We have also included an expanded chapter on alternative
medicine, in view of the present popularity of treatments generated
by that discipline and its disciples. Here we seek the same level
of documentation for the promises and therapies of alternative
medicine that are required and expected of high quality, cost-
effective conventional medicine. In this regard, the title of the book
has been changed to Living Healthier and Longer – What Works,
What Doesn’t.


Living Healthier and Longer –  What Works, What Doesn’t

Acknowledgements
The authors wish to recognize Jan Darling and Kay Bartecchi
for expert technical assistance. We appreciate the insightful and
thought-provoking quotations provided by Barbara Lindley Schrier.
The book cover was designed by David Bartecchi. We appreciate
the assistance of literary consultant Yvonne Kellar-Guenther,
Ph.D.


Living Healthier and Longer –  What Works, What Doesn’t

INTRODUCTION
Sadly, poor health choices of our youth lead to the 3 major
causes of preventable death. By early adulthood many of us
regularly use tobacco products, eat fast foods too often, weigh too
much, do not exercise enough and drink too much alcohol. The
human body is very forgiving during those early years. The human
body is also willing to accept changes or corrections to improve
one’s health. Making certain changes at almost any point in one’s
life can improve one’s life. These changes can also result in living
longer.
The goal of this book is to describe those factors that have
been shown to help people to live healthier and longer lives. We
also wish to point out there are a high number of factors which
claim such potential but have not been proven to do so.
In 2005, people in the U.S. were expected to live 77.9 years.
Our population is rapidly aging. By 2030, the number of Americans
65 and older will more than double to 71 million. These older
Americans will make up about 20 percent of the U.S. population.
Looking for ways to get and maintain good health is important for
individuals and for society. The cost of health care for an older
American is 3 to 5 times higher than the cost for those under 65.
By 2030, our already high health care spending is expected to
rise by 25 percent. This increase is largely because of our aging
population. To help lower these costs we need to become more
hands-on in preserving the health of older adults.
It is true that accidents, wars, natural disasters and getting
certain diseases can quickly end one’s life. However, it is important
to recognize smoking, poor diet and not enough exercise cause
almost 35 percent of deaths in the U.S. On the other hand,
Americans are living longer. This is because heart disease, cancer
and stroke, are causing fewer deaths each year. We plan to cover
the factors that contributed to this decline in deaths.


Americans are living longer. This is because heart disease, cancer and stroke, are
causing fewer deaths each year. We plan to cover the factors that contributed to this
decline in deaths.
Living Healthier and Longer –  What Works, What Doesn’t
Leading Causes of Death in the U.S.
Leading Causes of Death in the U.S.

Somewhat unexpected are the leading causes of death for 1


American women:


Living Healthier and Longer –  What Works, What Doesn’t

Improved medical care, prevention efforts and healthier lifestyles


have led to the increase in life span. These have also caused a
shift in the leading causes of death from infectious diseases and
acute illnesses to chronic conditions and degenerative illnesses.
The major chronic conditions are high blood pressure, arthritis,
coronary heart disease, cancers and diabetes. All of these
conditions or their treatments reduce the quality of life for older
adults.
We all get genes from our parents that have an important
influence on the quality and length of our lives. A recent Framingham
Heart study showed that people where both parents lived longer
had fewer health problems when they reached middle age. That
group had better blood pressures and cholesterol values than
those where only one parent lived longer. The group where both
parents lived longer also had fewer of the other risk factors for
heart disease and stroke. Healthy lifestyle choices however can
offset poor genetics. In the future, advances in genetic engineering
will help to improve our chances for a better and longer life. For the
present, however, doing the behaviors that have been shown to
lead to better health is the path we should follow. The behaviors
discussed in this book are the tried and tested actions, beliefs and
therapies supported by high quality studies. These are studies in
high quality medical journals.
We have made it a point not to write about advice that is hard
to follow or expensive. We also do not discuss anything that is not
available to the general public. In this book, we will not advertise
or support products that have not been shown by high-quality
research to extend life or insure good health.
Below is a list from McGinnis and Foege’s research study. In
their study, they looked at the cause of death for the 2.14 millions
US residents who died in 1990. They point out that about half
of deaths could have been avoided if people had changed their
behaviors.


Living Healthier and Longer –  What Works, What Doesn’t

Number of Percentage of
Deaths Total Deaths
1. Tobacco 400,000 19
2. Dietary factors and activity patterns 300,000 14
3. Alcohol 100,000 5
4. Microbial agents 90,000 4
5. Toxic agents 60,000 3
6. Firearms 35,000 2
7. High risk sexual behavior 30,000 1
8. Motor vehicle injuries 25,000 1
Total 1,060,000 49

Further Reading
McGinnis JM, Foege WH. Actual causes of death in the United
States. JAMA 1993;270.


Living Healthier and Longer –  What Works, What Doesn’t

Coronary Heart Disease


Avoid fried foods, which angry up the blood. If your stomach
disputes you, lie down and pacify it with cool thoughts. Keep
the juices flowing by jangling around gently as you move. Go
very light on the vices, such as carrying on in society. The
social ramble ain’t restful. Don’t look back. Something might be
gaining on you.
-Satchel Paige
Facts
1. There are many types of blood vessel and heart diseases.
This group of diseases is often called cardiovascular disease.
Coronary artery disease, also called coronary heart disease,
happens when blood carrying oxygen and nutrients to the
heart is blocked. A blood clot or a build-up of fatty substances
causes the block. This disease accounts for more than one-
half of cardiovascular deaths. About one-third of all deaths in
the US are a result of this disease.
2. A blocked artery that leads to the heart causes a heart attack.
Heart attack is the single largest killer of American males and
females.
3. Each year as many as 1,500,000 Americans will have a heart
attack. About one-third of them will die.
4. Twenty-seven percent of men and 44 percent of women die
within 1 year of having a heart attack.
5. Smoking is dangerous for people at high risk for coronary
artery disease. Smokers with this disease die 10 to 15 years
earlier than those who do not smoke.
6. Second-hand smoke is also dangerous. This is thought to
cause at least 40,000 heart disease deaths yearly in the U.S.
7. Men who eat a high fiber diet have a significantly lower risk of
heart attack than those whose diet is poor in fiber-rich foods.
This is especially true if the fiber comes from grains.
8. People who have what is called adult-onset diabetes mellitus
have a higher chance of dying from coronary disease than
those who do not have diabetes. For men, the chance is

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Living Healthier and Longer –  What Works, What Doesn’t

200 percent higher. For women, the chance is 400 percent


higher. Adult onset diabetes is type 2, noninsulin-dependent
diabetes.
9. Not exercising increases your risk of heart problems. Being
inactive makes it twice as likely that you will have coronary
artery disease.
10. Up to 80 percent of people who will develop heart disease could
have avoided it. To steer clear of heart disease, the person
needs to change their behavior to reduce the risk factors. The
key risk factors for heart disease include obesity, high blood
pressure, inactivity, and high cholesterol.
11. Seventy percent of heart attacks happen in people whose
coronary arteries are blocked less than 50 percent. The block
may be due to a blood clot, a sudden tightening of the coronary
artery, or both.
12. Controlling weight in young adults is important. This can
significantly reduce the chance of having coronary heart
disease as an adult.

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Living Healthier and Longer –  What Works, What Doesn’t

Coronary heart disease (CHD) is the leading cause of death in


the U.S. Over 6 percent of all Americans have this disease. This is
over 16 million people. CHD is responsible for about 700,000 U.S.
deaths each year. CHD is caused by the buildup of plaque inside
the coronary arteries. As the plaque builds up, it causes the wall
of the coronary arteries to change also. The arteries can become
narrower and block the blood flow. In some cases the plaque
buildup can rip apart, blocking the blood flow through the affected
artery. This leads to a heart attack, heart rhythm disturbances,
heart failure and potentially death. The importance of a heart
attack is related to its possible complications as follows:
• Within 1 year of having a first heart attack, 25 percent of men
and 38 percent of women will die.
• Within 6 years of a first heart attack, 18 percent of men and 35
percent of women will have another heart attack.
• 22 percent of men and 46 percent of women will have heart
failure.
• Seven percent of men and 6 percent of women will have
sudden death.
• Every 60 seconds, an American dies of heart disease.
There are several risk factors for the buildup of atherosclerotic
plaque. Yet, Dr. William C. Roberts says that the biggest risk is a
person’s cholesterol level, especially the serum LDL cholesterol
known as the bad cholesterol. Dr. Roberts is a well-known
cardiologist and pathologist. For a few people, about 1 in 500, high
cholesterol is a genetic problem. Others have high cholesterol
because of a poor diet and lack of exercise. Dr. Roberts thinks
it is time to switch gears from decreasing risk of atherosclerotic
events to preventing the plaque buildup. One way this can be
done is by using drugs, called statins, which help control the bad
cholesterol.
To date, a number of studies have proven the value of lowering
LDL cholesterol levels. Yet, it is also known that only about half
of the risk of heart failure comes from the identified risk factors.
Recognizing that the most common LDL cholesterol number
in people with heart attacks is about 140 mg/dl, the common
recommendations for drug intervention with statins would not be
“preventive”. Specifically, Dr. Roberts states,

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Living Healthier and Longer –  What Works, What Doesn’t

If a patient has a coronary event, however (or is at high risk


of an atherosclerotic event, such as having diabetes mellitus
or a previous non-coronary atherosclerotic event), the LDL
cholesterol goal is less than 100 mg/dl (with an “option” of less
than 70 mg/dl.). If it is useful for the LDL cholesterol to be less
than 100 mg/dl after a heart attack, surely it must be useful for
the LDL cholesterol to be less than 100 mg/dl before a heart
attack! Therefore, in my view, the goal for all populations – not
just those with heart or brain attacks or diabetes mellitus or non-
coronary atherosclerotic events – needs to be LDL cholesterol
less than 100 mg/dl and ideally less than 70 mg/dl. If such
a goal was created, the great scourge of the Western World
would be essentially eliminated, “primary” and “secondary”
prevention would be the same, and more than 100 million
Americans – rather than the present 13 million – would need to
be on a statin drug with or without ezetimibe (Zetia), or be pure
vegetation-fruit eaters.
These guidelines by Roberts are not widely accepted at this
time; however, he makes a sound argument for starting to use this
approach.
HDL, also called good cholesterol, can help prevent plaque. At
this time, however, we do not know how much HDL is needed to
prevent plaque. A low HDL cholesterol level may not be dangerous
if the LDL cholesterol level is very low. For example an HDL of only
15 mg/dl might be alright if your LDL is only 50. Roberts believes,
and we agree, that the following may be needed to prevent plaque
formation:
• You want your bad cholesterol or LDL level to be less than 70
mg/dl.
• You want your good cholesterol or HDL level to be above 20
mg/dl. (this very low level accepted only when the total and
LDL are very low)
• Your total cholesterol level should be less than 150 mg/dl.
Thus, treating increasing LDL cholesterol levels as early as
possible will reduce heart disease. This is true even for people
who show no other symptoms of heart disease. Therapy to reduce
LDL cholesterol levels should continue as long as goals are met.

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Living Healthier and Longer –  What Works, What Doesn’t

Other risks have also been identified that increase the chance
of heart disease and heart attacks. It is possible for people to have
heart attacks and die without having a known risk factor. This is
rare though. It is clearly shown that people who have more risk
factors are in the most danger of developing heart disease. Studies
suggest that more than 90 percent of heart problems happen to
people who have at least 1 risk factor. Only a few events typically
occur in people with no high or borderline risk factors. Avoiding
risk factors can help you live longer. The average life expectancy is
77.9 years. People who reach middle age without having any major
risk factors for heart problems can increase their life expectancy
by another 5.8 to 9.5 years.
Risk factors can be viewed in several ways. Some cannot be
changed; these include:
• Age.
• Sex.
• Race.
• Heredity or genetic factors.
Other risk factors can be changed. The most serious of these
are:
• Hypertension.
• Cigarette smoking.
• High cholesterol levels.
• Diabetes mellitus – avoid it or keep it under control.
• Enlarged heart.
• Cocaine use.
Things that you can do to effectively modify these risk factors
include:
• Eating foods that are good for you.
• Avoid becoming obese.
• Taking medications that reduce your risk factors. These include
high blood pressure medications and statins.
• Quitting smoking.
• Exercising regularly.
• Diabetes control.
• Not using cocaine.

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Living Healthier and Longer –  What Works, What Doesn’t

Other important modifiable risk factors include:


• Drinking too much alcohol.
• Oral contraceptive use.
• Too much stress.
• Factors involved in increased blood clotting, i.e., abnormalities
such as abnormal platelets, fibrinogen, clotting factors, etc.
• There is evidence that not having a close group of family or
friends increases the risk of heart attack. Setting at the time
of a first heart attack, such as:
• An individual living alone.
• A recent spousal loss or separation.
• Evidence of lack of social support.
In spite of the large number of risk factors, the determination
of the likelihood of development of coronary heart disease can be
based on 8 tried and true factors:
1. Higher LDL (bad) Cholesterol.
2. Blood Pressure. High blood pressure increases the workload
of the heart, causing it to enlarge and become weaker.
3. Smoking status. A smoker’s risk of developing heart disease
is 2 to 4 times that of a non-smoker. Even exposure to second-
hand smoke increases the risk of coronary heart disease.
4. Increasing age. More than 3 quarters of people who die of
coronary heart disease are 65 or older.
5. Being male. Men have a greater risk of having a heart attack
than women. Men are also more likely to have heart attacks
earlier in life.
6. Diabetes. Diabetes significantly increases the risk of
developing coronary heart disease, even when the blood
sugar is reasonably well controlled.
7. Low HDL (good) cholesterol levels. Higher levels are
protective. HDLs increase by exercising 3 to 5 times per
week.
8. Race and Heredity. Certain groups have a greater incidence
of coronary heart disease problems. These groups are: Blacks,
American Indians, and native Hawaiians.

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Living Healthier and Longer –  What Works, What Doesn’t

Corrective actions can effectively modify risk factors. Protective


actions include:
1. Stop smoking. Cigarette smoking is the most dangerous risk
factor for coronary artery disease. Quitting smoking allows the
risk for coronary to go back to that of a non-smoker within 2 to
3 years.
2. Correct diet problems to avoid obesity.
3. Assure blood pressure control. You would like your blood
pressure to be under 130/80. Controlling your blood pressure
reduces the chance of heart attacks and strokes.
4. Moderate alcohol consumption. Aim for no more than 1 or 2
glasses of wine or an equivalent per day.
5. Use of aspirin if your doctor recommends it. Aspirin decreases
blood clots or atherosclerotic plaques in coronary arteries.
6. Exercise more. One tip is to walk for 30 minutes 7 times a
week. Numerous studies have shown that regular exercise can
help prevent a first heart attack.
7. Improve HDL levels with increased exercise.
Exercise is tied to a number of desirable goals, including:
• Maintaining desirable body weight (body mass index).
kg body weight
Body mass index (BMI) = 25 or less is recommended
m2 height

• Elevating HDL cholesterol.


• Improving work capacity of the heart.
• Reducing blood pressure to 130/80. This is important if the
person already has coronary heart disease.
• Helping to manage stress.
There are some bad combinations of risk factors. Here are
some deadly combinations:
• A person with hypertension and high cholesterol who smokes
cigarettes.
• A woman who smokes and also uses oral birth control pills.
The earlier a person with modifiable risk factors is aware of
and changes these risk factors, the better. Changing these risk
factors help people avoid the lethal consequences.
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An article in the June 7, 2007 New England Journal of


Medicine noted a decline in death rates due to coronary heart
disease since the 1980s. The researchers believed this decrease
was due to reducing risk factors and use of new technologies. The
major contributors were:
• Reducing cholesterol. This reduced the chance of death by 24
percent.
• Reducing blood pressure. This reduced the chance of death
by 20 percent.
• Reducing smoking. This reduced the chance of death by 12
percent.
• Bypass surgery and angioplasty during or after a heart attack.
This reduced the chance of death by 11 percent.
• Medicines for heart attack. These include beta blockers and
angiotensin blockers. These medicines reduced the chance of
death by 10 percent.
• Heart failure therapies such as ACE inhibitors and decreasing
sodium and water retention with diuretics. This reduced the
chance of death by 9 percent.
• Increasing physical activity. This reduced the chance of death
by 5 percent.
There are other risk factors but we will only discuss them
briefly. These include:
• Elevated lipoprotein (a) levels.
• Elevated fasting insulin levels in nondiabetic patients.
• Greater amounts of small, dense LDL particles.
The first 2 are believed to encourage the formation of blood
clots. They also can lead to a buildup of plaque on the walls of
arteries. The size and density of LDL particles can be important
factors in estimating coronary artery disease risk. Patients with
small, dense particles have 3 times the risk of coronary artery
disease as those with large LDL particles.
In people with chronic heart disease, it is important to
recognize that there are “triggers” that can contribute to the
initiation of a heart attack. These triggers range from stress, anger,
grief and great excitement to heavy physical exertion, sexual
activity, excessive eating, and even wars, natural disasters, severe
weather, and air pollution, to name but a few. Stresses caused

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Living Healthier and Longer –  What Works, What Doesn’t

by infections or “recreational” drugs can also be triggers for heart


attacks. Remember, it is possible that you are at risk for chronic
heart disease but do not know it yet. Recognizing these triggers
and either avoiding them or managing them as they arise will help
keep you healthy.
For those who might wonder what a person with low risk factors
would look like, here is an example. The ideal is a person between
the ages of 35 and 74 who has:
1. Systolic blood pressure less than 120.
2. Diastolic blood pressure less than 80.
3. LDL cholesterol less than 100 mg/dl.
4. HDL cholesterol higher than 60 mg/dl.
5. Fasting glucose level less than 110 mg/dl.
6. Never smoked.
7. Reached the ideal weight.
8. Regularly exercises.
Recommendations
1. Assess, with the help of a physician, your cardiovascular risk
factor status. Re-evaluate your risk regularly.
2. If you smoke, STOP.
3. Eat a heart-healthy diet. This means a diet with less fat, less
meat, and more fiber-rich foods like fresh fruits and vegetables.
Try to eat at least 6 portions of fruits and vegetables daily.
4. Maintain normal blood pressure. Keep your blood pressure
below 140/90. People with kidney disease or diabetes should
maintain a level of 130/80 or lower.
5. Exercise regularly. Aim for 30 minutes per day 7 days per
week.
6. If you are overweight lose weight. Aim for desirable weight.
7. Use alcohol only in moderation. For example males should
aim for no more than 1 to 2 glasses of wine per day for males.
For females, no more than 1 glass per day.
8. Never use cocaine. Even the first use of this drug can cause
a heart attack or sudden death, or lead to permanent cardiac
damage.
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Living Healthier and Longer –  What Works, What Doesn’t

9. If you are a male age 50 years or older and have multiple


cardiovascular risk factors, talk to your doctor about taking
aspirin at 81 mg per day. Do not take an aspirin per day if
you have poorly controlled hypertension, ulcers, and bleeding
problems.
10. If you have adult-onset, type 2 diabetes, try to lose weight.
Weight loss may actually “cure” your diabetes or at least
allow for better blood sugar control. A 5 percent weight loss
maintained over 2 years has been shown to prevent adult
diabetes in high-risk, middle-aged people.
11. A “statin” should be the first drug used to lower elevated
cholesterols. Ezetimibe, also called Zetia, though shown
to lower cholesterol levels, has not been proven to affect
atherosclerosis or coronary heart disease.
Further Reading
Roberts WC. Atherosclerosis: its cause and its prevention.
American Journal of Cardiology. October 2006:1550-1555.
Domanski MJ. Primary prevention of coronary heart disease. New
England Journal of Medicine. October 11, 2007:1543-1545.
Greenland P, Lloyd-Jones D. Time to end the mixed and
often incorrect messages about prevention and treatment of
atherosclerotic cardiovascular disease. Journal of the American
College of Cardiology. November 27, 2007:2133-2135.
Friedewald VE, Ballantyne CM, et al. The editor’s roundtable:
atherosclerosis regression. The American Journal of Cardiology.
April 1, 2008:967-974.

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Living Healthier and Longer –  What Works, What Doesn’t

High Blood Pressure


To be 70 years young is sometimes far more cheerful and
hopeful than to be 40 years old.
-Oliver Wendell Holmes
Facts
1. More than half of all Americans over 65 years of age have high
blood pressure. Over 90 percent will eventually develop it.
2. For patients age 60 or older, treatment of high blood pressure
can:
• reduce death from all causes by 12 percent.
• reduce death from stroke by 36 percent.
• reduce death from coronary artery disease by 25 percent.
3. Studies suggest that when people with hypertension reduce
their diastolic blood pressure by 5 to 6 points, they decrease
the risk of coronary artery disease by 14 percent. The risk of
a stroke also goes down by 42 percent. The second number
of the blood pressure reading is the diastolic blood pressure
(130/80). This number represents the pressure in the arteries
when the heart is at rest.
4. Less than one-third of hypertensive people have their
blood pressure under control. This means most people with
hypertension have blood pressure that is at or above 140/80.
5. Statistics show that 35 percent of people whose blood
pressure is at or above 140/90 were never told they had high
blood pressure. These people do not know that they have
hypertension with a risk of heart attack, heart failure, and/or
stroke.
6. There are many things that can change your blood pressure
reading. These include problems with the tool used to take the
reading, like using a blood pressure cuff that is the wrong size.
The person taking the reading could also have a problem like
difficulty hearing. Finally, the patient could be nervous or have
recently exercised, making the reading too high. Because so
many issues can affect the reading, it is important to have several
repeated and accurate blood pressure measurements.

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Living Healthier and Longer –  What Works, What Doesn’t

7. Some of the medicines your doctor may prescribe can cause


high blood pressure. Always ask your pharmacist about
this when you buy either prescribed or over-the-counter
medicines.
8. Keeping your systolic blood pressure down is important.
Systolic blood pressure is the first number in the blood pressure
(130/80). It measures the blood pressure in the arteries when
the heart squeezes. Studies have shown that every 20 point
increase in this number doubles the chances of having a
stroke, heart attack, heart failure, and kidney disease.

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Living Healthier and Longer –  What Works, What Doesn’t

Around 72 million Americans have hypertension. This means


that they have had their blood pressure tested many times and their
pressure is at or above 140/90. It is important to note, however,
that hypertension can easily be controlled. Everyone 18 and over
should be screened for hypertension regularly.
It is important to know if you have hypertension because it
is a common cause of stroke, heart failure, and coronary artery
disease. This is especially true for the elderly. Hypertension leads
to heart attacks and strokes because it speeds up hardening of
the arteries. Large numbers of people die from the heart attacks,
strokes, and kidney failure caused by hypertension.
Hypertension has been called the “silent killer”. This is
because there are very few symptoms of hypertension. Usually,
it is discovered during routine health evaluations or screenings.
Studies have shown that more than 30 percent of those with
hypertension do not know they have the disease. Of those who
are aware, only about one-half are under treatment. Furthermore,
only about one-quarter of those who are getting treated are well-
controlled. Thus, the diagnosis and treatment of hypertension is a
major health care problem in this country.
It is now known that the risk of cardiovascular disease goes
up when blood pressure is over 110/80. We used to believe that
the diastolic pressure, the lower number, was more important for
estimating risks of stroke and heart attack. More recently it has
been recognized that the systolic pressure is more important. This
is especially true for those over age 55. Systolic pressure measures
blood pressure in the arteries when the heart squeezes. Often
patients 60 years and older will have isolated systolic hypertension.
This is when the systolic number is high but the diastolic blood
pressure is less than 90. Having systolic hypertension is associated
with increased coronary artery disease and strokes.
Ambulatory blood pressure measurements over 24 hours are
helpful. While this approach is expensive, it can help determine if
blood pressure is high even outside of the doctor’s office. About 80
percent of the time, blood pressures taken in the doctor’s office are
higher that those taken away from the office.
Another measurement called the pulse pressure is also
helpful to determine the risk of a heart attack or stroke. Pulse

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Living Healthier and Longer –  What Works, What Doesn’t

pressure is found by subtracting the diastolic pressure from the


systolic pressure. The difference between these 2 numbers tells
us about the stiffness of the artery. Stiffer arteries are linked with
cardiovascular complications.
People with high risk of cardiovascular problems should try to
keep their blood pressure at 130/80 or lower. Keeping the diastolic
pressure, the second blood pressure number, at 80 or lower is
important for diabetic patients. One way to lower blood pressure is
to make lifestyle changes. If lifestyle change alone does not work,
drug therapies can also be used.
Lifestyle changes might include:
• Losing weight through exercise and diet.
• Reducing salt intake.
• Drinking small amounts of alcohol.
• Exercising regularly.
• Quitting smoking.
Following the DASH diet has been proven to lower blood
pressure. DASH stands for Dietary Approaches to Stop
Hypertension. This diet is:
• Low in red meat and other saturated fats.
• High in fruits.
• High in vegetables.
• High in low-fat dairy products.
• High in whole grains.
The DASH diet is also rich in potassium. Potassium is a
mineral that has the ability to lower blood pressure. The best way
to get potassium is to eat fruits and vegetables. If you try to get
this mineral from supplements, you can get too much which can
be harmful.
Salt restriction is important in all hypertension patients. This
is especially true for African-Americans who tend to be more
sensitive to salt. People often do not realize how much salt they
are getting in their food and drinks. Preserved and canned foods
have a high salt content.
Drinking too much alcohol can cause hypertension. It is
estimated that about 8 percent of American men have hypertension

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Living Healthier and Longer –  What Works, What Doesn’t

because they are drinking too much alcohol. Drinking less alcohol
can help decrease blood pressure.
If changes in diet and drinking less alcohol do not control blood
pressure, then talk to your doctor about blood pressure medicine.
This medication has been shown to work well, especially in the
elderly. The use of drug therapy has reduced the numbers of
strokes by one-third and heart attacks by one-fourth for the elderly.
Deaths have been reduced by at least 10 percent for drug-treated
patients.
People with hypertension must work closely with their
physicians for the best results. They should have home blood
pressure monitors to keep track of their own progress. Advantages
of home blood pressure measurements are many, including:
• More realistic measures of actual blood pressure. As noted,
blood pressures taken on physician/office monitors tend to be
higher than those taken on home monitors.
• Close monitoring of how well the blood pressure medicine is
working.
• A quick connection between how you are feeling and your
blood pressure. This allows the person to understand what
signs their body is giving when their blood pressure is too high
or just right.
• A quick connection between stresses, activities, or other
illnesses that can affect blood pressure. This will help the
person and their doctor make adjustments in therapy quickly.
Patients should tell their doctors about other medications
they are taking. Here are some medicines that increase blood
pressure.
• Female hormones including birth control pills.
• Some arthritis medicine.
• Cold and sinus medicine. This includes medicine for colds and
sinus you can get over the counter.
• Diet aids. These are medicines to make you less hungry.
• Some antidepressant medications.
• Anabolic steroids. These are steroids used for building
muscle.
• Nonsteroidal anti-inflammatory drugs (NSAIDs). These are
medicines used to treat aches, pains, and arthritis.

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Living Healthier and Longer –  What Works, What Doesn’t

Cocaine can also increase blood pressure.


NSAIDs can be dangerous for elderly and those with
hypertension or kidney problems. These drugs can be gotten
over-the-counter. As a result, your doctor may not realize you are
using them. Some NSAIDs, however, can make antihypertensive
medications less effective. Aspirin and sulindac which is also called
Clinoril, though, are less likely to affect blood pressure.
The benefits of treating hypertension start within months of
beginning therapy. These benefits can kick in before a person’s
blood pressure is down in the desirable range. Large studies show
that using blood pressure medicine decreases:
• The death rate for people over 65 by almost 20 percent
• Heart attacks by 25 to 30 percent.
• Sudden cardiac deaths by 25 to 30 percent.
• Strokes by about 25-30 percent.
Drugs used to treat hypertension can have major complications.
These problems can even be life-threatening. This is especially
true in the elderly. Age can change how a body reacts to medicines.
Patients must discuss with their doctors any changes in their body
that they notice after starting, changing, or modifying medicine.
Recommendations
1. Have your blood pressure checked at least every 2 years. This
is true even if blood pressure measurements are normal.
2. Work closely with your physician to achieve good blood
pressure control.
3. Take your own blood pressure at home.
4. Understand your blood pressure medications. Ask your
physician or pharmacist for written information about each
drug. It is easy for them to give you information that has been
written specifically for patients.
5. NEVER stop taking blood pressure medications on your own.
Stopping certain medications can result in your blood pressure
going even higher than when you started. It is possible your
blood pressure could become so high that you will have a
stroke, heart failure, or heart attack. People often stop taking

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Living Healthier and Longer –  What Works, What Doesn’t

their medications because of bad side effects or costs. Talk to


your doctor about these concerns.
6. Avoid non-drug or natural treatments for hypertension. There
are many therapies that say they can help but have not been
proven yet. These include:
• Biofeedback.
• Yoga.
• Meditation.
• Acupuncture.
• Hypnosis.
• Certain fad diets.
7. It is important to quit smoking, lose weight, eat less salt, and
exercise. Of these 4, quitting smoking is the most important.
Cardiovascular complications are much higher for people with
hypertension who smoke. Losing as little as 5 to 10 percent
of body weight may control blood pressure with fewer and/
or lower doses of antihypertensive medications. At least 20
percent of hypertension patients increase their blood pressure
when eating foods high in salt. These include french fries,
chips, and canned foods. Thus avoiding salty foods and not
adding salt to food may help control blood pressure. This is
especially true of African-Americans, the elderly and diabetic
patients. For these groups, their blood pressures are “salt
sensitive.” While exercise does not appear to decrease blood
pressure as much as weight loss, it does lower the increased
cardiovascular risk. This risk is common in the hypertension
patient.
8. High cholesterol must be treated more aggressively in people
with hypertension than those with normal blood pressure.
Further Reading
National Institutes of Health (NIH)
National Heart, Lung and Blood Institute
Health.nih.gov

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Living Healthier and Longer –  What Works, What Doesn’t

Stroke
Do what you can with what you have, where you are.
-Theodore Roosevelt
Facts
1. Stroke is the third leading cause of death after heart disease
and cancer, in the U.S.
2. Each year about 550,000 Americans suffer new or recurrent
strokes, 50,000 will have a transient ischemic attack (TIA)
defined as symptoms which last less than 24 hours. A stroke
is defined by symptoms lasting longer than 24 hours.
3. The incidence of stroke more than doubles each decade after
age 55.
4. High blood pressure is a major contributing factor in up to 70
percent of strokes.
5. Patients who survive an initial stroke have a recurrence rate of
up to 18 percent during the following year. About 31 percent of
stroke victims die within a year.
6. After a TIA, the risk for a stroke is about 10 percent over the
next 90 day period. The greatest risk, however, is in the first
week after a TIA.
7. Stroke is the leading cause of serious long-term disability in
the U.S.
8. Smokers have significantly greater risks for stroke than non-
smokers.
9. A smoker with high blood pressure has 20 times the risk of
stroke as a nonsmoker with normal blood pressure.
10. About 1 in 9 patients receiving early thrombolytic or clot
dissolving therapy for stroke will be returned to minimal or no
disability.

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Living Healthier and Longer –  What Works, What Doesn’t

Stroke refers to a sudden impairment of brain function


sometimes termed “brain attack,” that results from the interruption
of circulation to one or another part of the brain, following either
blockage or hemorrhage of an artery supplying the area. The risk
of having a stroke increases with age, the risk being highest after
age 55. The risk is higher in men until the mid-50s, when it begins
to equal that of women. The risk of having a stroke also increases
with family history such as a close relative who has had a stroke,
heart attack, or transient ischemic attack [TIA]. Strokes can be
prevented by identifying and treating people at high risk before the
problem develops and by controlling risk factors. Controllable risk
factors for stroke include:
• High blood pressure - Hypertension (systolic pressure
greater than 140 mm Hg and diastolic pressure greater than 90
mm Hg) may be the cause of 40 percent of strokes. Improved
treatment of high blood pressure over the past 25 years has
been credited with the major reduction in stroke deaths during
that period. Many studies have shown that lowering systolic
blood pressure and maintaining good blood pressure control
by almost any antihypertensive medication, has been effective
in preventing strokes. Therefore, both systolic and diastolic
hypertension needs to be treated and controlled.
• Cigarette smoking - Smokers are 50 percent more likely to
have strokes than nonsmokers; cigarette smoking predisposes
to stroke by a variety of defined mechanisms. Those who quit
smoking have about the same risk of stroke as nonsmokers.
• Diabetes - It is estimated that diabetes can double the risk
of stroke. The mechanism for this is not completely clear, but
diabetes is a risk factor for cerebral arteriosclerosis. Contrary
to what one might expect, improving blood sugar control of
insulin-dependent diabetes does not appear to reduce the
incidence of stroke. Strokes that occur in the setting of high
blood sugars, however, tend to be more severe and disabling.
Controlling blood pressure has been shown to decrease the
occurrence of stroke in adult diabetic patients.
• Heart disease - heart rhythm disturbances such as atrial
fibrillation and heart failure, heart attack, previous heart valve
disease, or valve replacement can increase the likelihood of
having a stroke. Atrial fibrillation, a common cause of irregular

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Living Healthier and Longer –  What Works, What Doesn’t

heart rhythm in the elderly, can increase the risk of stroke to


as high as 7 percent each year. Medications, including blood
thinners, and ablation procedures can significantly reduce
stroke risks in these patients.
• Vascular disease - Significant blockage of the carotid artery
in the neck (greater than 70 percent narrowing) occurs in
about 5 percent of the elderly. Even if these patients are
without symptoms, the risk of having a stroke is 3 to 4 percent
each year. The carotid artery narrowing can be managed by
medications with or without surgery. However, depending on
associated factors, as many as 5 percent of patients who elect
surgery may suffer a stroke or die from the procedure itself.
The physician will listen to the area over the carotid artery in
the neck with a stethoscope to find evidence of blockage in
the carotid artery. If found, further testing will determine the
degree of blockage.
• Transient ischemic attacks (TIAs) - The risk of stroke is
increased in those who have had a TIA. Over 20 percent of
these people will subsequently have a stroke. Aspirin and other
medications have been shown to reduce the risk of stroke in
patients with TIAs, which are evidenced by fleeting or transient
episodes of:
• Unilateral weakness.
• Numbness.
• Distortion of speech.
• Loss of vision.
• Unsteadiness.
• Double vision.
• Cholesterol – Elevated cholesterol levels, alone or
accompanied by other cardiovascular risk factors, contribute
to the development of plaques in the arteries that supply the
brain. Many studies have now shown that cholesterol lowering
drugs (statins) are capable of significantly reducing the risk of
stroke in people with lipid problems and especially those with
coronary artery disease. Eating diets such as the Mediterranean
diet (low saturated fat, high monounsaturated fat, lots of fruits
and vegetables) is also valuable. A recent study from Harvard
reported that people who ate up to 6 servings of fruits and

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Living Healthier and Longer –  What Works, What Doesn’t

vegetables daily were at more than a 30 percent lower risk


of having a stroke compared with people who ate less than 3
servings daily.
• Alcohol - Moderate alcohol intake (not more than 2 drinks
daily) may be associated with a protective effect against stroke;
however, heavy alcohol intake, especially in men and in those
with hypertension, has been associated with an increased risk
of stroke.
• Oral Contraceptive Use – Women who use oral contraceptives
have an increased risk of stroke. This is especially a problem
for women over 35 years, for women who smoke, and for those
that use the older, higher dose hormone pills.
Though many believe that type A behavior (very active),
depression, hopelessness, anxiety, psychological stress, and
highly emotional life events could be risk factors for stroke, data
does not support this possibility.
There is some suggestion that unrecognized or “silent” strokes
occur in the elderly and are manifest only by a significant decline
in intellectual ability. Older people appear also to be at greater risk
of developing the more commonly recognized stroke picture.
Besides medications and surgical treatment, other approaches
to avoiding stroke are recommended. These methods act by
preventing or limiting further vascular lesions, controlling blood
pressure, or providing nutrients or antioxidants that may prove
helpful. This approach involves the maintenance of a low-
cholesterol, low-fat diet with plenty of fruits, vegetables, and
grains at a calorie level sufficient to maintain healthy weight. Also
valuable are daily exercise and the avoidance of salt if patients
have tendencies to high blood pressure.
For those with carotid arterial disease that causes ischemic
(deficient blood supply) events such as TIAs, aspirin is the drug of
first choice for stroke prevention. Aspirin reduces the relative risk
of stroke by about 25 percent with minimal side effects. The best
dose of aspirin for stroke prevention has not been determined,
but doses from a baby aspirin to a couple regular aspirin daily
are effective. For those who cannot tolerate aspirin, clopidogrel
(Plavix) is the drug of second choice.

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Living Healthier and Longer –  What Works, What Doesn’t

Up to 85 percent of strokes that occur in the U.S. each year are


ischemic strokes, with the remainder of the hemorrhagic (bleeding)
variety. A new approach to the treatment of acute ischemic stroke,
the “clot-buster” – tissue plasminogen activator (t-PA), when given
within 3 hours of the onset of stroke symptoms, has proven to be
quite effective, with patients 30 percent more likely to have minimal
or no disability 3 months after such treatment compared to patients
not receiving this agent. Unfortunately, only about 5 percent of
acute stroke patients receive this therapy because of their inability
to reach hospital emergency rooms within the 3 hour period.
Strokes, like heart attacks, are medical emergencies. People must
become more familiar with stroke symptoms, as noted above and
seek help immediately if treatments such as clot-busters are to be
effective. Once in the emergency room, patients should be studied
to determine and, if possible, eliminate cerebral hemorrhage and
other problems that contraindicate clot-buster therapy.
Patients with acute ischemic stroke who are not eligible for
clot-busting therapy should be started on aspirin at 160 to 325 mg
per day within 48 hours of initial stroke symptoms. Aspirin also is
valuable for its ability to prevent recurrent stroke in those who have
already had a stroke.
Other factors that are also important in preventing an initial
or subsequent stroke include exercising, avoiding illicit drug use
(cocaine, amphetamines), and controlling body weight.
Recommendations
1. Recognize that acute stroke is a medical emergency that
should be evaluated in a hospital emergency room as quickly
as possible – call 911.
2. Do not smoke – smoking nearly doubles the risk of ischemic
stroke.
3. Know your blood pressure and check it often as you age.
4. Eat at least 6 servings of fresh fruits and vegetables daily.
5. Be able to recognize warning signs of TIAs or strokes.
6. Patients with a TIA should be treated with a statin therapy.
7. Notify your physician if your heart beats irregularly.

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Living Healthier and Longer –  What Works, What Doesn’t

8. Exercise daily and aim for an ideal weight.


9. Those having a stroke and who are non-ambulatory are at
increased risk for developing blood clots in their legs (up to
1/3 of patients with a moderately severe stroke) and thus need
interventions or medications to prevent this development.
10. Patients with ischemic strokes should be discharged on a
“statin” drug along with lifestyle modifications and aspirin.
11. Stroke patients should have screening for dysphagia
(swallowing problems) which can be found in 25-50 percent of
such patients and could lead to aspiration and pneumonia.
Further Reading
National Institutes of Health (NIH)
National Institute of Neurological Disorders and Stroke
Health.nih.gov

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Living Healthier and Longer –  What Works, What Doesn’t

Cancer
That which does not kill me makes me stronger.
-Nietzsche
Facts
1. Thirty percent of cancer deaths are caused by tobacco.
2. Smoking and diet may cause up to two-thirds of U.S. cancer
deaths.
3. Diet, particularly high-fat and low-fiber, is a significant factor in
cancer deaths in the U.S.
4. People who are 40 percent over ideal weight have as high as
a 55 percent greater risk of dying from cancer than those of
normal weight.
5. Lung cancer is the leading cause of cancer-related deaths in
both males and females in the U.S.
6. Man-made chemicals, artificial sweeteners, pesticides, and
food additives are relatively insignificant or minor causes of
cancer.
7. About 60 percent of human lung cancers contain mutations
in the P53 tumor suppressor gene. The mutation, therefore,
abolishes the effect of this gene against cancer. A recent
study shows a direct link between a defined cigarette smoke
carcinogen (benzo [a] pyrene) and human cancer mutations.
8. Each year about 1,800 men and 210,000 women in the U.S.
learn that they have breast cancer.

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Living Healthier and Longer –  What Works, What Doesn’t

Cancer is a major cause of sickness and death in the U.S.


In 2007, we can expect about 1.5 million new cases and about
560,000 deaths from cancer. It is estimated that men have about
a 45 percent chance of developing cancer in their lifetimes, while
women have about a 38 percent chance.
Recent reports show that cancer death rates are decreasing
by 2.1 percent per year, nearly twice the annual decrease of prior
years. Among both men and women, death rates declined for most
cancers. Favorable trends in incidence and deaths were noted
for lung and colorectal cancer in men and women and for breast
cancer in women.
Cancer, of course, is not a single disease. There are many
different forms of cancer, each with its own pattern of progression
and potential for early detection, treatment, and prognosis. A
relatively small number of cancers make up the majority of cancer
cases:
Males Females
1. Prostate 1. Breast
2. Lung 2. Lung
3. Colon and Rectal 3. Colon and Rectal
4. Bladder 4. Uterine
5. Lymphoma 5. Lymphoma
6. Melanoma 6. Melanoma
7. Kidney
Of these cancers, lung, breast, prostate, and colorectal account
for more than 50 percent of all cancer deaths. Some tumors are
more prevalent than might be suspected. Studies of the prostate
gland during autopsy, for example, indicate that unsuspected
tumors occur in 30 percent of males at age 50 and as many as
100 percent of males by age 90.
Cancers can develop from any combination of genetic,
chemical, physical, or biologic insults to a body part’s cells.
Involved is also a complex contribution from diet, lifestyle, and
environmental factors.
Because effective treatments for many cancers are not always
available, the best method appears to be prevention and/or early
detection. The National Cancer Institute has estimated that early

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Living Healthier and Longer –  What Works, What Doesn’t

detection practices could reduce U.S. cancer death rates by 25


percent. Early detection is useful for cancers of the:
• Breast.
• Uterine cervix.
• Skin.
• Mouth.
• Thyroid.
• Colon and Rectum.
• Endometrium.
• Prostate.
• Testicle.
• Urinary bladder.
Prevention is useful for the following cancers:
• Lung - smoking cessation.
• Head and neck – smoking and chewing tobacco cessation.
• Skin – decrease sun exposure.
• Breast – screening mammography.
• Colon – screening colonoscopy.
• Cervix – routine pap smear.
Epidemiological studies have shown that daily consumption of
fresh fruits and vegetables is associated with decreased risks of
cancers of the:
• Lung.
• Prostate.
• Bladder.
• Esophagus.
• Colon/Rectum.
• Stomach.
• Cervix.
Eating a high-fat diet may be a factor in the development of
cancers of the:
• Breast.
• Colon.
• Prostate.

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Living Healthier and Longer –  What Works, What Doesn’t

People who consume diets high in salt-cured and smoked


foods have a higher incidence of cancers of the:
• Esophagus.
• Stomach.
Increased risks of cancers can occur from exposure to:
• Certain tumor-killing drugs.
• Industrial agents (asbestos) and pollutants.
• Radiation.
• Gasses (radon).
Women, including those up to the age of early 50’s, who do
aerobic exercises such as running, biking, and/or walking for 4
hours or more each week appear less likely to develop breast
cancer.
Eating large amounts of red meat (lamb, beef or pork) or
processed meat (sausages, canned meat, hamburgers, meats
that are smoked, salted or cured bacon) is associated with a
higher risk of colorectal cancer. Meats that are prepared by grilling,
barbecuing, roasting or frying can develop toxic materials on their
surfaces, which in some people might be associated with polyp
formation and bowel cancer.
In one study of stomach cancer, those who ate beef medium
well or well done had more that 3 times the risk of developing
stomach cancer as those who ate meat rare or medium rare.
That finding points to a relationship of some cancers to cooking
habits. Also of interest is the fact that gravy made from meat
drippings contains large amounts of cancer causing agents.
High consumption of meat is also associated with cancers of the
prostate and pancreas. The safest ways of cooking meat are by
baking, stewing and boiling.
Vitamin supplements have not been proven to prevent any
cancer and could in fact be harmful.
Although it is known that diets rich in fruits and vegetables lower
risks of developing many types of cancer, the exact agent in these
foods that lowers cancer risks is not known. Numerous studies
have shown that foods high in vitamins C and E, beta carotene,
and other antioxidants are associated with lower risks for virtually
all cancers. Specific vitamin supplements by themselves, however,

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Living Healthier and Longer –  What Works, What Doesn’t

have not proven effective and may potentially prove harmful. It


appears that it is the actual, natural food product itself and not the
antioxidant supplement that provides the protective benefit. Plant
foods are loaded with bioactive substances in various mixtures
and in combinations with minerals, little-studied chemicals, and
numerous unknown contributors that, in some ill-defined way,
protect us from many cancers. What we need to do for beneficial
effects is to eat a minimum of 6 servings of a variety of fruits and
vegetables each day.
The best recommendation for reducing the risk of colon cancer
is to increase the intensity and duration of physical exercise, limit
the intake of red and processed meat, consume recommended
levels of calcium, eat more fruit and vegetables, and avoid obesity
and excess alcohol consumption. Some recent studies are
suggesting a protective role for vitamin D.
Endometrial cancer is the most common female reproductive
cancer in the U.S. There is strong evidence for a relationship
between endometrial cancer and obesity. High levels of physical
activity, increased vegetable and fiber intakes can decrease risk
whereas red meat, saturated fat and animal fat may increase risk.
The risk of prostate cancer can be reduced by eating more
fruits and vegetables, limiting intake of red meats and dairy
products and maintaining a healthy weight and an active lifestyle.
One recent study relates to the increased risk of cancer to
patients from the radiation exposure associated with overusing
computed tomography (CT) scanning as a diagnostic tool.
Estimates suggest that up to 2 percent of all cancers in the U.S.
could be attributed to such radiation exposure.
The American Cancer Society also offers guidelines for early
detection of cancer in people without symptoms. It recommends
cancer-related checkups by physicians every 3 years for persons
ages 20 to 39 and annually for those ages 40 and older. People
at particular risk for certain cancers or with strong family histories,
however, should be evaluated more frequently. The American
Cancer Society recommends that checkups include:
• Health counseling (for instance, how to quit smoking).
• Exams for cancers of the:
• Breast.

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Living Healthier and Longer –  What Works, What Doesn’t

• Uterus.
• Cervix.
• Colon.
• Rectum.
• Prostate.
• Mouth.
• Skin.
• Testes.
• Thyroid.
• Lymph nodes.
It is well known that such screening is valuable, especially in
the case of breast cancer. Studies suggest that, if all women ages
50 to 69 had appropriate examinations along with mammography
annually, their death rate would decline 30 to 40 percent.
To maintain the proper perspective, it is re-emphasized that
smoking and improper diets are the causes of approximately 2/3
of U.S. cancer deaths, about 25 to 40 percent and 30 percent,
respectively.

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Living Healthier and Longer –  What Works, What Doesn’t

Recommendations
(Modified from the American Cancer Society)
For Cancer Prevention
1. Stop smoking; do not use smokeless tobacco; and avoid
second-hand smoke.
2. Maintain a desirable body weight.
3. Eat a varied diet with lots of high-fiber foods, such as whole
grain cereal, breads, and pastas.
4. Eat fruits and vegetables, at least 6 servings daily.
5. Cut down on total fat intake (less than 30 percent of total caloric
intake).
6. Limit alcohol consumption to no more than 2 drinks daily.
7. Limit consumption of salt-cured, smoked, and nitrate-cured
foods.
8. Keep sun exposure to a minimum; use appropriate
sunscreens.
9. Discuss needs versus risks of estrogen and progesterone
replacement with your doctor.
10. Recognize and avoid occupational cancer hazards and
potential radiation problems.
11. Avoid all unproven herbal supplements for prevention or
treatment of cancers.
Estrogen therapy has received a bad press because of cancer,
heart, stroke and blood clot concerns. Estrogen however is useful
and very effective in managing the disturbing symptoms of the
menopause, especially night sweats, hot flashes and vaginal
dryness. When used for these problems, it is best to utilize the
smallest effective dose and to take it with progesterone if you still
have a uterus.
For Breast Cancer Screening
1. Women ages 20 and older should do monthly breast self-
examinations.

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Living Healthier and Longer –  What Works, What Doesn’t

2. Women ages 40 to 49 should have mammograms every 1


to 2 years, at the physician’s discretion, and clinical breast
examinations every year.
3. Women ages 50 to 69 should have annual clinical breast
examinations and mammograms. A review of screening
effectiveness studies has led to the conclusion that such
screening can reduce breast cancer deaths by 20 to 30
percent.
4. For women ages 70 and older, evidence of benefit of
mammography is limited and conflicting. Physicians’
recommendations should be heeded.
5. Gene studies are now available and can prove valuable.
Mutations in BRCA 1 and BRCA 2 genes are the best known
causes of an inherited predisposition to breast and ovarian
cancer. Women with a significant family history of breast
(or ovarian) cancer and female relatives of women who test
positive for BRCA 1 and BRCA 2 mutations should be tested
for these mutations.
6. Recently, a research group led by an investigator from
the Roswell Park Cancer Institute reported a study that
demonstrated that women who smoked the most years,
consumed the highest number of cigarettes per day, and had
a specific gene, were at significantly increased risk of breast
cancer. Still another reason why women shouldn’t smoke.
7. Recently, the American Cancer Society recommended that
women at high risk for breast cancer (e.g., fat intake, obesity) get
a breast MRI every year along with a regular mammogram.
For Cervical Cancer Screening
Women ages 18 and older and those who were sexually active
at younger ages should have Pap tests and pelvic examinations
at least every 3 years and possibly yearly according to some
recommendations. Performing Pap tests every 3 years reduces
invasive cervical cancer by 91.2 percent. This is only slightly less
than 93.3 percent results from annual screening. Regular testing
can probably terminate at age 65 for women who have had regular
previous screening with normal Pap smears. Worldwide studies
show that deaths from cervical cancer have been reduced by 20 to

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Living Healthier and Longer –  What Works, What Doesn’t

60 percent since the implementation of cervical cancer screening


programs.
For Colorectal Cancer Screening
Screening for colorectal cancer is recommended for all
persons ages 50 and older. Annual fecal occult blood tests and
sigmoidoscopy screening every 3 to 5 years currently appears
reasonable. Every 5 to 10 years, a barium enema may be
performed in place of the sigmoidoscopy; and every 10 years a
colonoscopy may be performed in place of the sigmoidoscopy or
barium enema. Colorectal cancer screening should be continued
even in the elderly, stopping early only when you don’t expect the
patient to live 7 to 10 more years. The prevalence of colorectal
cancer in people over age 80 is about 4 percent.
In spite of the availability of good screening tests with life
saving potential, colorectal cancer screening is underutilized. Two
in 5 adults aged 50 and older report not having been screened.
Monitoring a high-risk patient, such as one who had adenomas
detected on colonoscopy, requires a colonscopy at least every 3
years. A colonoscopy with the removal of all colonic adenomas,
lowers the risk of colorectal cancer by 76 to 90 percent. Studies
have documented a 31 to 57 percent reduction in colon cancer
risk among persons who receive fecal occult blood testing. Earlier
screening should be done for those with family histories or prior
diagnoses of familial polyposis or ulcerative colitis.
For Prostate Cancer Screening
Digital rectal examination alone will miss 30 to 40 percent of
prostate cancers. The best method for early detection of prostate
cancer is to combine the digital rectal exam with measurement
of the prostate-specific antigen (PSA). Not everyone agrees that
regular PSA testing is important. Some organizations recommend
that for men aged 50 years and older and men at higher risk of
prostate cancer, clinicians should discuss with the patients the
potential benefits and possible harm of PSA screening, consider
patient preferences, and individualize the decision to screen.

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Living Healthier and Longer –  What Works, What Doesn’t

The percentage of men with prostate cancer related to PSA

PSA Probability of Prostate Cancer


4-10 20 – 50 percent
Above 10 50 – 75 percent
Above 20 90 percent
Some centers, like The Cleveland Clinic, have eliminated 4.0 as
the upper limit of normal in their PSA reports. Instead of a normal
range, they include risk ranges, which provide a more meaningful
clinical picture. They also give you a risk calculator (computer site
below) to help you interpret the reading.
www.compass.Fhcrc.org/edrnnci/bin/calculatory/main.asp
One definite value of PSA screening is its ability to detect
disease in young men, in whom the disease is often more
aggressive. Men with a first-degree relative diagnosed with
prostate cancer at a young age should begin screening at age
45. PSA screening should lead to further studies and an array of
available treatments, all with their own potential risks and benefits
that physicians must study and explain to their patients. Men with
a life expectancy of less than 10 years should not be screened.
The PSA test does not always indicate the presence or absence of
prostate cancer; in fact, only 20 to 35 percent of men with elevated
PSAs have prostate cancer. A slightly elevated PSA might indicate
only prostate enlargement, which is common as men get older, or
prostate inflammation. Up to 20 percent of localized and curable
prostate cancers can be associated with a normal PSA but are
detected by rectal examination. An increased rate of change of
PSA levels favors prostate cancer while free levels of PSA greater
than 25 percent of total favor benign prostatic hypertrophy.
For Lung Cancer Screening
New and sensitive detection techniques to better identify people
at highest risk for lung cancer are being developed, but are not yet
available for general use. Recently, low-dose helical CT scanning
for general lung cancer screening was not recommended by the
American College of Chest Physicians, even for smokers.

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Living Healthier and Longer –  What Works, What Doesn’t

For Other Cancer Screenings


As part of the periodic examination, physicians should examine
for cancers of the:
• Skin.
• Mouth.
• Testes.
It is helpful for patients to point out to their physicians new,
suspicious, or changing lesions on any parts of their bodies.
Further reading
National Cancer Institute (NICH)
www.cancer.gov
For Radon www.epa.gov/radon
The Guide to Clinical Preventive Services. 2006.
Clinical evidence. British Medical Journal. Concise, Summer
2006.
Jones JS, Klein E. Four no more: The “psa cutoff era” is over.
Cleveland Clinic Journal of Medicine. January 2007:30-32.

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Living Healthier and Longer –  What Works, What Doesn’t

Diabetes:
We are learning more about management.
If I’d known I was going to live this long, I’d have taken
better care of myself.
-Jimmy Durante
Facts
1. Diabetes is the sixth leading cause of death in the U.S. for
people over 75.
2. About 20 percent of the people ages 65 to 74 in the U.S. have
diabetes.
3. It is believed that as many as one-half of all people with
diabetes do not know they have it.
4. People with diabetes are 2 to 4 times more likely to die from
cardiovascular disease than those without diabetes.
5. Smoking increases men’s risk of getting diabetes. A Harvard
School of Public Health study said that men who smoke 25
or more cigarettes each day are twice as likely to end up with
diabetes as nonsmokers.
6. Being inactive may change a person’s blood sugar level. By
not moving very much they can go from a normal to a diabetic
range.
7. Taking selenium supplements can increase the risk of getting
diabetes.
8. Being overweight increases the risk of getting type 2 diabetes.
Over 70 percent of people with type 2 diabetes are either
overweight now or have been in the past.
9. People with pre-diabetes have a higher chance of getting
cardiovascular disease. This is a group who has not yet been
found to have diabetes but their blood sugar level shows they
could get it.
10. Smoking can also lead to type 2 diabetes. Up to 12 percent of
people with type 2 diabetes may have diabetes because they
smoked.

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Living Healthier and Longer –  What Works, What Doesn’t

Diabetes affects about 20.8 million Americans. This is about


7 percent of the population. Another 6.2 million have diabetes but
do not know it yet. This group is at risk for having disabling and life
threatening problems. Recent figures show that 1.5 million new
cases of diabetes were in people 20 years or older. Diabetes leads
to at least 225,000 deaths every year in the U.S. It is the sixth
leading cause of death in the U.S.
Type 1 diabetes is a disease in which the body does not
produce enough insulin. Type 2 diabetes is when the body cannot
properly use insulin. The cause of diabetes is not yet known. We
do know, however, that genetic and environmental factors play a
role in type 2 diabetes. Those who are obese and do not exercise
are at risk for type 2 diabetes.
Diabetic patients have an increased risk for heart attacks and
strokes. They also have a higher risk for kidney, eye and nerve
disease. About 65 percent of diabetic patients die of heart disease
and stroke.
There are people who do not yet have diabetes who are at
high risk for it. This group is said to have pre-diabetes. To see
if someone has diabetes, a fasting plasma glucose level test is
done. Pre-diabetic patients have a glucose level which is higher
than those without diabetes but lower than those with diabetes.

Fasting Plasma Glucose Level


Normal Below 100 mg/dl
Pre-Diabetes 100-125 mg/dl
Diabetes 126 mg/dl or above
Included in the realm of diabetes mellitus and its complications
are:
• High levels of sugar in the blood.
• Having little or no insulin. Insulin is a hormone made by the
pancreas. This is true for type 1 diabetic patients.
• Inability of your body to use insulin. This is for type 2 diabetes
• Tissues and organs breaking down earlier.
• Complications that lead to various disabling conditions and a
shortened life.

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Living Healthier and Longer –  What Works, What Doesn’t

About 9 percent of all diabetic patients have type 1 diabetes


mellitus. Patients with type 1 diabetes have a pancreas that has
little or no ability of make insulin. This form of diabetes is most often
seen in children and adolescents. Type 1 diabetes can, however,
occur at any age.
Around 91 percent of all diabetic patients have type 2 diabetes
mellitus. These patients’ bodies can still make insulin but their body
has a hard time using it. Type 2 patients are often ages 40 or older.
These patients are usually overweight and inactive. To help their
body handle the high blood sugars in type 2 diabetes, patients can
exercise and lose weight. There are also drugs which increase
insulin sensitivity in type 2 diabetes.
There are no known methods to prevent type 1 diabetes. As
noted above, type 2 diabetes can possibly be prevented or delayed
by lifestyle changes in adults at high risk.
Complications seen in both types of diabetes are similar. Both
types can lead to development of:
• Coronary artery disease.
• Stroke.
• Diseases in the blood vessels of the extremities.
• Nerve disorders.
• Kidney problems.
• Eye problems. This can include cataracts and retinal problems.
It should be noted that about 50 percent of adult blindness is
due to diabetes.
Diabetic patients are more likely to die from a heart attack or
stroke than someone without diabetes. Diabetic patients are also
more likely to have complications from a heart attack or stroke.
Diabetic patients can also have problems with eyesight or pass out
from low blood sugar. This can lead to:
• Falls.
• Fractures.
• Work-related accidents.
• Automobile accidents.
Depression is found in up to 70 percent of patients with
diabetic complications. This is a problem as depression can affect

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Living Healthier and Longer –  What Works, What Doesn’t

the course of the illness. Depressed diabetic patients are less in


control of their diets, medications, and exercise programs.
Educating diabetic patients about the disease and the risk
factors is important. Diabetic patients should know that diet,
smoking, high blood pressure, high cholesterol, and lack of exercise
can make diabetes worse. This can lead to other health problems.
As a result, a person who is not in control of their diabetes will die
sooner. They will also have a lower quality of life.
Studies have shown that improved blood sugar benefits people
with either type 1 or type 2 diabetes. Every 1 percent reduction
in the hemoglobin A1C (HbA1C) blood test helps. For example,
dropping from 8 percent to 7 percent reduces the risk of developing
eye, kidney and nerve disease by 40 percent.
Low blood pressure also helps. Keeping blood pressure at
or below 130/80 mm Hg or lower reduces the chance of a heart
disease or stroke by about 33 to 50 percent. Lower blood pressure
can also reduce eye, kidney, and nerve diseases by about one-
third.
Control of cholesterol can reduce cardiovascular complications
by 20 to 50 percent. Your HDL, LDL and triglycerides are higher
when you have diabetes. Finding and treating diabetic eye disease
with lasers can reduce the development of severe vision loss by
about 50-60 percent.
Diabetes is also the leading reason adults in the US have their
feet amputated or cut off. Complete foot care programs can reduce
amputation rates by 45 to 85 percent.
Drugs such as ACE-I can improve how well the diabetic
patient’s kidneys function. It turns out that treating high blood sugar
is more important than how it is treated. It does not matter if you
use an oral anti-diabetic agent or insulin. Recent studies, however,
suggest that one class of oral agents might be a problem for older
diabetic patients. Thiazolidines, for example Avandia, can increase
the risk of heart failure and death in older diabetic patients. A
low dose aspirin, about 81 mg, can help diabetic patients over
30 prevent cardiovascular problems. Knowledgeable, up-to-date
physicians interested in diabetes and skilled in teaching patients
can be a real asset to patients. These doctors can keep watch
on good blood sugar and blood pressure control. They will then

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Living Healthier and Longer –  What Works, What Doesn’t

use this information to anticipate and help their patients avoid


complications.
Some diabetic patients should take a low dose of aspirin every
day. This helps reduce the risk of having heart problems or a stroke.
Diabetic patients who are over 30 and have cardiovascular disease
risk factors should take a low dose aspirin. The American Diabetes
Association recommends 81 to 325 mg each day. Patients who
have already had cardiovascular problems should also take a low
dose of aspirin.
Smoking is even worse for patients with diabetes. Diabetic
patients already have vascular disease. Smoking makes it more
likely they will have cardiovascular problems. As a result, it is
important for people with diabetes to stop smoking.
Organic erectile dysfunction is common in men with diabetes.
Sildenafil, known as Viagra®, can be taken to effectively treat this
problem. Diabetic patients with coronary artery disease may be
at higher risk of problems if they use sildenafil. This is particularly
true for diabetic men taking nitrates for angina. Angina is chest
pain or discomfort that happens because your heart muscle does
not get enough blood.
Recommendations
1. Learn as much as you can about your diabetes.
2. Work with a doctor who is interested in, and knowledgeable
about diabetes. The doctor should also know about all the
complications that happen with diabetes. You may wish to add
an ophthalmologist, an eye doctor, to the team who cares for
you. Also, think about working with a dietitian.
3. Be in control of risk factors that could make your diabetes
worse. Also control the risk factors that can increase the
complications of your diabetes. These risk factors are cigarette
smoking, high blood pressure, high cholesterol, obesity, and
lack of exercise.
4. Keep your blood pressure below 130/80 mm Hg.
5. A good exercise program is extremely important.
6. Make the care of your feet a priority.

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Living Healthier and Longer –  What Works, What Doesn’t

7. Watch for the development of symptoms and signs that point


to depression and share this information with your physician.
8. If you smoke, quit.
Further Reading
National Institutes of Health (NIH)
National Institute of Diabetes and Digestive and Kidney Diseases
Health.nih.gov
American Diabetes Association
AskADA@diabetes.org
ADA website

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Living Healthier and Longer –  What Works, What Doesn’t

Bone Disease
An archeologist is the best husband a woman can have; the
older she gets, the more interested he is in her.
-Agatha Christie
Facts
1. It is estimated that 10 million people over 50 years of age have
osteoporosis. About 30 million over 50 are at risk. Osteoporosis
is a bone disease that weakens your bones.
2. About half of people with weak bones are not taking their
medicine.
3. By age 65, most women lose about 35 percent of their bone
mass.
4. About 15 percent of all women eventually suffer hip fractures.
5. As many as 20 percent of patients die within a year of hip
fracture.
6. Women whose mothers had hip fractures before age 80 are
twice as likely to have hip fractures themselves.
7. Bone loss occurs shortly after beginning glucocorticoid therapy.
This loss happens even for those who are using a low-dose
treatment. Taking 7.5 mg per day of prednisone can lead to
bone loss.
8. Steroid treatments often lead to weaker bones. About half
the patients who get long-term steroid treatments have
osteoporosis.
9. Only a small number of patients taking long-term oral cortisone
get medication to prevent or treat weak bones.
10. Estrogen is no longer approved for treatment of osteoporosis.
We no longer use estrogen because of the risky side effects.
11. Celiac disease can cause weak bones. Treating and stopping
this disease will allow the bones to become stronger.
12. Seventy-five percent of women are still not on treatment the
year following a fracture due to weak bones.

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Living Healthier and Longer –  What Works, What Doesn’t

In the U.S. today, 10 million people already have osteoporosis.


Another 30 million more have low bone mass. Those with low bone
mass are at increased risk for this disease. One out of every 2
women and 1 in 4 men over 50 will have an osteoporosis-related
fracture in their lifetime. This disease has led to more than 1.5
million fractures yearly. Over 2 million American men have
osteoporosis. Each year, 80,000 men have a hip fracture. One
third of these men will die within a year of the fracture. About 20
percent of osteoporotic fractures occur in men. Men with low levels
of testosterone are at risk for osteoporosis. Other causes include
being treated for prostate cancer, having glucocorticoid therapy,
and drinking too much alcohol.
Few people think about the fact that bone-related problems can
shorten your lifespan. Osteoporosis is a bone-thinning disease that
leads to increased bone fragility. Fragile bones make it more likely
you will have a fracture of the hip, spine, wrist, and ribs. Fractures
due to weak bones are a major public health threat for 44 million
Americans. About 68 percent of those at risk are women.
Osteoporosis is often thought of as a “silent” disease. This is
because bone loss can happen without any signs. People really
have no way of knowing their bones are becoming weak and
fragile. The first awareness of osteoporosis may follow a fracture
or collapsed vertebra. This often happens at the time of a fall,
sudden strain, or bump.
X-rays can reveal fractures and spinal deformities. X-rays
cannot help see the early stages of decreased bone mineral
density. Osteoporosis can be diagnosed by bone mineral density
testing. The higher the mineral density in your bones, the stronger
your bone is. A bone density test helps determine your risk of
developing fractures. The test also helps doctors decide if you
need to start therapy or if the therapy is working. One of the best
ways to do a bone density scan is to use a Dual-energy X-ray
Absorpitometry, also called a DEXA scan. This is a painless way to
look inside your body at your bones. Bone mineral density testing
has been recommended for all women over the age of 65. Those
younger than age 65 should have a bone density test if they:
• Have gone through menopause.
• Have a family history of osteoporosis.
• Have fractures.

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Living Healthier and Longer –  What Works, What Doesn’t

• Smoke cigarettes.
• Do not exercise.
• Drink too much alcohol.
• Take medicines like glucocorticoids and anticonvulsants.
• Have certain diseases that cause bone thinning.
Because changes in bone mineral density occur slowly with
treatment, it is best to get bone density tests every 2 years. In
special cases you may need to be tested more often. Talk to your
doctor about how often you should have a test.
Osteoporotic fracture rates increase significantly with age in
both men and women; but at any age, the risk is much greater in
women than in men. Elderly white women have about twice the
incidence of fractures as African-American women.
Women can lose up to 20 percent of their bone mass in the
5 to 7 years after they go through menopause. This rapid bone
loss makes them more likely to get osteoporosis. Women are also
more likely to live longer and more likely to fall. All of this explains
why women are more likely to get fractures due to weak bones.
Osteoporosis is responsible for more than 300,000 hip fractures
each year in the U.S. Out of 100,000 persons over 65 years old,
840 will have a fracture due to osteoporosis. Hip fractures are
painful and uncomfortable. They also can lead to disability and
loss of independence. About 25 percent of those who were living
independently when they got their hip fracture end up in long-term
care, living a year after the fracture. Hip fractures also increase the
risk of getting sick and dying. A person’s survival rate goes down
15 to 20 percent in the first year after a hip fracture. Though women
have more hip fractures than men, the death rate for men within 1
year of a hip fracture is 26 percent higher than for women.
While the causes of osteoporosis are not fully known, certain
people are more likely to develop the disease than others. Some
factors that increase the risk can not be changed. Others can be
changed. The risk factors are:

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Living Healthier and Longer –  What Works, What Doesn’t

Factors that Can Be Factors that Cannot Be


Changed Changed
• Consuming a low-calcium • Being female.
diet. • Being older.
• Being anorexic or bulimic • Being of a Caucasian or
(forced vomiting). Asian race.
• Smoking. • Having a small, thin frame.
• Drinking too much alcohol. • Having a family history of
• Not exercising. osteoporosis.
• Not moving around much. • Having menopause early in
• Malabsorption of calcium. life.
• Low testosterone levels in • Having an abnormal
men. absence of menstrual
• Endocrine disorders periods.
involving thyroid, adrenal, • Having diabetes.
or pituitary glands.
• Kidney and liver diseases
and certain tumors.
• Taking certain medications.
Some examples are using
proton pump inhibitors or
taking H2 blockers.
An important and often overlooked risk factor for osteoporosis
is taking medications that can damage bones. These medications
include:
• Glucocorticoids, a type of steroid.
• Excessive doses of thyroid hormone.
• Seizure medications. Some examples are Dilantin® and
barbiturates.
• Antacids that have aluminum in them.
• Heparin that is used long-term at a high-dose.
• Certain treatments for endometriosis.
• Specialized medicines. Some examples of these are
methotrexate, cyclosporin A, and cholestyramine.
Taking oral cortisone long term can weaken bones. Oral
cortisone is commonly used for arthritis, asthma, and chronic lung
disease. Only a small percentage of patients using steroids are

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Living Healthier and Longer –  What Works, What Doesn’t

also on programs to keep their bones strong. People who have


been taking steroids for awhile should get a bone density test. They
should also take calcium and vitamin D to help keep their bones
strong. The American College of Rheumatology recommends
getting 1,500 mg of calcium and at least 800 IU of Vitamin D daily
while on steroids. They also recommend people using steroids
do 30 to 60 minutes of weight bearing exercises each day. Most
patients on steroids will need alendronate. The common name for
this is Fosamax. Studies show that Fosamax is better than Vitamin
D in preventing bone loss due to steroid use. Teriparatide, also
called Forteo, also appears to be effective at stopping bone loss
due to steroid use.
Prevention of osteoporosis is very important. Here are some
activities that can be done to keep bones healthy:
• Get enough calcium, Vitamin-D, and Vitamin K by choosing
foods and drinks high in these vitamins. For example, dark
green vegetables are high in Vitamin K.
• Get fluoride. Fluoride is often in the water supply. Check to see
if this is true for your area.
• Avoid getting too much Vitamin A.
• Do weight bearing exercises. Some examples are walking,
hiking, jogging, stair climbing, weight training, tennis, and
dancing.
These behaviors are important for the health of your bones.
Start them early in life and keep doing them throughout your life.
Smokers should quit. Smokers appear to absorb less calcium from
their diets. Their bodies are not able to keep the calcium and use
it.
People diagnosed with osteoporosis should follow the behaviors
listed above. Taking medication can also help. The following 3
medicines have been found to effectively treat bone loss:
• Alendronate. The most common form is called Fosamax.
• Risedronate. The most common form is called Actonel.
• Ibandronate. The most common form is called Boniva.
These bisphosphonates can reduce hip fractures by about 50
percent. Teriparatide, a different medicine also known as Forteo,
is a drug used for special problems with high risk factors. For
those who cannot remember to take their medicine, there is a new

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Living Healthier and Longer –  What Works, What Doesn’t

approach that is being used. This is a drug, Zoledronic acid, that is


given once a year. Rather than taking a pill, a person would go in to
the doctor and be given the drug with a needle that goes into your
veins. A recent study suggested that 5 years of bisphosphonate
therapy was enough for many patients.
Approximately one-third of people ages 65 and older will fall
each year. Falls can be due to:
• Various medications that cause people to feel relaxed or
sleepy, lightheadeded, or dizzy.
• Various medicines that can cause loss of balance and lowered
blood pressure.
• Combinations of medications that present special problems.
• Loss of vision.
• Loss of hearing.
• Muscle weakness.
• Loss of coordination.
• Diseases that affect balance.
Recommendations
1. Be aware of personal risk factors you may have for osteoporosis.
These include:
• Weighing less than 127 lbs.
• Having already had a fracture because of weak bones.
• Having a parent or sibling who has had a fracture because
of weak bones.
• Smoking or having smoked in the past.
2. Get enough calcium and vitamin D and K. Vitamin D can also
help keep balance so you do not fall and injure yourself.
3. Exercise.
4. Stop smoking.
5. Check with your doctor about medications you take that can
cause osteoporosis. This is especially important if you are in a
high-risk category.
6. Understand the complications of falls. Come up with ways to
avoid falling.

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Living Healthier and Longer –  What Works, What Doesn’t

7. Limit how much alcohol you drink.


8. Avoid taking proton pump inhibitors. Taking Nexium, Prevacid,
or Prilosec, for more than 12 months can increase your risk for
hip fractures.
9. Make your home a safe environment. Have adequate lighting
and hand rails. Pay attention to household hazards like loose
carpeting, extension cords, or toys on the ground that can
cause you to trip. Keep things out of the way that you can trip
over.
10. Consider the many new drugs available to prevent and treat
osteoporosis.

Optimal Calcium and Vitamin-D Requirements


Recommended Recommended
Age Group Calcium Intake Vitamin D Intake
(mg of Calcium) (IU)
19-50 1000 400
51 to 70 1200 600 - 800
Over 70 1200 800 - 1000
The average American diet usually has less than half of the
calcium that is recommended. It is important that we get as much
calcium from our diets as possible. By drinking 8 oz. of skim milk
or 8 oz. of calcium-fortified orange juice, you can get 300 mg of
calcium. Calcium supplements are available in several different
forms. The supplements contain different amounts of elemental
calcium. Elemental calcium is the form of calcium your body
uses.
Multivitamin preparations often contain about 400 IU of Vitamin
D.
Calcium Sample Percent of Elemental Calcium
Supplement Source Elemental Calcium in 500 mg Tablet
alcium carbonate
C TUMS 40 200 mg
Calcium citrate Fortified orange juice 24 120 mg
Calcium gluconate tablet 9 45 mg

Eating food when you take calcium supplements helps


your body get the most calcium. When taken with food, calcium

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Living Healthier and Longer –  What Works, What Doesn’t

carbonate and calcium citrate are equally well absorbed by the


body.
Be careful about how much calcium you get. If you take 2,500
mg or more daily you can keep your body from getting enough
iron, magnesium, and zinc. It can also interfere with the absorption
of phosphorous which is also needed for bones.
Vitamin-D is necessary for your body to absorb the amounts
of calcium you need. People with low levels of Vitamin-D are at
increased risk for fractures due to weak bones. It can also lessen
the absorption of phosphorous which is needed by your bones.
Usually, Vitamin-D needs are met through exposure to sunlight.
A daily 10-minute exposure of the hands and face to sunlight can
generate 200 IU of Vitamin-D. Older people may have insufficient
exposure to sunlight. Older people may also need longer exposure.
Aging skin is less efficient at producing Vitamin-D in association
with sunlight. Also, elderly populations tend to drink less milk,
which is often fortified with Vitamin-D. Living in northern climates
that lack sunlight also adds to this problem.
Further Reading
National Institutes of Health
National Institute of Arthritis and Musculoskeletal and Skin
Disease
Bone Health
Health.nih.gov
The Guide to Clinical Preventive Services, 2006

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Living Healthier and Longer –  What Works, What Doesn’t

Dementia
Happiness? That’s nothing more than health and a poor
memory.
-Albert Schweitzer
Facts
1. About 3.4 million Americans age 71 or older have dementia.
2. One in 7 Americans age 71 and older has some type of
dementia, and 2.4 million of them have Alzheimer’s Disease
(AD).
3. About 5 percent of men and women ages 65 to 74 have AD, and
nearly half of those age 85 and older may have the disease.
4. AD patients live from 8 to 10 years after they are diagnosed,
but can survive for as many as 20 years.
5. No treatment has been proven to stop AD progress.
6. Dementia may be reversible in approximately 10 percent of
patients by treating hypothyroidism or depression or stopping
causal medications.
7. Delirium and depression may be misdiagnosed as dementia.
8. Dementia occurs in up to 20 percent of patients with HIV
infection.
9. Advanced age and family history are the 2 most important risk
factors for AD.
10. Genetics is an important determinant of dementia, especially
in early-onset AD.
11. A large number of drugs lead to memory and/or thinking
impairment.
12. In geriatric clinics, up to 10 percent of those seen for memory
problems are found to have reversible dementia related to
medications.
13. Regular exercise is thought to be able to delay the onset of
dementia and AD.

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Living Healthier and Longer –  What Works, What Doesn’t

Dementia is an acquired loss of memory and other mental


skills that interfere with the performance of daily activities and
relationships. Multiple areas of intellectual function are often
affected, with areas of impairment including:
• Abstract thinking.
• Language, repetition.
• Judgment.
• Perception.
• Planning.
• Problem-solving.
• Memory.
Important causes of dementia in older Americans include:
• Alzheimer's disease-50 to 85 percent.
• Vascular disease-10 to 20 percent, which includes
cerebrovascular phenomena such as:
• Inflammation of blood vessels.
• Emboli or hemorrhages.
• Single or multiple brain infarctions.
• Parkinson's Disease.
• Brain tumors or trauma.
• Infections, including:
• HIV.
• Tuberculosis.
• Syphilis.
• Meningitis.
• Creutzfeldt-Jakob disease.
• Metabolic disorders, including:
• Vitamin B12 deficiency.
• Hypothyroidism.
• Alcohol abuse.
• Poor nutrition.
• Medications, either alone or in combination, such as those
used for:
• Pain.
• High blood pressure.
• Sleep.

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• Sedation.
• Treatment of psychiatric illnesses.
Patients need to consult their physician or pharmacist about
the role of medicines in dementia.
Dementia is responsible for about 120,000 deaths annually,
the deaths being strongly associated with its severity. Dementia
patients are at increased risk for falls and automobile accidents.
As many as 33 percent of demented persons who were still driving
had motor vehicle crashes or moving violations within the previous
6 months. This fact points to the potential for harm to patients,
family members, and care-givers as well as to the public.
Dementia is commonly overlooked in its early stages, the time
when reversible factors that cause or contribute to the disorder can
be managed best. Finding and correcting underlying causes could
result in improvement in some patients; these causes include:
• Depression.
• Vitamin B12 deficiency.
• Drug excess or toxicity.
• Hypothyroidism.
• Alcohol abuse.
• Poor nutrition.
• Space-occupying lesions such as a subdural hematoma.
• Normal pressure hydrocephalus.
• High fever and dehydration.
Common medications often associated with memory
impairment or dementia-like situations include steroids, ulcer
or heartburn treating drugs, anxiety treating drugs and sleeping
medications.
The number of demented patients who experience long-term
improvement is relatively small. Some estimates suggest that
10-15 percent of dementia patients have a potentially reversible
condition such as a drug intoxication, depression, or treatable
endocrine problem like thyroid disease or a nutritional disorder.
Other studies have shown that about one-half of elderly dementia
patients have at least 1 coexisting illness, the treatment of which
could result in improvements for many patients. Diabetes, high
blood pressure in middle age, and high cholesterol values are all

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Living Healthier and Longer –  What Works, What Doesn’t

associated with poorer mental performance later in life. Stimulating


the brain with crossword puzzles, reading newspapers and other
challenges, once thought to be effective, are probably of little proven
value in delaying or preventing dementia. Having lots of friends
and acquaintances and participating in many social activities is
associated with reduced cognitive decline and decreased risk of
dementia in older adults.
Evidence exists to support the association between
cardiovascular health and cognitive health. It is important to
recognize that controlling cardiovascular risk factors might reduce
the risk of experiencing cognitive decline. Once again, cholesterol,
blood pressure and diet control appear helpful. Regular exercise
also appears valuable in delaying the onset of dementia and AD.
No treatment has been proven to stop AD. According to the
prestigious Medical Letter (February 2007) “currently available
drugs for the treatment of AD and other dementias can produce
some limited symptomatic improvement.” The acetylcholinesterase
inhibitors donepezil (Aricept), rivastigmine (Exelon) and
galantamine (Razadyne) and the NMDA-receptor antagonist
memantine (Namenda) have produced modest improvements
in cognition, activities of daily living and behavior. The benefits
of cholinesterase inhibitors are small and difficult to measure.
Behavioral and other non-pharmacological interventions should
always be attempted.
More commonly used medications can be valuable in treating
certain symptoms or associated disorders that are commonly
seen with AD, such as depression, psychosis and agitation. Some
observational studies suggest the possibility that “statin” drugs
may be able to delay the onset of dementia. More data are needed,
however.
Recommendations
1. If you have difficulty with memory, making judgments, or
communicating with others, consult your physician or one
specializing in dementia.
2. Be familiar with areas of impairment that suggest dementia.
3. When consulting a physician regarding dementia, bring a
family member or close friend who is familiar with your day-to-
day activities.
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4. Check your family history for possible cases of dementia,


realizing that diagnosis may have been missed or the symptoms
attributed to aging.
5. Don’t overlook the possibility of AIDS as a cause of dementia
in an elderly patient.
6. Exercise regularly.

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Living Healthier and Longer –  What Works, What Doesn’t

Infections/HIV and the AIDS Epidemic


The biggest disease today is not leprosy or tuberculosis but
rather the feeling of being unwanted.
-Mother Theresa
Facts

1. Recent studies suggest that there are over 420,000 persons in


the U.S. living with AIDS.
2. Over 16,000 persons died with AIDS in 2005.
3. AIDS is the leading cause of death in the U.S. for those ages
25 to 44 years.
4. Males make up about three quarters of patients diagnosed
with AIDS in 2005, most coming from male to male sexual
contact.
5. About 10 percent of AIDS cases in the U.S. occur in those
aged 50 and older.
6. About 40,000 persons in the U.S. become infected with HIV
each year.
7. It is estimated that 250,000 people infected with HIV in the
U.S. do not know that they are infected.
8. Estimates suggest that there are approximately 1 million
asymptomatic carriers of hepatitis B virus in the U.S.
9. Sixty to eighty percent of people who use illicit drugs
intravenously have evidence of hepatitis B virus infection
10. Severe pneumocooccal bacterial infections result in death in
30 to 40 percent of elderly patients.
11. Influenza is the major cause of death due to infectious disease
in the U.S., the last report suggested 56,000 deaths per year.

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At the turn of the twentieth century, the main causes of death


in the U.S. were infectious diseases such as influenza, bacterial
pneumonia, tuberculosis, and gastrointestinal infections. The
development of vaccines and antibiotics, improved hygiene,
regulations for food handling, and treated water supplies have
led to major inroads in preventing and controlling these diseases;
however, new and often difficult to treat infectious agents have
proven to be major threats to public health. Viruses, especially
human immunodeficiency virus (HIV), hantavirus, and hepatitis
viruses, recently have been of particular concern.
Today, when considering infections that shorten life in
significant numbers of people, HIV infection quickly comes to mind.
AIDS (acquired immunodeficiency syndrome), a term denoting the
later stages of HIV infection with complications, has become the
leading cause of death for people ages 25 to 44 years. Recent
information tells us that HIV/AIDS is the eighth leading cause of
death in the U.S.
AIDS is not only a problem for young adults. About 10 percent
of all cases diagnosed each year occur in both males and
females, ages 50 and older. In certain areas of the country with
high concentrations of people over 50, this group makes up 14
percent of AIDS cases. Increasing numbers from this group are
from heterosexual transmissions and probably are also related
to this population’s lack of knowledge about HIV infection and its
characteristics, diagnosis, and transmission. Unfortunately, the
AIDS virus, which can have symptoms like dementia and weight
loss (not uncommon in the elderly), might not even be considered
in diagnosing elderly populations.
Current estimates suggest that there are over 420,000
persons in the U.S. living with AIDS, with approximately 40,000
new infections occurring each year. The vast majority of people
infected with HIV will develop AIDS.
According to the Centers for Disease Control and Prevention,
men who have sex with men and injection drug users account
for more than 80 percent of AIDS cases. Most other cases result
from:
• Transmission from mother to fetus.
• Sexual partners of injection drug users.
• Transfusion of infected blood or blood components.
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Living Healthier and Longer –  What Works, What Doesn’t

In theory, the virus can be spread by contact with an infected


individual's feces, saliva, or urine, though such cases are rare.
People at high risk for HIV infection include:
• Men who have sex with men.
• Injection drug users.
• Sex partners of injection drug users.
• Prostitutes and their sex partners.
• Homosexual, bisexual, or heterosexual people who have had
HIV-infected sex partners.
• Those who have had blood product transfusions between 1978
and 1985.
• Those having multiple sex partners, especially if engaging in
unprotected sex (i.e., not using latex condoms).
It is important to be aware of the fact that women on highly
active antiretroviral therapy can still shed the virus intermittently in
the genital tract. Thus the potential exists for sexual transmission
of HIV even among women whose virus appears to be controlled.
HIV screening tests using blood mostly, but also saliva or urine,
are available and effective. Rapid HIV tests and home testing kits
are available. Positive tests are followed with more confirmatory
studies. It is now recommended that HIV screening be applied to
all patients age 13 to 64 years in all health care settings, including
emergency room visits and primary care appointments. Patients at
high risk for HIV infection should be screened annually.
During outbreaks of avian influenza among poultry, there is
a possible risk to people who are in contact with infected birds or
their excretions. Such individuals can develop severe respiratory
distress pictures associated with a high death rate. Oseltamivir
(Tamiflu) may be of some value in such cases. No vaccines are
generally available yet.
SARS, severe acute respiratory syndrome, is a viral respiratory
illness caused by a coronavirus. SARS, though uncommonly seen
in the U.S., has caused many deaths in certain countries. The virus
is spread mostly by close person-to-person contact and possibly
by airborne spread. Basic infection control measures are essential
and effective in preventing transmission of this deadly virus.
Other infections from bacteria, viruses and fungi are common
throughout life and are found to varying degrees in different age
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Living Healthier and Longer –  What Works, What Doesn’t

groups. A small number of infections in the U.S. cause a large


amount of sickness and death.
Pneumococcal bacterial disease can cause major sickness
and death, especially in the elderly who, through aging, are thought
to lose some immunologic functions, making them less able to
withstand infections. Pneumonia may be difficult to diagnose in
the elderly and some cases will be unresponsive or difficult to
treat. In some cases, especially hospitalized patients, pneumonias
can be prevented by careful feeding and attention to swallowing
mechanisms of sick patients and, if possible, by avoiding tubes
that assist with feeding or breathing in such patients.
About 35 percent of pneumococcal bacteria responsible for
infections are resistant to at least 1 drug and 17 percent were
resistant to 3 or more drugs, complicating treatment efforts.
Outbreaks of resistant pneumococcal pneumonias are still reported
in nursing homes, institutions caring for HIV-infected persons, and
child care centers. A pneumococcal conjugate vaccine is available
and capable of preventing many infections due to drug-resistant
pneumococci.
Influenza can cause significant sickness and death during
epidemics. The elderly are at increased risk for the major lethal
complication of influenza which is pneumonia. An effective influenza
vaccine is available and can reduce deaths associated with
influenza outbreaks. For the elderly or other individuals at high risk
during community outbreaks, antiviral medications are available
and can be used in support of vaccination. They are effective when
administered as treatment and when used as a preventative agent
after an exposure to influenza virus. Oseltamivir (Tamiflu) and
zanamivir (Relenza) are the only antiviral medications currently
recommended. Amantadine or rimantidine are no longer used.
Tuberculosis (TB) case rates and deaths from TB have been
steadily declining. Hispanics and Blacks continue to have the
largest percentage of cases. Asians and Native Hawaiians or
other Pacific islanders also have high case rates. In 2005, there
were over 14,000 TB cases reported in the U.S., more than half
occurring in foreign-born patients. People infected with HIV are
more likely to develop active TB than others. Major problems and
increased deaths have been associated with the development of
resistance to many of the standard drugs used to treat TB.

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Skin tests and chest x-rays can help detect TB infection


in exposed people who do not have symptoms. Such people
include:
• Persons infected with HIV.
• Persons in close contact with TB patients.
• Healthcare workers.
• Immigrants.
• Residents of long-term care facilities.
• Alcoholics.
• Illicit drug users.
Recently, a blood test – QuantiFERON – TB Gold test (QFT-G)
has become available to help diagnose TB and can be used in the
same circumstances in which the tuberculin skin test is used.
The finding of a newly positive TB skin test reaction is important
because a drug, isoniazid, has proven effective in preventing the
subsequent development of active TB in such people.
The number of cases of multi-drug resistant TB has been
steadily declining, now about 1 percent of cases. Drug therapy
(combined with directly observed therapy, such as the medicine
taken in presence of health care provider) is available and proving
effective for this disease.
Viruses are also the cause of hepatitis B and C, both of which
can cause severe liver damage in the form of cirrhosis and liver
cancer. As many as 50,000 persons become newly infected with
hepatitis B each year. The greatest risk coming from injecting illicit
drugs, but also commonly from sexual activity. Mother to baby/
child and child to child spread is also important. An estimated
20,000 new infections with hepatitis C are suggested annually.
The incidence of all forms of hepatitis has been decreasing in
recent years. Healthcare workers are especially at risk for these
diseases.
A vaccine is available for hepatitis B. It prevents hepatitis B
disease and its serious consequences, like liver cancer. This is the
first anti-cancer vaccine. It should be given to those at increased
risk including:
• Healthcare workers.
• People with hemophilia.

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• People living with hepatitis B infected persons.


• People at high risk.
• People traveling to parts of the world with a high prevalence
of hepatitis B (e.g., Asia), particularly if engaged in risky
behaviors (e.g., sexual activity).
The risk of acquiring hepatitis C infection is also increased by
the use of illegal drugs, blood transfusions, solid organ transplants
or long term kidney dialysis. There is no hepatitis C vaccine.
Recommendations
1. Learn basic information about HIV infection and AIDS.
Educational material is often provided by hospitals and public
health departments.
2. If you are in a high-risk category for HIV infection (such as
engaged in unprotected sex with a person of unknown HIV
status), discuss this situation with your physician and obtain
HIV testing.
3. People with new or multiple sex partners should use latex
condoms.
4. Seek monogamous sexual relationships with uninfected
partners.
5. Patients ages 65 or older, ages 50 or older and living in
institutional settings, or having problems such as diabetes,
chronic heart or lung disease (emphysema), or chronic kidney
problems should obtain pneumococcal vaccines. Patients who
have had surgical removal of the spleen or have nonfunctional
spleens (sickle cell disease) should obtain pneumococcal
vaccines.
6. Insure proper oral hygiene for patients in nursing homes or on
ventilators to prevent pneumonias.
7. Hand-washing (especially after bowel movements) is one of
the most effective and most overlooked ways to prevent the
spread of disease.

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Further Reading
National Institutes of Health.
National Institute of Allergy and Infectious Disease.
Health.nih.gov.
Centers for Disease Control and Prevention (CDC).
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention
The Clinical Guide to Preventive Services. 2006.

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Living Healthier and Longer –  What Works, What Doesn’t

Sex
Really, sex and laughter do go very well together, and I
wondered —and still do —which is the more important.
-Hermione Gingold
Facts
1. A high percentage of people experience sexual problems at
some time in their lives, but many enjoy sex into their 80s.
2. Numerous medications and recreational drugs can interfere
with sexual functioning.
3. Between 20 and 30 million men in the U.S. are consistently
unable to have an erection adequate for sexual intercourse.
4. About 85 percent of impotence is due to physical causes such as
vascular disease, high blood pressure, diabetes, neurological
problems, medications, smoking, or excessive alcohol. About
15 percent is caused by psychological problems.
5. Over 60 percent of men with erectile dysfunction will respond
positively to drugs like sildenafil (Viagra®).

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To date, the authors have found no good studies to indicate


that good sex extends life. However, few would deny that good
sex throughout life makes life more enjoyable. Good or bad sex
is somewhat difficult to define. Probably easiest is to say that
the sexual experience depends on whatever the involved couple
mutually finds satisfying or unsatisfying.
For satisfying sexual function to occur, there must be a
complex interaction of psychological, nervous, vascular, and
endocrine systems. Problems involving one or more of those
systems interfere with normal sexual function, and the resulting
sexual dysfunction can lead to interpersonal problems for the
couple, which can worsen the sexual difficulties. The causes of
sexual dysfunction are similar in men and women, though the
manifestations of sexual dysfunction are more easily recognized in
men. Fortunately, most cases of sexual dysfunction are treatable
by approaching the underlying physical or psychological problems.
It is important, however, that people recognize that such a problem
exists.
The most common problem regarding sexual function in the
male is decreased erectile function. For the female, loss of desire
for sexual activity is the most common problem and often the most
difficult to treat.
Sexual dysfunction, as suggested by changes in sexual desire
and ability, can be a result of:
• An underlying emotional or psychiatric disorder.
• Anxiety.
• Stress.
• Depression.
• Schizophrenia.
• Dementia.
Professional help from physicians or trained specialists may
be needed in many cases. In all cases, thorough histories, and
physical examinations, and appropriate laboratory evaluations are
essential.
Sexual dysfunction may be the earliest appearance of an
illness that, in one way or another, interferes with interactions of
the nervous, vascular, and endocrine systems. Impotence, the

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Living Healthier and Longer –  What Works, What Doesn’t

inability to achieve an erection adequate for sexual intercourse, is


a distressing problem for men that can be caused by a variety of
illnesses; recognized disorders include:
• Conditions involving the brain and spinal cord, including:
• Parkinson's disease.
• Multiple Sclerosis.
• Strokes.
• Herniated discs.
• Certain blood vessel disorders.
• Hypertension.
• Coronary artery disease.
• Endocrine disorders, including:
• Diabetes mellitus.
• Thyroid disorders.
Low levels of the male hormone testosterone are responsible
for only a small percentage of impotence cases. Likewise,
menopausal problems or menstrual irregularities are rarely the
cause of sexual difficulties in women.
Unfortunately, correction or control of illnesses may not always
eliminate sexual dysfunction. However, if the dysfunction is caused
by a medication, the problem can often be resolved.
Drugs that interfere with sexual function include:
• High blood pressure medications, including:
• Diuretics (thiazides, spironolactone).
• Alphamethyldopa.
• Beta-blockers.
• Hydralazine.
• Reserpine.
• Guanethidine.
• Prazosin.
• Estrogen.
• Recreational, abused, or illicit drugs, including:
• Tobacco.
• Cocaine.
• Heroin.
• Opiates.

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• Alcohol.
• Antidepressant medications, including:
• Tricyclics (e.g., Elavil®).
• Monoamine oxidase inhibitors.
• Trazodone.
• Serotonin re-uptake inhibitors (e.g. Prozac®).
• Drugs that act on the central nervous system, including:
• Phenytoin (Dilantin®).
• Barbiturates.
• Phenothiazines.
• Others, including:
• Antihistamines/decongestants.
• Cimetidine.
• Cancer chemotherapeutic agents.
• Clofibrate.
• Tranquilizers.
• Digoxin.
• Estrogen.
A relatively common recent problem is the use or abuse of
high doses of anabolic steroids by recreational body builders.
Use of these agents can be associated with a wide range of
serious complications and even death. The good news for men
with impotence (erectile dysfunction) is that most can be helped.
Aphrodisiacs do not work (except for a possible placebo effect);
nor do such popular items as ginseng, rhinoceros horn, melatonin,
or various other herbs.
After all efforts have been made to determine a treatable
cause of erectile dysfunction, drugs known as phosphodiesterase
inhibitors can be tried. These drugs are effective, easy to use and
without major side effects in most users. Sildenafil (Viagra®),
vardenafil (Levitra®), and tadalafil (Cialis®) are generally equal in
effectiveness, though tadalafil has a longer duration of effectiveness.
All are contraindicated in men taking nitrate preparations for
coronary artery disease. Men with sexual dysfunction who have
low serum testosterone levels could benefit from testosterone
replacement therapy.

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It is commonly recognized that blood levels of testosterone


in men decline with age. The question often arises whether
testosterone supplements are of any value in older men with
low normal testosterone levels. A recent study of testosterone
supplementation in older men did not support a net benefit
on several indicators of health and functional and cognitive
performance over a 6 month period.
Of interest is the fact that, because erectile dysfunction is
commonly associated with cardiovascular disease, good control
of cardiovascular risk factors may be good for sexual performance;
especially important are:
• Exercise.
• Diet.
• Alcohol restriction.
• Not smoking.
A study at the University of South Carolina School of Medicine
found that men whose total cholesterol was greater than 240
mg/dl were almost twice as likely to become impotent as those
whose cholesterol levels were below 180 mg/dl. Studies at Duke
University also suggest that cholesterol-blocked vessels may slow
the flow of blood to the penis, which contributes to impotence.
Unfortunately, research on female sexual dysfunction has not
been as productive as that for male sexual dysfunction. At present,
there are no really effective drugs for the treatment of sexual
dysfunction in females.
A common source of anxiety related to sexual activity occurs
after a heart attack or coronary bypass surgery. The concern is
that sexual intercourse may trigger another heart attack. However,
studies suggest that heart attack patients who are otherwise doing
well have little, if any, risk from sexual intercourse and should be
able to resume sexual activity during the second week after hospital
discharge. One recognized source of increased risk, however, is
having sex with a person other than one’s usual partner.
It has been suggested that sexual intercourse as an exercise
might be the equivalent of climbing about 20 stairs. If this is true,
it is better understood why sexual activity as an exercise factor,
or cholesterol burner, does not contribute to life extension. On the
other hand, a happy wife is more likely to see that her husband gets

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his 6 servings of fruits and vegetables daily, avoids depression,


takes his medications, and visits his doctor.
Recommendations
1. If you experience sexual dysfunction problems, do not hesitate
to seek professional help.
2. Communicate to your partner the sexual feelings and behaviors
in which you would like to engage.
3. Remember that certain diseases and various drugs can cause
sexual dysfunction.
4. Most couples eventually experience some form of sexual
problems that can be satisfactorily resolved by knowledgeable,
caring physicians.
5. Ask your physician about trying a phosphodiesterase inhibitor
for your erectile dysfunction.
Further Reading
National Institutes of Health (NIH)
Sexual Health (General)
Health.nih.gov
Emmelot-Vonk MH, Verharar HJ, et al. Effect
�����������������������
of testosterone
supplementation on functional mobility, cognition, and other
parameters in older men. Journal of the American Medical
Association. January 2, 2008:39-52.

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Injuries/Accidents
Domestic Violence
With a good heredity, nature deals you a fine hand at cards;
and with good environment, you learn to play the hand well.
-Walter C. Alvarez, M.D.
Facts
1. Injury is the third leading cause of death in the U.S.
2. Each year motor vehicle crashes result in 40,000 deaths,
500,000 hospitalizations, and 4 million emergency room
visits.
3. More than 40 percent of crashes are alcohol related.
4. Thirty percent of Americans do not routinely use seat belts.
5. Falls are the second leading cause of unintentional injury
death in the U.S.
6. Smoking materials have been implicated in up to 33 percent of
residential fire deaths among the elderly.
7. Increased use of automobile safety restraints contributed to a
32 percent decline in the death rate from car crashes.
8. Domestic violence is the leading cause of injury to women
in the U.S., with an estimated 4,000 women killed each year.
Battering accounts for about one-half of all serious injuries in
women presenting to emergency departments.
9. When compared with nonsmokers, smokers are 1.5 times
more likely to have motor vehicle crashes, 1.4 to 2.5 times
more likely to be injured at work, and twice as likely to suffer
other unintentional injuries.

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Injury is an important cause of death in the U.S., accounting


each year for about 4.3 million potential years of life lost prematurely
before age 70. Injuries are not necessarily accidents, meaning those
that occur by chance and are unavoidable, because they usually
can be attributed to preventable behavioral and environmental
factors. Important causes of injuries include:
• Motor vehicle crashes.
• Burns.
• Drowning.
• Poisoning.
• Falls.
Injuries commonly occur in the workplace. In the U.S., 17 work-
related fatalities occur each day; their leading causes are:
• Motor vehicles - 23 percent.
• Machines - 13 percent.
• Homicides - 12 percent.
• Falls - 10 percent.
• Electrocutions - 7 percent.
• Strikes by falling objects - 7 percent.
• All others - 28 percent.
Motor vehicle crash-related injuries are important causes of
death. Motor vehicle fatality rates are highest for the young and
elderly. Drivers ages 70 and older have more fatalities than middle-
aged drivers, related to:
• Loss of vision.
• Loss of hearing.
• Dulled reaction times.
Dementia particularly impairs driving ability, as do alcohol and
sleep disorders.
All drivers should recognize the value of:
• Seat belts.
• Helmets (bicycle or motorcycle).
• Air bags.
• Periodic vision and hearing exams.
• Driving free of the influence of:
• Alcohol.

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• Illicit drugs.
• Certain over-the-counter medications.
• Certain prescription medications.
Many medications have mind-altering effects. About one-third
of drivers killed in crashes are intoxicated by alcohol. Drunk drivers
are at a disadvantage because their driving skills are impaired,
they are less likely to use seat belts and are more likely to speed.
Drugs such as marijuana, cocaine, and tranquilizers are also
important contributors to lethal crashes.
Wearing a seat belt can increase the survival rate of car crash
passengers by one-half. Those thrown from vehicles are 24 to 40
times more likely to be killed. Frontal air bags can potentially reduce
the risk of death by an additional 9 percent among belted drivers
and by 20 percent among unbelted front-seat passengers. Your
physician may comment and advise you on the habits, physical or
mental deficiencies, or prescribed medications that can hamper
your ability to drive or operate machines that require significant
skill and attention.
At least one-third of older adults fall each year in the U.S.,
resulting in over 14,000 deaths and 1.8 million emergency room
visits. Falls by elderly people lead to injuries, such as hip fractures,
which, in turn, result in death about 20 percent of the time within
1 year. Among the elderly, hip fractures are the most frequent
serious consequence of falling; approximately 20 percent of falls
result in direct impact on the hip. Wearing protective pads may
reduce the risk of hip fractures in this group.
Some environmental risk factors can be corrected to help
prevent falls; risk factors include:
• Pavement irregularities.
• Slippery floors.
• Poor lighting.
• Poor-fitting or inadequate shoe size.
Helping to protect against falls, especially for the elderly, are:
• Weight bearing exercise.
• Gait retraining.
• Gait aids such as a walker.

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• Adequate vision correction, yearly eye exams.


• Recognition of medication side effects.
Combinations of these efforts can reduce the risk of falling by
about 30 percent.
Burn injuries, most commonly flame and scald injuries, have
the highest death rate for those ages 60 and older. Cigarette
smoking is an important cause of fire and burn injury deaths and is
associated with about 25 percent of residential fires. Homes often
do not have smoke detectors, and sometimes elderly patients
may not hear or respond to alarms. Avoiding smoking, especially
in bed, and attention to the temperatures of tap water, food, and
drinks can greatly reduce the incidence of fire and burn injuries.
Unintentional poisonings lead to a significant number of deaths
among adults, the highest incidence being in young adult men.
Most of these deaths are related to overdose of alcohol or drugs
such as heroin and cocaine. Elderly patients with arthritis or other
painful problems may use too much aspirin or other pain relievers
that can lead to:
• Gastrointestinal bleeding.
• Confusion.
• Kidney failure.
• Pulmonary edema.
In the U.S. each year, 4 to 8 million women, from all cultural
and socioeconomic groups, suffer physical abuse inflicted by their
spouses or partners. Men are the victims of about 2.9 million
intimate partner-related physical assaults. Adult women are more
likely to be sexually assaulted, beaten, and killed in their own
homes at the hands of their male partners than any place else or
by anyone else in society.
Estimates also suggest that up to 2 million cases of elder
abuse occur annually in the U.S. This is of particular concern as
the population ages. The mistreatment of the elderly may be even
more difficult to identify because of:
• The relative isolation of this group.
• The tendency not to report this form of abuse.
• The subtle forms that this abuse can take so that it is often
undetected.

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Help for such victims involves community efforts that include


individuals, agencies, healthcare facilities, and law enforcement
organizations who are motivated to work together for the reduction
and prevention of violence. Victims should understand that they can
initiate help simply by calling 911. Getting to a hospital emergency
room will also initiate desired assistance.
Recommendations
1. If you have been drinking alcohol or using mind-altering drugs,
do not drive or operate potentially dangerous machinery.
2. If you have difficulty walking or have frequent falls, inform
your physician, who will look for and work to correct reversible
causes.
3. Do not smoke, especially in bed.
4. Be sure to have periodic vision and hearing tests.
5. Always wear a seat belt or helmet (motorcycle or bicycle).
6. Recognize that medicines you take may have potential mind-
altering effects.
7. Learn what facilities your community has for aiding victims of
domestic violence.
Further Reading
Centers for Disease Control and Prevention (CDC)
Injury, Violence and Safety
Injury Center

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The Bad (Polypharmacy)


and the Ugly (cocaine, methamphetamines,
marijuana, and anabolic steroids)
There are some remedies worse than the disease.
-Publius Syrus
Facts
1. Elderly Americans (ages 65 and over) account for the purchase
of 30 percent of all prescriptions and 40 percent of over-the-
counter drugs.
2. Age-related changes in elderly patients allow drugs to maintain
their effects longer, have unusual or unexpected actions, and
cause more bad reactions with serious and life-threatening
outcomes.
3. A large study of patients 65 and older found that 20% filled at
least 1 prescription for an inappropriate medicine.
4. In a given year, well over 175,000 people in the U.S., aged 65 or
older, will visit an emergency room due to an adverse reaction
to commonly prescribed medication. Warfarin (Coumadin),
insulin, aspirin, clopidogrel (Plavix) and digoxin are common
offenders.
5. The average nursing home patient receives 4 to 7 different
medications daily.
6. Fifty-one percent of drugs have label changes due to major
safety issues discovered after marketing.
7. Four percent of approved drugs are ultimately withdrawn from
the market for safety reasons.
8. Cocaine-related injuries are a major cause of death among
young adults in urban areas such as New York City.
9. A heart attack is the most commonly reported cardiac
complication of cocaine abuse.
10. Chest pain is the most common cocaine-related medical
problem, resulting in the evaluation of more than 64,000
patients annually for possible coronary artery problems.

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During the last 30 years, the number of FDA-approved


drugs available for the treatment of diseases and their medical
complications has increased from 650 to more than 9,500, and
of those there are approximately 1,000 generic compounds. The
shear volume of drugs makes it impossible, without the aid of
sophisticated computer systems, for physicians to master knowledge
of the complex actions of specific drugs, their complications, their
interactions with other drugs, and their altered activities in various
disease states. Fortunately, recent developments have made more
drug information available so that physicians may keep abreast of
the latest findings.
Polypharmacy
The seriousness of problems related to adverse drug events is
apparent, considering that:
• Prescription-related drug problems result in about 119,000
annual U.S. deaths.
• Twenty-eight percent of hospitalized patients experience
adverse drug events annually, thus occurring in 8.8 million
hospitalizations each year.
• Tens of thousands of fatalities in hospitalized patients in the
U.S. occur annually due to drugs.
• One in 4 people ages 65 and older receive at least 1 of 20
drugs that are potentially inappropriate for elderly patients.
• Thirty percent of elderly patients use 8 or more prescription
drugs daily, and the elderly population takes an average of 18
prescription drugs per year.
It is estimated that 10 to 30 percent of hospital admissions
among the elderly are related to drug problems such as:
• Inappropriate drug prescribing.
• Noncompliance.
• Adverse drug events.
Elderly people are especially prone to adverse drug events
because of their intake of multiple medications, use of herbal
preparations unknown to their physicians, and their incidence of
multiple chronic diseases. This problem is of particular concern
because the elderly population is expected to increase from 31
million in 1989 to 52 million in the year 2020.

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The FDA suggests 6 tips to avoid medication mistakes:


1. Know the names of your drugs.
2. Ask your pharmacist or physician questions.
3. Know what your drugs treat.
4. Read the labels and follow directions.
5. Keep your doctors informed.
6. Keep a list of all your medications.
Cocaine
Cocaine is a powerfully addictive stimulant drug. In a particular
year, more than 5 million Americans use cocaine, with about one-
third of those using the drug monthly. Though figures are difficult
to determine, it has been estimated that more than 30 million
Americans have tried cocaine at least once.
Cocaine can cause problems no matter what the route of
administration (intranasal, smoking, or intravenous injection) and
can be directly related to a variety of problems including:
• Heart attacks.
• Seizures and headaches.
• Respiratory distress.
• Mental problems.
• Muscle necrosis and renal failure.
Indirectly, cocaine can be associated with:
• Homicides.
• Suicides.
• Motor vehicle accidents.
Heart attacks are the most commonly reported cardiac
complication of cocaine use. Even small amounts of the drug
can trigger an event, even in the first time user. Heart attacks can
occur shortly after use or on the following day, and can occur in
a young person with normal coronary arteries, suggesting the
occurrence of spasm and occlusion of a coronary artery. The
risk of heart attack is tremendously increased in the 60 minutes
following cocaine use. Cocaine can also cause sudden death by
other mechanisms, such as:

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• Heart rhythm disturbances.


• Strokes.
• Sudden major increases in blood pressure.
Besides the drug itself, certain adulterants found in street
cocaine can present major problems. Cocaine along with alcohol
is a combination that can easily result in a drug-related death.
Heroin
Heroin is a highly addictive drug. A white powder processed
from morphine, it is one of the most rapidly acting opiates. The drug
itself is associated with serious health problems, heart and lung
conditions, mental problems, and infectious diseases including
HIV/AIDS and hepatitis. About 70 to 80 percent of new hepatitis C
(HCV) infections in the U.S. are among injection drug users. Street
additives, often poisonous, can cause ever further and occasionally
lethal problems. Up to 8 percent of drug-related emergency room
visits have been related to heroin abuse. The extent of heroin use is
suggested by surveys that show that 1.3 percent of eighth graders
and 2.5 percent of tenth and twelfth graders used heroin at least
once. Heroin is associated with significant incidence of overdose
and death. A broad range of effective treatments are available for
heroin addicts.
Methamphetamines
Methamphetamines are addictive stimulants that are closely
related to amphetamines, but have longer lasting and more toxic
effects on the brain. Their chronic long term use can lead to
psychotic behavior, hallucinations, heart attacks, and strokes by
their ability to affect the contraction of blood vessels. They can be
taken orally, by snorting powder, by needle injection or by smoking.
More than 12 million Americans have tried methamphetamines at
least once in their lifetimes. Even small amounts can cause serious
complications in some people. Methamphetamine abuse has been
closely linked to risky behaviors, resulting in sexually transmitted
diseases and other infectious diseases including HIV.
Ecstasy
Ecstasy, along with Rohypnol and Ketamine, belong to a
group known as date rape drugs. They are colorless, odorless and
tasteless, which allows them to be slipped into a victim’s drink.

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They can cause a victim to pass out, unable to resist what is being
done to them, and leaving them unable to recall what happened
to them. Chronic use of these drugs can cause changes in brain
function, coma and seizures. Ecstasy can interfere with the body’s
ability to regulate one’s temperature, causing severe temperature
elevations and organ damage. These drugs, used mostly by teens
and young adults who are part of a nightclub, bar, rave, or trance
scene, can be deadly.
Marijuana
Marijuana is the most commonly used illicit drug. An estimated
97 million Americans aged 12 or older have tried marijuana at least
once in their lifetimes. Marijuana is an addictive drug that can have
important effects on memory, learning, attention, coordination and
anxiety. Marijuana smokers can have many of the same respiratory
problems as tobacco smokers. One marijuana cigarette can have
the same effect on the lungs as smoking up to 5 cigarettes in
succession. Marijuana smoke contains 50-70 percent more
cancer causing hydrocarbons than does tobacco smoke. Use of
marijuana appears to facilitate one’s progression to even more
dangerous drugs.
Anabolic steroids
The abuse of anabolic steroids is driven by a desire to change
one’s appearance and performance. Young people and especially
athletes are commonly recognized as abusers of these potent
drugs. It is estimated that adults, in the hundreds of thousands,
mostly men, but also women, have knowingly or unknowingly
placed themselves at risk with these drugs. These drugs can lead
to early heart attacks, strokes, liver tumors, kidney failure and
serious psychiatric problems. Various injected steroid preparations
have placed users at risk for contracting dangerous infections
such as HIV/AIDS and hepatitis B and C. Users also are at risk for
cancers and death.
Recommendations
1. At least once a year, bag all your pills, take them to your doctor,
and ask if you still need them and if there are any you can do
without.

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2. Remember that a medication (or combination of medications)


you take could explain a worsening of your condition, new
symptoms, or even a new illness.
3. Learn as much as you can about your medications. Elderly
patients should ask for help (from family, friends, caregivers,
etc.) with this sometimes burdensome task.
4. Be sure to inform your physician of any herbal preparations
that you are taking.
5. NEVER, EVER, USE ANY FORM OF COCAINE.
6. If already dependent on cocaine, seek the assistance of your
physician or a substance-abuse specialist.
7. Refrain from using heroin, marijuana, methamphetamines,
ecstasy, and anabolic steroids.
Further Reading

National Institutes of Health


National Institute on Drug Abuse
Health.nih.gov
U.S. Department of Health & Human Services
halthfinder.gov
U.S. Food and Drug Administration (FDA)

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Smoking
Tobacco drieth the brain, dimmeth the sight, vitiateth
the smell, hurteth the stomach, destroyeth the concoction,
disturbeth the humors and spirits, corrupteth the breath,
induceth a trembling of the limbs, exiccateth the windpipe, lungs
and liver, annoyeth the milt, scorcheth the heart, and causeth
the blood to be adjusted.
- Tobias Venner
Facts
1. An average smoker dies 8 years earlier than a nonsmoker.
2. Studies suggest that 30 to 40 percent of the half million yearly
U.S. deaths from coronary heart disease are due to smoking.
3. Smoking only 1 to 4 cigarettes a day can more than double the
risk of death from coronary artery disease.
4. Smoking is the cause of 30 percent of all deaths from cancer.
5. When you smoke, everyone around you smokes.
6. Female nonsmokers who are regularly exposed to others’
smoke are 91 percent more likely to have heart attacks than
those not exposed.
7. Nonsmokers living with smokers have a 30 percent higher risk
of dying from heart disease than do nonsmokers without such
exposure.
8. Cigarette smoking is the number one preventable cause of
premature death in the U.S.
9. A 40-year study of British physicians has predicted that about
half of all regular smokers will eventually die as a result of
cigarette use.
10. Cigarette smoking is the leading risk factor for age-related
macular degeneration, the leading cause of blindness in
people older than age 65.
11. Up to 12 percent of type 2 diabetes mellitus cases can be
related to smoking.

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Smoking and other tobacco use has been chosen as the first
risk factor discussed in this book because it best exemplifies the
concept that is hoped to be relayed to readers: one’s life can be
extended significantly by certain reasonable actions. The best and
most recent data indicate that smoking-related illnesses account
for nearly 1 in 5 deaths and more than one-fourth of all deaths
among those ages 35 to 64.
In the U.S., according to the best recent estimate, when those
who die from passive smoking (the breathing of sidestream smoke
emitted from burning tobacco) are included, tobacco kills about
438,000 people each year.
Heart disease, not cancer, is the main disease caused by
smoking. Though heavy smoking for long periods is generally
recognized as a problem, smokers tend to ignore studies that
show that lesser exposures can also be lethal. In one major study
of nurses, it was found that those who smoked 1 to 4 cigarettes
daily had a 2.5-fold increase risk of fatal coronary artery disease
and nonfatal heart attack when compared to nurses who did not
smoke. Some people are so sensitive to tobacco smoke that the
mere entrance into a smoke-filled room can cause their coronary
arteries to go into spasm, occlude blood flow and cause chest pain
and possible damage to the heart muscle. Recent studies from the
U.S. and several foreign countries show that ordinances prohibiting
smoking in all public places, including bars, restaurants, and
workplaces have cut down on heart attacks by up to 40 percent.
Non-smokers who are exposed to secondhand smoke at home or
work increase their heart attack risk by 25-30 percent and their
lung cancer risk by 20-30 percent.
Smoking causes about 90 percent of lung cancer deaths in
women and almost 80 percent of lung cancer deaths in men. The
risk of dying from lung cancer is more than 23 times higher among
men who smoke cigarettes, and about 13 times higher among
women who smoke cigarettes compared with never smokers.
Smoking is associated with cancers of the:
• Mouth.
• Throat.
• Larynx.
• Esophagus.

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• Stomach.
• Pancreas.
• Cervix.
• Kidney.
• Ureter.
• Bladder.
• Colon.
As occurs with heart disease, cancer, in certain unfortunate
people, can be caused by short periods of exposure to relatively
small numbers of cigarettes. Passive smoking, such as exposure
to parents' smoke during childhood and adolescence as well as
exposure from living with a spouse who smokes or working with
fellow employees who smoke, is also a recognized cause of lung
and other cancers. Cigarette smoking is also the leading cause
of lung illness and death in the U.S., causing more than 84,000
deaths from such problems as:
• Emphysema.
• Pneumonia.
• Bronchitis.
About 90 percent of all deaths from emphysema are attributable
to cigarette smoking.
Problems related to use of tobacco products are present at
each and every age. An article in Time magazine reported that
even 3 insurance firms owned by tobacco companies charged
smokers nearly double for term life insurance because smokers
are about twice as likely to die at a given age.
The hazards of smoking extend well into later life. Among those
over age 65, the rates of total deaths among current smokers were
twice that of those who never smoked. Oral cancer in men who
use smokeless tobacco (such as snuff and chewing tobacco),
typically occurs in the older than age 65 group, though it can be
seen much earlier.
The recent resurgence of cigar smoking overlooks the fact that
there is no safe form of tobacco, just as there is no safe period
of time for tobacco use. Estimates of deaths from pipe and cigar
smoking just prior to the recent increase in cigar sales were 14,000
yearly in the U.S. The popularity of cigars among young people is

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in part related to the belief that cigars are a safe alternative to


cigarettes. However, a report from the National Cancer Institute
suggests that people who smoke cigars daily have about the
same risk for oral, laryngeal, and esophageal cancers as cigarette
smokers. Also, cigars give off thick clouds of secondhand smoke
containing similar cancer-causing substances as cigarettes,
though in considerably higher concentrations.
Even cigar smokers who do not inhale are exposed to their
own environmental tobacco smoke, and smoke, of course, is
definitely a risk factor for coronary artery disease and emphysema.
Previous cigarette smokers who turn to cigars are more likely to
inhale than those who have not smoked cigarettes. It would not
be unusual for a cigar smoker to take in more nicotine and other
smoke toxins than a cigarette smoker, depending on the person’s
manner of smoking and the type of cigar smoked. Regular cigar
smokers have a significantly increased risk of lung cancer as well
as coronary artery disease. A recent study from London showed
that primary or secondary cigar smokers were more likely than
nonsmokers to suffer a fatal or non-fatal heart attack or stroke.
More study is needed to determine the degree of the health risks
of the occasional cigar smoker.
In the past, many smokers switched to lower tar and nicotine
cigarette brands rather than quitting, in the misguided belief
that they can smoke more safely. A wealth of scientific evidence
contradicts this strategy, however, because smokers inhale these
low-yield cigarettes more deeply and smoke more of them to
obtain the same nicotine kick.
Those fortunate enough to escape death from tobacco toxin
exposure can still find themselves compromised in later life by
damaged hearts or emphysematous lungs. These and other
consequences of tobacco-related injuries can make afflicted
people more at risk for other illnesses (such as pneumonia, stroke)
common to later life.
Much still can be gained by those who, after any period of
using any quantity or variety of tobacco (cigarettes, cigars, pipes,
snuff, or chewing tobacco) at any age, quit. That is provided the
deadly condition has not yet become visible. These include:

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• After about a year, deaths from heart disease drops halfway


back to that of nonsmokers and after 5 years to the rate equal
to nonsmokers.
• Risk of lung cancer is cut in half in 5 years, and approaches
the risk of non-smokers after about 15 years.
• Lifelong smokers who quit at age 50 double their chances of
living to age 65.
Smokers who die between ages 35 and 64 lose 23 years of life
compared to age-matched nonsmokers.
Today smokers are quitting in large numbers with the help of
sympathetic physicians and through the use of or help from:
• Nicotine patches and gums (which can be purchased over-
the-counter).
• Nicotine Lozenges
• Nicotine nasal spray (Nicotrol NS).
• Nicotine inhaler (Nicotrol Inhaler).
• Bupropion (Zyban).
• Behavior modification programs.
• Effective medicines for associated anxiety.
• The almost daily reports in the media regarding the dangers of
tobacco.
• Acknowledgements of subversive activities of the tobacco
industry.
Varenicline (Chantix) is a newly approved and effective drug
that works by blocking the pleasant effect of nicotine on the brain.
Several studies point to its effectiveness, and we have seen some
good responses in some difficult cases. Varenicline is probably
the best of the available drugs able to help those who are serious
about ending their tobacco dependence. The FDA however warns
that some patients on varenicline have experienced changes in
behavior, agitation, depression and even suicide concerns. These
changes point to the need to take this medication under a doctor’s
supervision.
The nicotine nasal spray has the advantage of delivering
nicotine more rapidly than gum, patches or inhalers, but not
nearly as rapidly as cigarettes. The nicotine inhaler has added
effectiveness because it simulates the habitual hand-to-mouth

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action that is so common to smoking. Bupropion (Zyban), an


extended-release antidepressant appears to work in smokers with
or without a past history of depression. It also appears, in some
people, to lessen the common problem of weight gain that is often
related to quitting smoking. All these drugs, by themselves or in
combination, especially when accompanied by some behavioral
support, have value in helping people quit smoking and remain
tobacco free.
For those who find cost to be a factor, an inexpensive
antidepressant, nortriptyline, may be effective for nondepressed
smokers.
Studies suggest that participation in regular, vigorous physical
exercise facilitates smoking cessation in women. The exercise
program, in conjunction with a cognitive-behavioral smoking
cessation program, not only facilitated smoking cessation, but also
delayed weight gain in women smokers and improved exercise
capacity. Such a program could be a valuable addition to all
smoking cessation programs.
Recommendations
1. If you are a smoker, quit. If you chew tobacco, stop.
2. If you live with a smoker, discuss your concerns for your health
with him/her and review data together. Your goal should be
that smokers not smoke in your presence or in rooms that
you frequent or, if possible, anywhere in your house. Tobacco
toxins have tremendous capabilities of moving from room to
room and from one floor to another.
3. For similar reasons, if you must live in an apartment, look for a
smoke-free apartment.
4. If you are exposed to passive smoke at work, discuss your
concerns with fellow employees or your boss. It may be
necessary to change jobs. Your personal physician may be
able to document your distress or risks from such exposure.
Studies have shown added risk for those exposed to passive
smoking both at home and at work.
5. For help quitting smoking, seek the assistance of your physician
or a physician skilled in smoking cessation programs. Because
smokers have more depression, physicians may detect and

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treat this in the process of supporting their patients’ tobacco


cessation programs.
6. Tips for individuals who require extra assistance in quitting are
listed below.
Tips to Help You Stop Smoking
Patients should realize that approximately 40 million Americans
have quit smoking and that about 95 percent of these stopped on
their own without any formal cessation program. Quitting rates are
about twice as high for those who quit on their own as for those
who participate in formal smoking cessation programs.
Of the various strategies for quitting, those who do so “cold
turkey” are more likely to remain abstinent. Ongoing encouragement
and assistance from physicians has also been cited by successful
quitters as important in their decisions to quit and in preventing
relapses.
Those who want to quit smoking should realize that some
short-term discomforts/withdrawal symptoms will occur; these
include:
• Dry mouth.
• Sore throat.
• Sore gums.
• Sore tongue.
• Headache.
• Trouble sleeping.
• Fatigue.
• Hunger.
• Tenseness.
• Irritability.
• Coughing.
These symptoms peak within a few days but usually last only
a week or 2. Relapses can occur in the first week after quitting and
even for months afterwards, and these can be particularly hard
times. Slips may occur, especially during periods of emotional
turmoil, but should not be equated with total failure. It is important
to keep trying. Many successful quitters failed repeatedly before
they were finally able to quit.

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A great deal of experience with smokers and their efforts to quit


has led organizations such as the National Institutes of Health, the
National Cancer Institute, and the American Heart Association to
recommend the following tips to help smokers in their efforts to
quit.
Getting Ready to Quit
1. Select a target date for quitting, possibly a special day, such as
a birthday, anniversary, or holiday.
2. Decide positively that you want to quit. Try to avoid negative
thoughts about how difficult it might be.
3. List all the reasons why you want to quit. Write them down and
carry them with you. Read them whenever you are tempted to
smoke.
4. Notice when and why you smoke. Try to find the things in your
daily life that you often do while smoking, such as drinking
your morning cup of coffee or talking on the telephone.
5. Change your smoking routines. Keep your cigarettes in a
different place, make them difficult to find. Smoke with your
other hand.
6. Smoke only in certain places, such as outdoors, or in places
that are uncomfortable.
7. Begin to condition yourself physically. Start a modest exercise
program, drink more fluids, get plenty of rest, and avoid
fatigue.
8. Choose your environment. Spend more and more time in
places where smoking is not allowed.
9. Ask your spouse or a friend to quit with you. Share your feelings
and offer mutual support.
10. Switch to a brand of cigarettes you find distasteful.
11. Collect all your cigarette butts in 1 large glass container to
remind yourself of the filth that smoking represents. Don’t
empty your ashtrays. This will remind you how many cigarettes
you smoke each day.

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12. Smoke only those cigarettes you really want. Catch yourself
before you light up a cigarette out of pure habit.
13. Think of quitting in terms of 1 day at a time.
The Day You Quit
1. Throw away all your cigarettes and matches. Put away your
lighters and ashtrays.
2. Change your morning routine. When you eat breakfast, sit at
a different place at the table. Stay busy, exercise, go to the
movies.
3. When you get the urge to smoke, do something else instead.
Try to replace the urge by chewing sugarless gum or mints.
Snack on celery or carrots.
4. Remind family and friends that this is your quit date and ask for
their help over the next couple of weeks.
5. Carry other things to put in your mouth, such as gum, hard
candy, or a toothpick.
6. Spend this day and following days with non-smokers and in
places where smoking is not allowed.
7. Drink large quantities of water and fruit juices (avoid caffeine
beverages).
8. Avoid alcohol, coffee, or other beverages that you associate
with cigarette smoking.
9. If you miss the sensation of having a cigarette in your hand,
play with something else, such as a pencil, paper clip, or
marble.
10. Visit your dentist and have your teeth cleaned to get rid of
tobacco stains.
11. Reward yourself at the end of the day. Estimate the amount of
money you saved and buy yourself a treat, such as a movie or
a book, and enjoy your favorite meal.
12. Limit your socializing to healthful, outdoor activities and sports
in situations in which it would be difficult to smoke.

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13. Don’t allow yourself to think that “1 cigarette won’t hurt.” It


will!
Staying Off Cigarettes
1. Don’t worry if you are sleepier or more short-tempered than
usual. These feelings will pass.
2. Begin to increase your exercise program.
3. Review in your mind the positive things about quitting, such
as how much you like yourself as a nonsmoker and the health
benefits to you and your family. A positive attitude can help
through rough times.
4. When you feel tense, try to keep busy. Think about ways to
solve the problem; tell yourself smoking won’t make it any
better; and do something else.
5. Eat regular meals. Feeling hungry is sometimes mistaken for
the desire to smoke.
6. Start a money jar with the money you save by not buying
cigarettes.
7. Let others know you quit smoking. Most people will support
you.
8. If you slip and smoke, don’t be discouraged. Many former
smokers tried to stop several times before they finally
succeeded. Quit again.
9. Watch your food and calorie intake so as not to gain weight
during this period. Count calories if necessary. Increased
exercise can help burn calories.

10. Follow-up visits with your physician, usually at the end of the
second week, may prove helpful. Further help in the form of
extra motivation, advice, and/or nicotine gum or patches might
be suggested or instituted.
11. Watch out for triggers that are commonly recognized as
stimulating a sudden, intense urge to smoke, such as:
• Working under pressure.
• Feeling blue.

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• Talking on the telephone.


• Having a drink.
• Watching television.
• Driving your car.
• Finishing a meal.
• Playing cards.
• Drinking coffee.
• Watching someone else smoke.
12. When possible, support new taxes that raise the price of
cigarettes, making the smoking habit even more painful.
13. Periodically, write down new reasons why you’re happy you
quit and post these where you’ll be sure to see them.
This extensive, though not exhaustive, list is not meant to
be burdensome to the potential quitter. The authors recommend
reviewing the list and selecting those items you can implement
successfully, realizing that all have value and have proven effective
for some people.
Further Reading and Information
Centers for Disease Control and Prevention (CDC)
Bartecchi C, Alsever R, Nevin-Woods C., et al. Reduction in the
incidence of acute myocardial infarction associated with a citywide
smoking ordinance. Circulation. 2007:1490-1496.
Bartecchi C, MacKenzie T, Schrier RW. ��������������������������
The human cost of tobacco
use. New England Journal of Medicine. 1994:906-912.
Samet J. Smoking bans prevent heart attacks. Circulation.
2006:1450-1451.
The Clinical Guide to Preventive Services. 2006.
A tobacco quitline - 1-800-QUITNOW.
Web sites that support quit attempts (http://www.becomeanex.org)
and (http://www.quitnet.com).

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Good and Bad Cholesterol


As I see it, every day you do 1 of 2 things: build health or
produce disease in yourself.
-Adelle Davis
Facts
1. At any cholesterol blood test number, a 10 percent increase in
serum cholesterol has been associated with a 20 percent or
greater increased risk of coronary artery disease.
2. A 10 percent reduction in serum cholesterol could result in as
much as a 10 percent reduction in death from coronary artery
disease.
3. At least 40 million Americans are thought to have cholesterol
levels high enough to require medical attention.
4. Studies suggest that only 45 to 65 percent of patients with
high cholesterol had evidence of treatment.
5. Newer drugs that have been shown to lower cholesterol in
patients with cardiovascular diseases also have been shown
to prolong life significantly.
6. These drugs, commonly called statins, not only have the ability
to decrease the risk of the first or subsequent heart attack or
stroke but also have the capacity to prevent such problems
from occurring at all.
7. At present, for cholesterol problems in persons 75 or older,
there are not enough data to determine the value of screening
or treating. For individual cases, however, the decision to treat
should be left to one’s physician who is skilled in the principles
of lipid management. In any case, for older people who already
have heart disease, it is suggested that lowering cholesterol
can reduce the risk of having a heart attack by as much as
50%.

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Cholesterol is a soft, waxy, fat-like substance produced by


animals. It is normally found throughout the human body, and is
necessary for healthy body function. The substance becomes a
problem when too much is present and is deposited in the wrong
places, such as in the coronary arteries or arteries leading to the
brain or blood vessels in the legs.
Cholesterol travels throughout the body in the blood stream
packaged in units called lipoproteins:
• Low-density lipoprotein (LDL), also known as bad cholesterol,
is the main cholesterol-carrying compound in the blood. It
plays an important role in plaque formation within arteries.
• High-density lipoprotein (HDL), also known as good cholesterol,
helps remove cholesterol from arteries and transports it to the
liver for clearance from the bloodstream.
• Very-low-density lipoprotein (VLDL) transports triglycerides to
the tissues where they are broken down and used for energy
or are stored. Triglyceride formation is increased when excess
calories are present.
Some people inherit a disorder that results in high cholesterol
levels and severe coronary artery disease at a young age.
Others have cholesterol problems due to lifestyle choices such
as diet, inactivity, or smoking. Some have combinations of these
behaviors.
Levels of fats in the blood can be determined by direct
measurements. The total cholesterol measurement, the most
common test, is made up of LDL, HDL, and other blood lipid
particles. Some helpful normal numbers to remember for people
without known heart disease are:

Cholesterol Type (mg/dL)


Total Blood Cholesterol Less than 200 mg/dL
HDL (Good) Cholesterol Over 40 mg/dL (Men)
Over 50 mg/dL (Women)
LDL (Bad) Cholesterol Less than 100 mg/dL
Triglycerides Less than 150 mg/dL
As discussed earlier, it may be reasonable to have an LDL
cholesterol goal of 100 mg/dL or less for all people. Diet and

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exercise might be able to achieve this goal in some people, but


others may require medications to help one reach that goal. When
combined with the following risk factors:
• High blood pressure.
• Diabetes.
• Age.
• Smoking.
• Obesity.
• Family history.
• Lack of exercise.
• Lower socioeconomic status.
LDL cholesterol levels above 100 increases significantly the
risk of developing cardiovascular disease, and thus requires further
attention and probably medications. The presence of multiple risk
factors further magnifies the problem in the affected patient. Those
who are placed in the high-risk group due to the combination of
elevated cholesterol and risk factors should seek their physician’s
advice to outline programs for cholesterol control and risk factor
reduction. It is suggested that for each 1 percent reduction in blood
cholesterol, there may be a 2 percent reduction in heart attack risk.
The value of lowering “bad” LDL cholesterol is now unquestioned.
Reducing LDL levels not only decreases the number of recurrent
events in heart patients but also prevents coronary heart disease
in persons at low to moderate risk of developing such problems.
Lowering LDL cholesterol levels has been shown to reduce
complications of the atherosclerotic process, including:
• Total deaths.
• Fatal and nonfatal heart attacks.
• Incidence of strokes.
• Unstable angina pectoris.
• Peripheral vascular disease (even to ages in the mid-70s).
The program to lower LDL cholesterol levels should begin
with diet and exercise. If an individual is overweight, achieving a
desirable body weight is important. Dietary modifications, such
as replacing saturated fats with unsaturated fats or omega-3 fatty
acids and increasing the fruits and vegetables in the diet even
beyond the 6 daily recommended, can be most helpful. Avoiding
all trans-fats and eating more fiber is also helpful. Eating 25 grams

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(women) and 38 grams (men) of soluble fiber can lower LDL levels.
Examples of soluble fiber include barley, oatmeal, beans, peas,
citrus fruits, pears, apples, strawberries and eggplant.
Plant sterols and stanols are found in fruits, vegetables,
vegetable oils, nuts, seeds, cereals, legumes and other plant
sources. Two good commercial sources are the butter substitutes
Take Control and Benecol. Plant sterols and stanols (2 grams
per day) reduce the amount of cholesterol that gets absorbed by
the gut. They can reduce LDL cholesterol by about 10 percent.
They are especially useful for heart attack patients with high
cholesterols. Sterols and stanols can also be obtained naturally
from whole foods which offer even more benefits.
Although use of specific diets can be effective, it is often difficult
for people to comply with some programs, especially for the long
term. An evaluation by a skilled dietitian with close follow-up can
be most helpful.
If desired LDL cholesterol levels cannot be achieved by these
methods, use of a cholesterol lowering drug such as a statin, is
in order. These agents have been associated with a 50 percent
or greater decrease in LDL levels, a tendency to increase “good”
HDL levels, and an ability to lower triglyceride levels. Presently
there are 6 statin drugs, listed doses are equivalent:
All are effective, usually within 3-4 weeks, with few side effects;
but each may vary somewhat in potency at certain dosages, timing
of doses, side effects, duration of activity and cost. All prove to be
more effective when combined with healthy diets, weight reduction,
exercise and other interventions.
• Atorvastatin (Lipitor) ������ 10 mg.
• Fluvastatin (Lescol) ������ 80 mg.
• Lovastatin (Mevacor) ������ 40 mg.
• Pravastatin (Pravachol) ������ 40 mg.
• Simvastatin (Zocor) ������ 20 mg.
• Rosuvastatin (Crestor) ����� 5 mg.
In addition to lowering blood cholesterol levels, statins also
have beneficial effects on the inner surfaces of blood vessels,
reducing inflammatory responses, stabilizing plaque in blood
vessels, and preventing rupture of obstructing plaque, which can

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lead to blockage of coronary vessels and heart attacks. They also


have an effect on clot formation in blood vessels.
Other drugs favorably affect cholesterol levels. These include:
• Niacin – reduces LDL cholesterol. It can be added to the
statins.
• Bile acid sequestrants – mild reduction in LDL cholesterol.
• Ezetimibe (Zetia) – a cholesterol absorption inhibitor. It can
reduce LDL cholesterol by about 20 percent, and is well
tolerated. It is also effective when combined with statin drugs.
Unlike statins, however, it has not yet been shown to affect
atherosclerosis or coronary heart disease.
At present, there is controversy about who should be screened
for high cholesterol. Physicians will inform their patients about which
tests are needed, when they are needed, and how patients should
prepare for the tests. Certainly those at risk for coronary artery
disease, those who have suffered heart attacks, and middle-aged
men with cardiac risk factors are in need of screening studies.
Family or personal histories of cholesterol or vascular problems
such as a stroke, also suggest benefit from screening. Abnormal
cholesterol studies are of less value in persons ages 70 years and
older unless they are known to have coronary artery disease.
Alternative lipid measurements have at times been proposed,
but fare no better than traditional LDL and HDL measurements.
Finding elevated total cholesterol in young or middle –aged
people suggests the need to measure other lipoprotein levels.
For those at risk, the higher the total cholesterol level, the greater
the risk of cardiovascular disease. This risk is further increased
if the LDL cholesterol is high and the HDL is low, a particularly
bad combination. Under any circumstances however, high LDL is
undesirable because it causes atherosclerosis. However, low HDL
by itself is also of concern. We must also keep in mind that people
with high HDL levels can still have heart attacks. HDL cholesterol
has important roles in the body. It takes up excess cholesterol from
the lining of the blood vessels and carries it off to the liver for
disposal. It also has other roles that provide protection for arteries.
Causes of low HDL cholesterol (less than 40 mg/dl) include:
• Elevated triglycerides.
• Overweight and obesity.

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• Physical inactivity.
• Type 2 diabetes.
• Cigarette smoking.
• Very high carbohydrate intake.
• Certain drugs – beta-blockers, anabolic steroids, progestational
agents.
• Genetic predisposition.
Because low HDL levels are associated with greater risks for
coronary heart disease, it is advantageous to attempt to raise HDL
levels. This can be accomplished through:
• Exercise.
• Weight loss.
• Stopping smoking.
• Moderate alcohol drinking.
• Dietary changes, especially eating lesser amounts of foods
containing trans-fats and replacing dietary calories from
carbohydrates with those from unsaturated fats.
• Some drugs such as niacin and statins.
It appears that elevated triglyceride levels contribute to an
increase in risk for cardiovascular disease. The evidence for
beneficial effects from treating hypertriglyceridemia, however,
is less well established than the treatment of LDL cholesterol
elevations. Mild to moderate hypertriglyceridemia has the potential
to deteriorate into severe hypertriglyceridemia. It is especially
important that triglycerides be measured while fasting because
a recent meal or even a cup of coffee can raise triglyceride
levels. High plasma triglyceride levels on their own or especially
in combination with other cholesterol problems appear to be
associated with coronary heart disease, and very high triglyceride
levels can precipitate bouts of pancreatitis.
Causes of elevated triglyceride levels:
• Obesity or overweight.
• Physical inactivity.
• Cigarette smoking.
• Excess alcohol intake.
• High carbohydrate diets.
• Different diseases – type 2 diabetes, chronic renal failure,

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nephrotic syndrome, thyroid and liver diseases and systemic


lupus.
• Certain drugs – corticosteroids, estrogens, retinoids, higher
doses of beta-blockers, tamoxifen, antipsychotics.
• Various genetic lipid problems.
Serum triglyceride levels:
• Normal less than 150 mg/dl.
• Borderline high 150-199.
• High 200-499.
• Very high 500 or more.
Good programs are available for control of abnormal triglyceride
levels; however, diet and exercise should form the basis of any
program. Weight loss for obese patients is definitely helpful. Some
people may require drug treatment along with diet and exercise.
Drugs that can help reduce triglycerides include:
• Omega-3 fatty acids – 4 grams daily.
• Fibrates.
• Statins.
• Niacin, up to 3 grams daily.
• Combinations of a fibrate and ezetimibe (Zetia).
Effective drug programs require close cooperation between
patients and physicians, because these drugs can have annoying
as well as rare serious side effects. Lipid lowering drug programs
need to be long-term and continuous. Unfortunately, about 50
percent of patients on these drug programs discontinue therapy on
their own within 1 year. Only about 25 percent of patients continue
drug therapy through the end of the second year.
Recommendations
1. Know your lipid levels.
2. Men aged 35 years and older and women aged 45 and older
should be screened for lipid disorders. Earlier screening may
be valuable if an individual has risk factors for coronary heart
disease. Screening at 5 year intervals is reasonable in absence
of recognized risk factors.
3. Know the risk factors that you have and eliminate or control as
many as possible.

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4. Follow a regular exercise program.


5. Eat at least 6 servings of fruits and vegetables daily.
6. Middle-aged men with high cholesterol and/or other risk factors
may consider having 1 to 2 alcoholic drinks daily. Alcohol intake
in excess of 1 to 2 drinks per day is not recommended.
7. If a low-cholesterol, low-fat diet does not control your lipid
problem, you may be a candidate for cholesterol-lowering
drugs to be used along with your diet.
8. You can enjoy shrimp and other shellfish which contain
cholesterol but are low in saturated fat and thus less likely to
raise the blood cholesterol levels.
Further Reading
Barter P, Gotto A, et al. HDL cholesterol, very low levels of ldl
cholesterol, and cardiovascular events. New England Journal of
Medicine. September 27, 2007:1301-10.
National Institutes of Health (NIH)
National Heart, Lung and Blood Institute
Health.nih.gov

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Obesity
More die in the United States of too much food than of too
little.
-John Kenneth Galbraith
Facts
1. About 2/3 of adults in the U.S. are overweight or obese, nearly
one-third are obese.
2. People who are 20 percent or greater over ideal body weight
are at higher risk of developing coronary artery disease.
3. People who are 40 percent or greater over ideal body weight
are at much higher risk for diabetes, heart disease, and cancers
of the colon, prostate, breast, gallbladder, ovary, uterus and
cervix.
4. Obesity is believed to be responsible for 14 percent of cancer
deaths in men and 20 percent in women.
5. About one-third of all cases of hypertension are thought to be
caused by obesity.
6. In America, only the Bible sells better than diet books.
7. The risk of diabetes increases from twofold in those who are
mildly overweight to tenfold in those who are severely obese.
8. Of individuals who lose weight, up to 95 percent regain the
weight in 5 years or less.
9. You can eat yourself to death.
10. Obesity is associated with about 112,000 excess deaths per
year in the U.S.
11. “Apple-shaped” women are more than twice as likely to develop
heart disease as are “pear-shaped” women.
12. Overweight and obesity have been associated with gastro-
esophageal reflux disease (GERD).
13. Bariatric surgery with resultant weight loss can result in
remission of diabetes in up to 90 percent of obese diabetic

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patients. It can reduce the risk of death associated with obesity


by as much as 30 percent.
14. The “latest” and “greatest” fad diet usually fails to enable long-
term weight loss.
15. A daily exercise program correlates best with sustaining weight
loss.

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People who weigh 20 percent more than ideal body weight are
considered obese.
Obesity Shape

Distribution of excess weight, indicated by body shape, is


also important. Apple-shaped (top-heavy) bodies indicate that
extra weight is centered around the waist; pear-shaped (bottom-
heavy) bodies indicate that extra weight is centered on the hips
and thighs. Of the 2, apple-shaped bodies are more troublesome
because they are associated with greater risks for:
• Heart disease.
• Stroke.
• High blood pressure.
• Diabetes.
Pear-shaped women are thought to have more difficulty than
apples in changing their shape by dieting and exercise.
The size of an individual’s waist can be a reflection of both
total and abdominal fat. Studies tell us that waist sizes greater
than 40 inches in men and 35 inches in women are associated

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with increased risks of acquiring a variety of significant medical


problems. One must be careful however not to substitute belt size
for waist measurement. The latter is more accurately determined
at the level of the navel. One study showed that women with waist
measurements of 38 inches or more had greater than 3 times the
risk of developing cardiovascular disease than those with waists of
28 inches or less. Sophisticated studies of coronary artery calcium
and the presence of abdominal aortic plaque showed strong
associations with waistline measurements.
Obesity can be found at all ages but is increasingly seen as
people grow older and peak at middle-age. Consideration of weight
category is often viewed in relation to an individual’s height.

Height/Weight Chart

Health professionals, however, often use the Body Mass Index


(BMI) to determine if a patient might have problems. The BMI
is calculated by determining a person’s weight and height and
charting the findings on the BMI table; the column within which the
findings are situated provides the BMI number, which serves as a
reasonable estimate of fat mass.
The largest study on obesity and deaths ever conducted,
involving more than 1 million Americans, was published by the
American Cancer Society in The New England Journal of Medicine.
It showed a definite link between being overweight and a higher risk
of dying from cancer or heart disease for people of all ages. This

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study focused on the BMI and showed that healthy non-smoking


white men and women and black men had an increasing risk of
death starting at a BMI of 25. The largest group of white males,
with a BMI of 40 or greater, were found to be 2.5 times more likely
to die than their healthiest peers.
This study has led researchers to suggest that obesity is
probably the second leading preventable cause of death in the
U.S., cigarette smoking being the first. The fact that about one-fifth
of U.S. adults have a BMI of 30 or more suggests the magnitude
of the problem.

The BMI is interpreted


This study has led researchersastofollows:
suggest that obesity is probably the second
• Underweight
leading preventable cause of death in the less than smoking
U.S., cigarette 18.5 being the first. The
fact that about one-fifth of U.S. adults have a BMI of 30 or more suggests the magnitude
• Normal
of the problem. 18.5 – 24.9
• Overweight
The BMI is interpreted as follows:
25 – 26.9
• Obese
• Underweight 2718.5
less than – 29.9
• Normal 18.5 – 24.9
• Moderately
• Overweight obese 30 – 34.9
25 – 26.9
• Severely obese
• Obese 27 – 35 – 39.9
29.9
• Moderately obese 30 – 34.9
• Morbidly obese
• Severely obese more than 40
35 – 39.9
• Morbidly obese more than 40
Body Mass Index
Body Mass Index

Height
(inches) Body Weight (pounds)
58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167
59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173
60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179
61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185
62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191
63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197
64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204
65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210
66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216
67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223
68 125 131 138 144 151 158 164 170 177 184 190 197 203 210 216 223 230
69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236
70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243
71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250
72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258
73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265
74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272
75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279
76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287
77 160 168 177 185 193 202 210 219 227 235 244 252 261 269 278 286 294
78 164 173 181 190 198 207 216 224 233 242 250 259 268 276 285 293 302
BMI = 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Appropriate Overweight Obese

To determine BMI, locate your height in the left-hand column, then move across to your weight. Your BMI will be
listed at the bottom of the column where the height and weight intersect.

110
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Studies suggest that up to 50 percent of those with a tendency


to weight excess have some form of inherited predisposition. A
recent study, however, suggests that even those with a strong
family history of obesity (implying strong genetic factors that control
fat mass) are still able to lose weight in response to increased
physical activity, thus pointing to the importance of our behavior in
weight status. Other explanations for weight excess include:
• The concept that a body mechanism, possibly controlled by
genes, seeks a certain weight as if it were a set point for a
given individual.
• Deficient exercise.
• Hormonal factors.
• Eating or emotional disorders can occur with stress or
depression.
• Dietary factors, such as excess fat intake.
A recent study suggested that friends, siblings, and spouses
had more chance to become obese because they followed the
lead of social partners. This concept would encourage us to look
at obesity as a public health problem.
In any case, weight gain occurs when calories taken in are
greater than calories expended. Every 3,500 calories consumed
in excess of those burned increase weight by about 1 pound. The
reverse is true for weight loss.
It has been estimated that the average American consumes
3,700 calories per day, though only one-half that amount for women
and two-thirds that amount for men is probably needed for good
body maintenance. People tend to eat more when serving sizes
are larger. Our population is eating out more, where serving sizes
are getting larger in recent years. This may explain the success of
certain popular and successful restaurants and fast food outlets.
Being overweight and especially being obese has serious
adverse consequences for health and longevity. Even a mild to
moderate degree of weight excess can increase the risk of health
complications and death at every age group.
Overweight people often have significant problems with blood
fats (e.g., cholesterol and triglyceride levels), which partially
explains the increased risk of coronary artery disease and the

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likelihood of heart attacks. People who weigh 40 percent or more


than ideal body weight are at increased risk for cancers of the:
• Colon.
• Prostate.
• Breast.
• Gallbladder.
• Kidney.
• Stomach.
• Uterus.
• Ovary.
One large study showed that women who gained more than
40 pounds after age 18 were 3 times more likely to have heart
attacks than women who gained less than 12 pounds. Obesity is
thought to be responsible for about one-third of all cases of high
blood pressure.
High blood pressure in overweight people is also associated
with an increased incidence of stroke and risks of developing:
• Diabetes.
• Gallbladder disease.
• Gout.
Obesity can be associated with stresses on certain weight-
bearing joints, resulting in arthritis and varying degrees of disability.
Obesity, without other risk factors, may increase the likelihood of
heart attack, especially for apple-shaped people.
In addition to known risk factors for cardiovascular disease,
being of the male gender is associated with cardiovascular
disease. In this regard, obesity in males is more of the apple-
shape variety.
Overweight people also have more complications after surgery;
wounds heal more slowly and infections are more common.
Additionally, obesity is associated with:
• Anxiety.
• Stress.
• Depression.
• Sleep disturbances (sleep apnea).
• Other consequences that affect quality and length of life.

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For improvement in quality and length of life, overweight and


obese people should strive to achieve weights that are close to
ideal for their age, sex, height, and body builds. A large study of
nurses has put to rest concerns about adverse effects of thinness.
That study showed that increased death rates thought to be
present in very thin people were partly due to cigarette smoking or
weight loss associated with cancers or other serious conditions.
It may be impossible for some people to reach desired
weights, but even modest weight reduction has been associated
with increased longevity and improved diabetes and high blood
pressure control. It has been suggested that the initial goal of
weight loss therapy should be to reduce body weight by about 10
percent from the initial weight. The need or desirability of further
weight loss can then be considered. To achieve this weight loss
you should plan a diet with about 500 to 1000 calories a day
less than you usually eat. Some of the calorie loss, as much as
20 percent, could come from a modest, daily exercise program.
Weight reduction can be achieved with the help of physicians or by
a team approach of a physician, dietitian, and counselor.
The National Weight Control Registry that surveys people who
have lost weight and kept it off states that most of these people
did it on their own without going to the commercial weight loss
programs. Registry participants cut their food intake and increased
their physical activity – 90 percent exercised, on average, about 1
hour per day, 62 percent claimed to watch less than 10 hours of
television each week.
Dieting alone can help weight loss, but exercise provides
additional benefits. Regular physical activity is especially important
for weight maintenance. Exercise alone, however, is a difficult way
to actually lose pounds. It takes a lot of exercise to lose 1 pound.
Exercise is helpful in preventing one from regaining lost weight.
Physicians or psychiatrists/psychologists can assist with behavior
modification programs.
Also, certain drugs can help in special situations. Physician-
prescribed appetite suppressants, phentermine and sibutramine,
always combined with prudent diets, can provide better weight loss
results compared with diet therapy alone. Sibutramine (Meridia)
affects the brain chemicals that help control appetite, but can
raise blood pressure levels in some people. However, some diet

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medications have significant side effects, including an extremely


rare form of irreversible high blood pressure in the pulmonary
blood vessels. Appetite suppressants have also been associated
with heart attacks, even in young patients with normal coronary
arteries. These medicines can be useful for significantly obese
people whose serious health problems from their obesity outweigh
the risk of taking them. Patients must be closely monitored. A
newer anti-obesity drug – rimonabat has been found to have major
problems associated with its use, and cannot be recommended.
Another anti-obesity drug, orlistat (Xenical) or its half-strength,
over-the-counter version, Alli, acts by inhibiting absorption from the
gut of about 30 percent of the fat that we ingest. Studies suggest
that Xenical causes modest weight loss and certain health benefits
related to that loss. An advantage of this agent over others is the
fact that less than 1 percent of the drug passes from the bowel
into the blood, making it less likely to cause side effects in other
organs of the body. Problems related to Xenical have been largely
centered in the gastrointestinal tract, and due to increased fat in the
stool. The drug’s mechanism of action can affect blood levels of fat-
soluble vitamins such as A and E; thus, vitamin supplements are
needed with this therapy. Long-term adverse effects of prolonged
use are as yet unknown.
Pregnant women and people ages 65 and older should not
initiate diets without consulting their physicians. For the severely
obese patient (weight is 100 percent or 100 lbs. above ideal) who
is at high risk for adverse health problems related to their obesity,
surgery appears to be a reasonable option. Various surgical
procedures, performed by skilled surgeons at specialized referral
centers, offer the best long-term hope for these people. Patients
undergoing such procedures must be followed for extended
periods postoperatively to avoid potential complications. For certain
people, weight-loss surgery results in impressive improvement in
weight and health. Over a 1 to 2 year period after such surgery, an
individual can lose 50 to 60 percent of their excess weight.
Liposuction cannot be recommended for such patients because
the fatty tissue removed has been known to reaccumulate in the
same site or at times at other sites.
The American public is deluged with dietary advice in the
form of books, tapes and videos. In many cases, the advice is

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wrong, unsound, unhealthy, and dangerous. Though it would be


impossible to comment on all the dietary plans, one would do
best by avoiding presently popular plans suggested in: Dr. Atkins’
New Diet Revolution, The Five Day Miracle Diet, The Beverly Hills
Diet, Sugar Busters!, Enter the Zone, Protein Power. In reality,
any diet that helps you eat less (fewer calories) will allow you to
lose weight, as long as you follow it. Before embarking on any
new diet program, patients should check with their physicians or
with registered dietitians for advice. Another option is to seek help
from weight-loss organizations such as Weight Watchers, Jenny
Craig, and other organizations that have joined the Federal Trade
Commission’s Partnership for Healthy Weight Management.
The use of alternative medicine approaches to weight loss
have become popular in recent years. Such products as chromium
picolinate, ma huang, hydroxycitric acid found in plants, Garcinia
cambogia and Garcinia indica, to name but a few, have not been
proven effective and at times, some of these products have been
proven toxic. They are best avoided.
Recommendations
1. Try to achieve a weight close to ideal for your age, sex, build,
height, and musculature.
2. Dieting, as suggested by your physician, and exercise should
be the basis of any weight-loss program. This will work even if
you have inherited a tendency toward obesity.
3. If you are unable to achieve ideal weight, lose as much weight
as you can.
4. Avoid fad diets and medications or programs not approved by
your physician.
5. Before initiating any weight loss program, determine if you
have a medical condition (e.g., hypothyroidism, adrenal
hormone excess, Cushing’s syndrome, or kidney, heart, or liver
disease) that causes weight gain or if you take medications
that contribute to weight gain (e.g., cortisone preparations).
6. Try to associate with leaner people.
7. Avoid all dietary supplements or herbs that claim to promote
long-term weight loss.

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Further Reading
National Institutes of Health
National Institute of Diabetes and Digestive and Kidney Disease
Obesity
Health.nih.gov
Centers for Disease Control and Prevention (CDC)
Obesity and Overweight
Flum D, Khan T, Dellinger E. Toward the rational and equitable use
of bariatric surgery. Journal of the American Medical Association.
September 26, 2007:1442-1444.

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Alcohol
Eat not to dullness. Drink not to elevation.
-Benjamin Franklin
Facts
1. About 30 percent of U.S. adults drink too much and have
problems related to drinking alcohol.
2. Excessive alcohol use is the third leading lifestyle-related
cause of death in the U.S.
3. Alcohol-related deaths account for 2.7 million patient years of
potential life lost annually in the U.S.; 65 percent of that loss is
due to alcohol-related injuries.
4. People dying from alcohol related causes lose an average of
26 years of normal life expectancy.
5. About one-third of drivers killed in vehicle crashes are
intoxicated by alcohol.
6. The risk of dying in a traffic accident is 8 times greater for
heavy drinkers than for nondrinkers.
7. The risk of fatal single-vehicle crashes in drivers with blood
alcohol concentrations of 0.09 percent is 11 times greater
than for nondrinkers. At blood alcohol concentrations of 0.15
percent or greater, the risk is 380 times greater.
8. Of suicide victims, 50 percent are intoxicated with alcohol or
other drugs.
9. It appears that, in women, 2 to 3 drinks per day is associated
with a 30 percent increase in breast cancer incidence or
deaths; higher levels of alcohol consumption are associated
with a 70 percent increase.
10. Alcohol can cause high blood pressure.

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Alcohol is believed to be the most frequently abused drug


throughout the world. It is associated with shortening life as a
prominent contributor to:
• Death and bodily damage from automobile accidents.
• Suicides.
• Other violent deaths.
In the U.S. over 75,000 deaths each year are due to alcohol.
About 5 percent of our population drinks heavily while 15 percent
binge drink (drinking more than 4 drinks on a single occasion).
Additionally, liver cirrhosis, often a complication of alcoholism, is
a relatively common cause of death among people ages 25 to
46. The presence of cirrhosis caused by alcohol considerably
shortens the expected lifespan. Significant alcohol ingestion over
many years can result in severe heart problems and heart failure,
and short-term heavy ingestion, such as in binge drinking, can
lead to heart rhythm disturbances and even death.
Alcohol abuse also has been linked with cancers of the
gastrointestinal and respiratory tracts and even the breast. Women
who drink similar amounts as men appear to be more at risk for
complications because they:
• Appear to metabolize alcohol differently from men.
• Have a lower volume of body water.
• Reach a higher blood alcohol concentration in a shorter period
of time with the same intake.
Moderate drinking is defined as 2 drinks per day for men and 1
per day for women (a drink equals 12 oz. of regular beer, 5 oz. wine,
or 1½ oz. of distilled spirits at 80 percent proof). One study found
that ingestion of more than 2 drinks per day and progressively
greater levels of consumption were associated with higher all-
cause mortality.
It has become apparent that moderate to heavy drinkers (such
as those who drink 3 or more alcoholic beverages per day) have an
increased risk of liver damage and stomach bleeding when taking
aspirin, other salicylates, acetaminophen, ibuprofen, naproxen, or
ketoprofen. These are non-steroidal anti-inflammatory medicines
(NSAIDS) recognized as over-the-counter pain relievers and fever
reducers.

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Excessive alcohol use has immediate effects that increase the


risk of many harmful health conditions:
1. Unintentional injuries, including traffic injuries, falls, drowning,
burns and firearm injuries.
2. Violence, including intimate partner violence and child
maltreatment.
3. Risky sexual behaviors.
4. If pregnant, miscarriage, stillbirth, and a combination of
physical and mental birth defects.
5. Alcohol poisoning that can result in death.
Alcohol is also a problem for the elderly. Up to 10 percent of
older adults living at home may have problems with alcohol. An
even greater problem is seen in nursing homes.
Because their body fluids are decreased, the elderly have
resulting higher rates of blood alcohol levels and complications
than younger people who drink the same amount of alcohol.
Alcohol excess in the elderly can lead to various other problems,
such as:
• Blood pressure elevation.
• Depression.
• Frequent falls.
• Nutritional, vitamin, and mineral deficiencies.
• Degenerative brain disorders.
• Dementia.
• Damage to the pancreas.
Because older adults often live alone, their drinking problems
may not be recognized until major problems develop, and their
death rate is high. Professional help is important in this group,
whose responses to treatment are as good as those of younger
drinkers.
Those who drink alcoholic beverages must determine their
limitations of alcohol intake and maintain control of intake. Help in
determining personal alcohol dependence can be obtained from
answers to the CAGE questionnaire:

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C - Have you considered Cutting down on your drinking?


A - Have you ever become Angry or Annoyed about questions
concerning your drinking?
G - Have you ever felt Guilty about your drinking practices?
E - Do you ever begin your day with an Eye opener?
A result of 2 or more “yes” answers to the questionnaire suggests
the likelihood of alcohol dependence; a result of “yes” answers to
all 4 strongly points to it. The recognition of alcohol dependence
should be followed by treatment programs organized by personal
physicians or special teams with recognized expertise.
People with family histories of alcoholism are at risk of becoming
alcoholics themselves. In fact, drinkers with alcoholic parents are 4
times more likely to have problems with alcohol consumption than
drinkers who have no family histories of alcohol problems. Genes
have a lot to do with our risks of becoming alcohol dependent, but
are not exclusive predictors of such risk. Environmental factors
such as adverse life events or work-related stresses are also
important.
The earlier that alcohol dependence is detected and treated,
the more likely it can be successfully treated and complications
involving the liver, heart, and neurological disorders can be
avoided. As many as 50 percent of alcohol-dependent people do
not recognize their disorder.
At present, there is no universally effective approach to the
treatment of alcohol dependence. A variety of psychological,
social, and medical interventions have proven effective to one
degree or another. In combination with these interventions, certain
drug therapies can improve outcomes. The U.S. Food and Drug
Administration has approved 3 medications for the treatment of
alcohol dependence. An older drug, disulfiram (Antabuse) deters
alcohol ingestion by triggering adverse reactions such as nausea,
vomiting, diarrhea and flushing in those who continue to drink.
Though potentially effective, this drug has been associated with
significant problems and is not frequently used at this time. It
does appear to benefit those patients who are highly compliant or
receive their medications under supervision.

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Naltrexone (ReVia) has been effective in reducing alcohol


consumption and increasing abstinence by lessening the
pleasurable effects of alcohol and reducing cravings for it. This
effect occurs in alcoholic patients as well as in social drinkers.
It is especially useful when combined with other therapeutic
interventions. Naltrexone has an advantage in that it can be given
in a daily oral form or a monthly injectable formulation. It especially
benefits patients with a family history of alcohol problems and also
patients with strong alcohol cravings.
Acamprosate (Campral) appears to reduce cravings for alcohol
by an effect on neurotransmitters in the brain. It also reduces
some of the problems caused by alcohol withdrawal. It has been
approved to treat alcohol dependence in people who have quit
drinking, and is effective.
Another drug that appears promising, though not yet approved
for alcoholism therapy, is topiramate, a drug already used for
seizure disorders and migraine headache prevention.
Another facet of alcohol ingestion must also be considered
in view of recent findings. It appears that moderate consumption
of alcohol (no more than 2 standard drinks daily for men and 1
for women) may be a reasonably good thing. Studies suggest
that this consumption exerts a protective effect against coronary
artery disease. Consuming 1 or 2 alcoholic drinks daily results in
a 30 to 60 percent reduction in the risk of developing coronary
artery disease and even appears to improve the chances of an
individual’s survival should they develop a heart attack. In spite of
this suggested benefit, we do not recommend that individuals who
do not drink begin drinking to gain this potential benefit.
The mechanism for this beneficial effect could be its ability to
elevate HDL cholesterol. Much has been written about the type
of alcohol that is most beneficial. In several regions of France,
people eat diets rich in saturated fats and cholesterol but have
low incidence of coronary artery disease, a situation termed the
French Paradox.
Some researchers suggest that it is red wine, popular in
France, that provides protection because it, unlike white wine,
incorporates the skins of red grapes (which contain large amounts
of phenolic compounds that behave like antioxidants) into the

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production process. Antioxidants, along with other substances in


red wine that prevent blood clotting, may explain the reduction of
coronary risk.
Other researchers feel that the ethanol itself causes the
beneficial effect, which then could explain similar benefits from
drinking red or white wine, beer, or other spirits. Many believe that
other factors common to the French should also be considered,
such as the increased amounts of fruits and vegetables (containing
antioxidants) they consume. Moreover, the French drink alcohol in
moderation and with meals. Also, the French dine differently than
Americans, eating more heavily at midday than in the evening.
Other elements of the French or Mediterranean diet such as
eating olive oil may also be important. Still other explanations
for the French Paradox have been suggested. The French may
not classify all the same entities recognized by the Americans
and British as causes of death from coronary artery disease.
Additionally, it has been suggested that the French have not had
a long enough exposure to the high animal fat diets they presently
consume so as to allow them to show the consequences of
these diets, as are seen in other Western countries. It must be
remembered, however, that the French, who boast the largest
consumption of wine in the world, have much higher rates than
other groups with lesser alcohol intakes of:
• Cirrhosis.
• Upper gastrointestinal malignancies.
• Accidents.
• Suicides.
• Violent deaths.
Alcohol in moderation (1 to 2 drinks daily) appears to lower risks
for ischemic stroke, the most common type, which usually results
from the development of a blood clot in an atherosclerotic blood
vessel that supplies a portion of the brain. All forms of alcoholic
beverages are beneficial in the modest consumption suggested,
but larger amounts (7 or more drinks daily) significantly increase
the risks of this stroke type. Though the exact mechanism for this
protective effect with alcohol is not known, several factors, no doubt,
contribute. Such factors include alcohol’s ability to increase HDL
cholesterol levels and to interfere with clot formation in cerebral
and coronary arteries.

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Recommendations
1. If you don’t drink alcohol, don’t start.
2. If you wish to drink, some cardiac benefits may be derived
from light to moderate drinking:
• No more than 2 drinks daily for men.
• No more than 1 drink daily for women.
• No more than 1 drink daily for those ages 65 and older.
3. Discuss openly your alcohol intake with your physician.
4. People with concerns about breast or gastrointestinal cancers
or strong family histories of alcoholism should discuss these
situations with their physicians.
5. Some people should consider avoiding alcohol altogether,
including:
• Women who are pregnant or are trying to conceive.
• People who plan to drive or perform other activities that
require unimpaired attention or muscular coordination.
• People taking antihistamines, sedatives, or other
medications that can magnify alcohol's effects.
• Recovering alcoholics.
• Persons being treated for anxiety or depression, since
alcohol is thought to affect their clinical course and
response to treatment adversely.
Further Reading
National Institutes of Health (NIH)
National Institute on Alcohol Abuse and Alcoholism
Health.nih.gov
Centers for Disease Control and Prevention (CDC)
Alcohol & Public Health
Kuehn B. New therapies for alcohol dependence open options
for office-based treatment. Journal of the American Medical
Association. December 5, 2007:2467-2468.

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Stress and Depression


A vigorous 5-mile walk will do more good for an unhappy but
otherwise healthy adult than all the medicine and psychology
in the world.
-Paul Dudley White
Facts
1. Primary care physicians treat depression and anxiety more
than they treat heart disease, hypertension, or diabetes.
2. Up to 50 percent of patients with unexplained chest pains are
really suffering from anxiety.
3. One-third of coronary artery patients have disease-related
depression or anxiety.
4. About 16 percent of all suicides are committed by individuals
ages 65 and older.
5. Depressed persons have suicide rates at least 8 times higher
than those of the general population.
6. Psychosocial stress interventions (group psychotherapy,
counseling, relaxation training, and stress-reduction programs)
reduce recurrent cardiac events (death and heart attacks) by
35 to 75 percent.
7. Pet owners have fewer risk factors for heart disease than
people without such companions.
8. Depressed people have increased deaths from coronary artery
disease and cancer.
9. Depression is common in smokers and those who are alcohol-
dependent.
10. Up to two-thirds of persons with depression go undetected
and untreated.
11. Depressive disorders occur in an estimated 6 percent of the
general population but may be found in as many as 50 percent
of those with medical illnesses.
12. Between 10 percent and 15 percent of older people have
depressive symptoms.

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13. Depressive disorders are the fourth most important cause of


disability worldwide.

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At many points in life, people face various stresses of varying


degrees. Such stresses can aggravate existing medical problems
and possibly trigger new conditions. Various stressors have at
times been associated with increased risks for heart attacks or
strokes. These include:
• Anger.
• Death of someone close.
• Involvement in a war.
• Being present during an earthquake or like catastrophe.
Other stresses, especially when problems are ongoing, may
lead to various problems, from high blood pressure to cancer to
sudden death; such stresses include:
• Major financial problems.
• Significant family problems.
• Loss of loved ones.
• Unresolved grief.
• Occupational stress.
• Divorce.
• Having certain diseases or physical problems.
These responses to stresses and/or their complications can
be associated with shortened life-spans. Stressful life events
themselves can significantly increase the risk of death; these
include:
• Divorce or separation.
• Financial difficulty.
• Being sued.
• Insecure feelings at work.
One interesting study showed that the risk of heart attack
increases 14 times in the first 24 hours after the death of a loved
one. By the end of the second day, the risk was still 8 times higher
than normal.
People who have family histories of depression or live
particularly stressful lives are also prone to depression, especially
if they:
• Have sudden, major life changes.
• Are unmarried or widowed.

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• Lack supportive social networks.


• Have certain physical conditions such as:
• Cancer.
• Stroke.
• Heart disease.
• Dementia.
• Any chronic illness.
• Parkinson’s Disease.
Studies show that depression may run in families and children
of depressed parents may be at a higher risk for depression.
One study has shown that death occurs several times more
frequently in heart attack patients who also meet criteria for
major depression in the 6 months after the event than those
without depression. It also appears that the recent development
of depression (not chronic depression) in older men is a risk factor
for heart attacks.
Depression is also associated with biochemical disruptions
in the brain, which fortunately respond to drug treatment. Drug
treatment can also be effective in treating depression that results
from stressful events.
Depression is common in American society, with about
15 percent of the population suffering from a major depressive
disorder at some time in their lives. Unfortunately, this disorder
is diagnosed and treated in fewer than one-third of these people.
Among the elderly, major or minor depression is seen in about 5
percent of patients in primary care clinics and up to 25 percent
of patients in nursing homes. Sadly, most elderly with depression
fail to seek help. Moreover, depression can mimic dementia in the
elderly.
Depressed people often have repeated visits to their physicians
with complaints of:
• Vague pain.
• Low energy.
• Fatigue.
• Insomnia.

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• Digestive problems.
• Sexual difficulties.
Physicians often fail to recognize symptoms of depression,
which include:
• Persistent feelings of:
• Sadness.
• Hopelessness.
• Pessimism.
• Anxiety.
• Loss of interest or pleasure in ordinary activities, including
sex.
• Irritability.
• Restlessness.
• Decreased energy.
• Fatigue.
• Feeling slowed down.
• Loss of appetite.
• Weight loss.
• Unintentional weight gain.
• Sleeping too little or too much.
• Difficulty with:
• Concentration.
• Remembering.
• Making decisions.
• Feelings of:
• Guilt.
• Worthlessness.
• Helplessness.
• Thoughts of death or suicide.
• Suicide attempts.
• Not caring whether one lives or dies from medical illness.
• Excessive crying.
• Recurrent aches and pains that do not respond to treatment.
• Personality change.
• Substance abuse.
Of concern for all patients with depression is the possibility of

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suicide. Depression appears to be associated with about one-half


of all suicides and is one of the strongest factors for attempted and
completed suicides.
Suicide is a special problem in depressed older adults. About
25 percent of all suicides are committed by people ages 60 and
older.
Depression is often a recurrent illness but can be treated
effectively if it is recognized. Certain illicit drugs, alcohol, and
prescription and non-prescription medicines can cause or
complicate depression. Depression may also be a side effect of
various medications or may be associated with numerous medical
illnesses. Depression can also be related to seasonal decreases
in the length of daylight, noted at both the northern and southern
latitudes.
It has become clear that isolation from others is bad. Though
data on the value of human connections are difficult to obtain,
it appears that people with adequate social networks suffer less
depression and live longer than those without such support
systems. Valuable support system assets that allow and help
people cope with stresses and complexities of life include:
• Friends.
• Companions.
• Acquaintances.
• Comrades.
• Spouses.
• Associates.
• Lovers.
• Families.
• Pets.
Of untold value is belonging to such groups as:
• Religious communities.
• Social networks.
• Families.
• Communities.
• Sports teams.

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Fortunately, medications are available that are safe and


effective for the treatment of depression. Drugs, in fact, are the
first-line treatment for depression.
A variety of effective antidepressants are available; these
include:
• Selective serotonin reuptake inhibitors (SSRI’s).
• Tricyclics.
• Tetracyclics.
• Lithium.
Drugs from these groups, when combined with psychotherapy
may be even more effective. These drugs can be effective within
weeks, allowing the depressed individual to return to normal daily
activities rather quickly. Continued therapy is effective in preventing
recurrent bouts of depression.
Electroconvulsive therapy is occasionally used and is effective
for cases of severe depression. It is suggested that 80 percent of
people with serious depression will improve with medications and/
or psychological counseling. Researchers are studying transcranial
magnetic stimulation (TMS) as a possible therapy for major
depression. This technique uses short magnetic pulses (roughly
the strength of an MRI scanner’s magnetic field) to stimulate the
cerebral cortex of the brain.
Recommendations
1. Do not be afraid to ask for help.
2. If you can eliminate, reduce, or modify stresses in your life, do
so. Discussion of your stresses with physicians, psychiatrists/
psychologists, or friends may help.
3. A routine exercise program often proves valuable for a variety
of mental and emotional problems.
4. Maintain regular hours of adequate sleep (6 to 8 hours daily).
5. If you have symptoms of depression, seek your physician’s
help to sort out possible causes such as drugs or illnesses and
start you on a treatment program.

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6. Although thoughts of suicide are common in depression, such


thoughts should encourage prompt consultation with your
physician.
7. Develop and foster support groups in your life.
8. Do not drink alcohol if you are depressed or anxious or caffeine
beverages if you are anxious; such drinks may increase
symptoms.

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Immunizations
The value of life lies not in the length of days, but in the use
we make of them. A man may live long yet live very little.
-Montaigne
Facts
1. Every year, more than 50,000 Americans, almost all of whom
are adults, die from a vaccine preventable disease. Many times
that number require hospitalization.
2. Among older adults, only 52 percent receive influenza vaccines
and 28 percent receive pneumococcal vaccines. These
vaccines are free to Medicare and Medicaid beneficiaries.
3. Vaccines in adults can prevent up to 80 percent of deaths due
to influenza, 60 percent of cases of invasive pneumococcal
disease and 90 percent of hepatitis cases.
4. More people die from pneumococcal infections (40,000
annually) than any other vaccine preventable disease.
5. Influenza is one of the leading causes of death in people over
age 65, and the most common infectious cause of death in the
U.S.
6. Less than one-third of the high risk persons for whom influenza
immunization is recommended have received the vaccine.
7. An estimated 40,000 lives would be saved each year in the U.S.
if vaccines against influenza, pneumococcus and hepatitis B
virus were beneficially employed.

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Immunizations can reduce the incidence of major causes


of disease, disability, and death in adults, especially in older
populations. Routine vaccination programs can save lives with
minimal effort expended.
Influenza Vaccine
Most deaths from influenza virus infections occur in the elderly,
but rates of infection are highest among children. In the U.S.,
about 36,000 deaths and more than 225,000 hospitalizations are
recorded each year. Vaccination from influenza results in:
• Less severe illness.
• Lower fever.
• Lower medical expenses.
• Considerably lowered deaths.
Hepatitis A Vaccine
Epidemics of hepatitis A are usually caused by fecally
contaminated water or food; this is responsible for about one-half
of cases in the U.S, at least 27,000 cases each year.
A small risk of death is associated with hepatitis A, but deaths
increase with increasing age. Certain people are at higher risk for
hepatitis A, including:
• Institutionalized persons and workers at such institutions.
• Travelers to countries where hepatitis A is common.
• Men who have sex with men.
• Users of injection or street drugs.
• Those in close contact with hepatitis A persons.
The effectiveness of the hepatitis A vaccine appears to be
quite good. It is given in a 2 dose schedule, 6 or more months
apart. A combined hepatitis A and hepatitis B vaccine, given in 3
doses, also can be used.
Varicella
Chicken pox tends to be more severe in adults and patients
with immune deficiencies, causing increased complications, such
as encephalitis, in those groups. About 5 percent of adults in the
U.S. are susceptible to varicella. Vaccination is effective, protecting
95 percent of recipients from getting a serious form of disease.

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Shingles Vaccine
The shingles vaccine, Zostavax, has been approved for people
60 years old and older. It has been shown capable of reducing the
risk of shingles by about 50 percent and postherpetic neuralgia by
about 67 percent. Postherpetic neuralgia can be a painful problem
and occurs in one-third of untreated cases in people over 60.
The vaccine is expensive and it may not be needed if you had a
documented case of shingles in the past.
problem and occurs in one-third of untreated cases in people over 60. The vaccine is
Recommendations
expensive and it may not be needed if you had a documented case of shingles in the
past.problem and occurs in one-third of untreated cases in people over 60. The vaccine is
1. Obtain
expensive andthe necessary
it may immunizations
not be needed at thecase
if you had a documented appropriate ages,
of shingles in the
and
past. keep
Recommendations immunizations current.

1. 2. Travelers to third world at countries should


ages,consider
and keep having
Recommendations
Obtain the necessary immunizations the appropriate
hepatitis
immunizations vaccines
current. as well as other vaccines suggested
1. Obtain the necessary immunizations at the appropriate ages, and keep by the
location. current.
immunizations
2. Travelers to third world countries should consider having hepatitis vaccines as well
as2.other
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and suggested
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aged location.
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9-26 consider
years or having hepatitis
older, vaccines asactive,
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as other vaccines suggested by the location.
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and women receive Gardasil
aged 9-26 years ortoolder,
protect against
if sexually active,cervical cancers,
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3. Girls
Gardasil and womenagainst
precancerous
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genital years
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sexually active,
genital should receive
warts.
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genital warts.to protect against cervical cancers, precancerous genital lesions, and
genital warts.
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December2478
5,5, andpages
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2007, 2479.
pages 2478
2478 and and
24792479

Recommended
Recommended adultimmunization
adult immunization schedule,
schedule,bybyvaccine
vaccineand ageage
and group
group
(United
(United States,October
States, October 2007
2007––September
September 2008)
2008)
Age group (yrs)
Vaccine
Age group (yrs)
19-49 50-64 > 65
Vaccine
Tetanus, diphtheria, 19-49 1 dose Td booster50-64
every 10 years > 65
Tetanus, diphtheria,
pertussis (Td/Tdap)* 1 dose
Substitute 1 doseTd
of booster
Tdap for every
Td 10 years
pertussis
Human(Td/Tdap)*
papillomavirus 3 doses Substitute 1 dose of Tdap for Td
Human(HPV)*
papillomavirus 3 (females)
doses
(0, 2, 6
(females)
(HPV)* mos)
(0, 2, 6
Measles mumps, rubella mos) 1 or 2 doses 1 dose
(MMR)*
Measles mumps, rubella
Varicella* 1 or 2 doses 2 doses (0, 4-8 wks) 1 dose
(MMR)*
Influenza* 1 dose annually 1 dose annually
Varicella*
Pneumococcal 2 doses (0, 4-8 wks)
Influenza* 1 dose annually 1-2 doses 1 dose
1 dose annually
(polysaccharide)
Pneumococcal
Hepatitis A* 2 doses (0, 6-12 mos, or 0, 6-18 mos
1-2 doses 1 dose
(polysaccharide)
Hepatitis B* 3 doses (0, 1-2, 4-6 mos)
Meningococcal
Hepatitis A* * 2 doses (0, 1 or more
6-12 doses
mos, or 0, 6-18 mos
Zoster
Hepatitis B* 3 doses (0, 1-2, 4-6 mos) 1 dose
* Covered by*the Vaccine Injury Compensation Program
Meningococcal 1 or more doses
For all persons in this category who meet the age requirements and who lack evidence of immunity (e.g., lack
Zoster 1 dose
documentation of vaccination or have no evidence of prior infection)
* Covered by the Vaccine Injury Compensation Program
Recommended if some other risk factor is present (e.g., on the basis of medical occupational, lifestyle, or other
For allindications)
persons in this category who meet the age requirements and who lack evidence of immunity (e.g., lack
documentation of vaccination or have no evidence of prior infection)
Recommended if some other risk factor is present (e.g., on the basis of medical occupational, lifestyle, or other
indications)
134
114
Living Healthier and Longer –  What Works, What Doesn’t

Vaccines that might be indicated for adults based on medical and other
indications (United
Vaccines that might beStates,
indicated October 2007
for adults based on – September
medical and other 2008
indications (United States, October 2007 – September 2008

Indication
Immuno- Diabetes, Asplenia
HIV Infection
compromising heart (including
conditions disease, elective Kidney
(excluding human CD4+ chronic splenectomy failure, end-
immunodeficiency T lymphocyte count pulmonary and terminal stage renal
virus [HIV]), disease, complement Chronic disease, Health-
medications, < 200 > 200 chronic component liver receipt of care
Vaccine Pregnancy radiation cells/ǐL cells/ǐL alcoholism deficiencies) disease hemodialysis personnel
Tetanus,
1 dose Td booster every 10 years
diphtheria,
pertussis
Substitute 1 dose of Tdap for Td
(Td/Tdap)*
Human
papillomavirus 3 doses for females through age 26 yrs (0, 2, 6 mos)
(HPV)*
Measles mumps,
rubella (MMR)*
Contraindicated 1 or 2 doses
Varicella* Contraindicated 2 doses (0, 4-8 wks)
1 dose
TIV or
Influenza* 1 dose annually
lAIV
annually
Pneumococcal
(polysaccharide)
1-2 doses
Hepatitis A* 2 doses (0, 6-12 mos, or 0, 6-18 mos
Hepatitis B* 3 doses (0, 1-2, 4-6 mos.)
Meningococcal * 1 or more doses
Zoster Contraindicated 1 dose
* Covered by the Vaccine Injury Compensation Program
For all persons in this category who meet the age requirements and who lack evidence of immunity (e.g., lack documentation of
vaccination or have no evidence of prior infection)
Recommended if some other risk factor is present (e.g., on the basis of medical occupational, lifestyle, or other indications)

Further Reading
Further Reading

Campos-Outcalt D, Temte JL. ACIP Releases 2007-2008 Adult Immunization Schedule.


Campos-Outcalt D, Temte
American Family Physician, NovemberJL. Acip
������������������������������
15, 2007, releases
pages 1558-1567. 2007-2008 adult
immunization PreventiveAmerican
schedule.
The Guide to Clinical Services, 2006. Family Physician. November
15, 2007:1558-1567.
Centers for Disease Control and Prevention (CDC).
Vaccines and Immunizations.
The Guide to Clinical Preventive Services, 2006.
Adult Immunization. Journal of the American Medical Association, December 5, 2007,
pages 2478-2479.
Centers for Disease Control and Prevention (CDC).
Vaccines and Immunizations.
115
Adult Immunization. Journal of the American Medical Association.
December 5, 2007:2478-2479.

135
Living Healthier and Longer –  What Works, What Doesn’t

Diet
One should eat to live, not live to eat.
-Moliére
Facts
1. According to research, it is important that less than 30 percent
of the total calories you eat and drink come from fat. Only 20
percent of the people in the US do this.
2. Making sure that less than 30 percent of your total calories
come from fat will lower the chance of dying from coronary
artery disease.
3. The average American’s diet is 36 percent fat.
4. Up to 50 percent of the people living in nursing homes in the
U.S. may be not be getting all the nutrition they need.
5. A large British study showed that eating fresh fruit was
important. Eating fresh fruit every day led to fewer deaths from
coronary artery disease and stroke.
6. Trans-fatty acids may be more harmful that saturated fats.
Trans-fatty acids come from a process that adds hydrogen
atoms to unsaturated fats. This makes the fats more saturated
and thus more solid.
7. Trans-fatty acids act like saturated fats. Both increase level of
bad cholesterol and reduce the level of good cholesterol in
your blood.
8. A typical 12 oz. can of soda has up to 10 spoons of sugar.

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Living Healthier and Longer –  What Works, What Doesn’t

What we eat, how much we eat, and what we do not eat is


important for the quality and length of our lives. It is important that
we set up healthy dietary patterns as early in life as possible. Once
set up, it important they we keep these patterns throughout life.
What is eaten influences the development of such problems
as:
• High blood pressure.
• Coronary artery disease.
• Stroke.
• Several cancers.
• Type 2 diabetes.
• Gallbladder disease.
The word diet scares many people. There are many diets out
there, each claiming to be the right one for you. Can they all be
so different and still work to keep you healthy? Even among the
legitimate diets, there is controversy and confusion. Nutrition and
dietary experts often cannot agree.
So, let’s see if we can make it simple. But, first we need to know
some of the vocabulary. We all know that foods have calories. A
calorie is a measure of energy. When foods are broken down in the
body, energy is released, allowing the body to perform its functions.
A specific amount of calories that we get from food is needed to
allow the body to function. Extra calories can be stored as fat or
carbohydrates, resulting in weight gain. If not enough calories are
available in the food for the body’s needs, the body will use what
was previously stored. If this happens a lot, the person will lose
weight.
Now, if you eat 3,500 calories more than the body needs, you
will gain a pound. On the other hand, if you are very active and
burn 3,500 calories more than you eat, you will lose 1 pound.
The basic calorie requirement, just to maintain existence, for the
human body is 12-14 calories per pound of body weight per day
for a male. Women need less. They need about 10-12 calories
per pound. Thus, a 150 pound male would require 1800 calories
per day to maintain existence. It used to be thought that a 150
pound man burning 100 calories/mile would need to run or walk
35 miles to lose 1 pound. However, recent information suggest
otherwise. Ralph La Forge at Duke University pointed out that our

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Living Healthier and Longer –  What Works, What Doesn’t

body uses calories even when sitting still. He argues that running
and walking burn different calories because the body has to work
harder to run. Thus, the 150 pound man would use 54 calories per
mile when walking up to 3.5 miles per hour. If the same man was
speed walking, he would burn 97 calories at 3.5 to 5 miles per
hour. Finally, the man would burn 107 calories jogging or running.
Running burns about twice the calories as a moderate walk over
the same distance.
Food manufacturers help us by providing labels on their
products. Figure 1 is a typical label one might see on a container
of food. These labels can tell us a lot of information. Nutrition labels
tell us:
• how many calories are in 100 grams of this food.
Food manufacturers help us by providing labels on their products. Figure 1 is a
• label
typical theone
energy
might content of the food.
see on a container of food. These labels can tell us a lot of
• The
information. amount
Nutrition of protein,
labels tell us: carbohydrate, fat and fiber of a standard
• how many calories are in a 100 grams of this food.
serving.
• the energy content of the food.
Many ofpublications
• The amount are alsofatavailable
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Manyabout a type
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government.

Nutrition Facts
Serving Size 2 crackers (14 g)
Servings Per Container About 21
Amount Per Serving
Calories 60 Calories from Fat 15
% Daily Value*
Total Fat 1.5g 2%
Saturated Fat 0g 0%
Trans Fat 0g
Cholesterol 0mg 0%
Sodium 70mg 3%
Total Carbohydrate 10g 3%
Dietary Fiber Less than 1g 3%
Sugars 0g
Protein 2g

Vitamin A 0% • Vitamin C 0%
Calcium 0% • Iron 2%
* Percent Daily Values are based on a 2,000
calorie diet. Your daily values may be higher
or lower depending on your calorie needs:
Calories: 2,000 2,500
Total Fat Less than 65g 80g
Sat Fat Less than 20g 25g
Cholesterol Less than 300mg 300mg
Sodium Less than 2400mg 2400mg
Total carbohydrate 300g 375g
Dietary Fiber 25g 30g

We can now begin to look at which food groups have been proven to be most
beneficial to our bodies. Remember we eat for a number of reasons. We eat to satisfy
138
our hunger, and nourish our bodies. We also eat just for the pleasure and joy of eating
or drinking something good. It is important that whenever we can, that we eat the foods
that are best for us.
Living Healthier and Longer –  What Works, What Doesn’t

We can now begin to look at which food groups have been


proven to be most beneficial to our bodies. Remember we eat for
a number of reasons. We eat to satisfy our hunger, and nourish
our bodies. We also eat just for the pleasure and joy of eating or
drinking something good. It is important that whenever we can,
that we eat the foods that are best for us.
Before talking about specific food items, we should have
some idea about portion or the size of a serving. Here are some
guidelines.
• 1 cup = size of a fist.
• ½ cup = size of palm of hand or 4 ounces.
• 3 ounces = size of a deck of cards.
• ¼ cup = size of a golf ball.
• 1 teaspoon = size of the tip of a thumb.
• 1 portion = 3 ounces.
• 1 gram = weight of a paperclip.
Now that we have an idea of portions, we can talk about how
to figure out how many calories we need in a day. The American
Cancer Society has a tool called a calorie counter. This counter
allows you to estimate the number of calories that you need each
day. The number of calories you need is based on how much you
currently weigh or how much you want to weigh, your activity level,
and your gender. You can find the calorie counter on the American
Cancer Society website.
Now that we know how to figure out the number of calories
that we need each day, we need to think about the best way to get
those calories. Not all calories are equal. Some are better used
by our bodies than others. Figuring out the best combination of
dietary ingredients that will benefit our bodies and still meet our
caloric need is important. Carbohydrates, proteins and fats make
up about 90 percent of the dry weight of the typical diet. These 3
also make up 100 percent of the energy needed. Carbohydrates
and proteins contain 4 calories per gram. Remember, 1 gram is
equal to the weight of a paperclip. Fats provide 9 calories per gram
and ethanol 7 calories per gram. When thinking about your whole
diet, the following is commonly considered the ideal combination:
• Fat 20 – 35 percent of daily calories
(saturated fat should be less than 10 percent).

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Living Healthier and Longer –  What Works, What Doesn’t

• Protein 10 – 35 percent of daily calories.


• Carbohydrates 45 – 65 percent of daily calories.
Fats
Great importance should be attached to the amounts and
types of fat in the diet. Dietary fats are classified as saturated
or unsaturated. Saturated fats are the most powerful dietary
contributors to high blood cholesterol levels. Saturated fats will
increase the level of LDL, the bad cholesterol. These fats present a
special problem because they interfere with removal of cholesterol
from the blood. As a result, the cholesterol stays in the blood and
builds. You do not need to actually eat or drink any saturated fats.
Your body is able to produce these on its own. Most of the saturated
fat in the American diet comes from cheeses and ground beef. The
saturated fat in butter, whole milk and some cheeses can increase
LDL cholesterol levels more than the saturated fat in beef.
Trans-fatty acids are formed when manufacturers’ process
foods, like margarine. They take their unsaturated fats and make
them more solid and shelf-stable. This process creates trans-fatty
acids. Foods with trans-fatty acids lead to higher levels of LDL
cholesterol and lower HDL cholesterol levels. These foods can also
increase triglyceride levels. As a result, food with trans-fatty acids
is more harmful than food that has saturated fats. Many fast foods
like doughnuts, French fries, store bought breads and cookies have
high levels of trans-fatty acids. However, it is not always required to
list the level of trans-fatty acids on food labels. Diets high in trans
fats, saturated fats and cholesterol increase the risk of coronary
heart disease and some cancers. Trans fats and saturated fats in
our diet increase the level of triglycerides in the blood.
Unsaturated fats are found primarily in plants. There are of 2
kinds of unsaturated fats: monounsaturated and polyunsaturated.
These fats can actually reduce the level of bad cholesterol, LDL,
when they are substituted for saturated fats in the diet.

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Examples of dietary fats are:


Saturated Monounsaturated Polyunsaturated
Butter Avocado Corn oil
Cheese Canola oil Cottonseed oil
Chocolate Cashews Margarine
Cocoa butter Olives Mayonnaise
Coconut Olive oil Pecans
Cream Peanuts Safflower oil
Egg yoke Peanut butter Soybean oil
Hydrogenated oil Macadamia nuts Sunflower seeds
Ice cream Hazelnuts Walnuts
Lard Pistachios Pine nuts
Meat Almonds
Poultry
It is better to eat monounsaturated fats than the polyunsaturated
fats. This is because it is harder to oxidize monounsaturated fats.
Oxidization is needed to make a fat form a plaque that builds on
the artery walls. However, too much of any kind of unsaturated fat
increases the risk for heart disease and cancer. In attempting to
lower the fat in one’s diet, do not replace the fat with carbohydrates.
Doing this can lower the levels of good cholesterol, HDL.
Some people may find it hard to follow diet programs. In such
cases, it may be better for physicians to provide basic eating
guidelines, which may include suggestions that patients:
• Maintain desirable or ideal weights for their height.
• Eat less fat. Especially avoid animal fat and cholesterol.
• Eat less meat.
Fiber
As the amount of fiber in a diet increases, the risk of heart
attack and stroke decreases. This is done in part by lowering insulin
levels. Fiber also helps protect against diabetes mellitus. Fiber
helps in achieving blood sugar control in diabetic patients. There is
some thought that fiber may be protective for some cancers. Fiber,
the indigestible component of plant foods, can be found in:
• Fruits and vegetables.
• Whole grains.
• Beans.

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Living Healthier and Longer –  What Works, What Doesn’t

• Nuts.
• Seeds.
• Breads.
• Pastas.
Whole grains are much more valuable than refined grains.
This is because whole grains have higher fiber contents and more
nutrients. Whole grains also have more valuable phytochemicals
with antioxidant capability.
There are 2 types of fiber, insoluble and soluble. Insoluble fiber
tends to increase how quickly food moves through our digestive
systems. Soluble fiber helps reduce your cholesterol levels. Your
body needs both. Sources of insoluble fiber include whole-grain
cereals, whole-wheat bread, and crackers. Soluble fiber is found in
legumes, fruits, oats, barley and some vegetables. High fiber foods
are also valuable because they tend to be filling. Studies suggest
that fiber may reduce calorie intake by blocking the digestion of
fats and proteins eaten with it.
Unfortunately, most people get only 15 grams of fiber in their
diet. The goal is to get 25 to 30 grams every day. A variety of foods
and supplements with high fiber content include:
• Post 100 percent Bran (1/3 cup) 8.0 grams
• Kellogg’s Raisin Bran (1 cup) 8.0 grams
• Kellogg’s All-Bran Extra Fiber (1/2 cup) 13.0 grams
• General Mills Fiber One (1/2 cup) 13.0 grams
• Apple (medium with skin) 3.7 grams
• Prunes (10, dried) 8.5 grams
• Kidney beans, red (1 cup, boiled) 6.0 grams
• Lima beans (1/2 cup) 13.0 grams
• Metamucil (1 rounded tsp.) 6.6 grams
• Perdiem, plain (1 rounded tsp.) 3.4 grams
• Citrucel (1 rounded tsp.) 4.0 grams
Fish
Americans eat about 16 pounds of seafood each year. Fish is
a great source of protein.
Eating a fatty fish even once per week has been associated
with a reduced risk of coronary heart disease. Some examples of

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Living Healthier and Longer –  What Works, What Doesn’t

fatty fish are salmon, mackerel, herring, sardines, trout or tuna.


These fish may reduce the risk of coronary heart disease because
they are high in omega-3 fatty acids. These fatty acids are thought
by some, but not all researchers to be cardioprotective. Usually, 2
servings of 3 ounces of fish are recommended each week. Fish
intake has also been associated with a lower colorectal cancer
risk.
The very popular shrimp dishes have very little omega-3 fats.
Lobster has even less omega-3 than shrimp. Though fish may
contain mercury in varying amounts depending on the type of
fish, the amounts are small. The benefits of eating fish probably
outweigh the risks.
Fruits and Vegetables
Fruits and vegetables are loaded with micronutrients.
Micronutrients are vitamins and minerals that the body needs to
function. Fruits and vegetables also have:
• antioxidants
• disease preventing phytochemicals.
• disease preventing or disease fighting indoles.
• isothiocynates.
• sulforaphane.
• phenic acids.
• phytoestrogens.
• infection fighting saponins.
• fiber.
A host of other known and unknown agents are also found
in fruits and vegetables. Eating adequate amounts of fruits and
vegetables is associated with a reduced risk of coronary heart
disease, stroke and several cancers. We recommend 6 or more
servings daily. In choosing from the large variety of fruits and
vegetables, choose a wide range of colors. You can eat fruits and
vegetables in any form. Some different forms are fresh, dried,
canned, frozen, and juice.
Studies show that less than one-third of the population actually
eats 6 servings of fruit and vegetables a day. Most people eat
less than 1 serving each day. Worse yet, only a small percentage
of our population even know why it is important to eat fruit and

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Living Healthier and Longer –  What Works, What Doesn’t

vegetables.
Currently there is a movement toward eating vegetarian diets.
Studies show that those eating meatless diets have much lower
death rates. Vegetarian diets are also linked with a low risk of
dying from cancer. Several variations of strict vegetarian diets are
both attractive and healthful.
If you eat meat, it is important to understand that eating lean
cuts of red meat and white meats are best. Red meats include
beef, veal, and pork. White meats include poultry like chicken and
turkey and fish. According to one study, both lean red meats and
white meats are lower in fat. This fact allows for greater flexibility
in eating a lipid-lowering diet. As a point in fact, however, white
meat does have fewer calories, less total fat, and less saturated fat
than the same size or weight portion of red meat or dark poultry.
Cholesterol content is similar for all except fish. Fish is generally
lower in cholesterol.
What About Other Items in the Diet?
Eggs
We said little, and certainly nothing good, about eating eggs in
the earlier editions of this text. One reason is that 1 egg contains
213 mg of cholesterol. This is important when considering that
the total daily recommended allowance for cholesterol is 300 mg.
In recent years, however, eggs have become more heart-friendly.
Some are enriched with omega-3 fatty acids. Other eggs have gone
through a process that lowers the cholesterol content of the egg.
An egg is still a good source of inexpensive protein and nutrients.
It is not as harmful as the saturated fats found in many meats
causing high blood levels of cholesterol. Two recent and rather
large studies of eating eggs came to some surprising conclusions.
Except for diabetic patients, who must still limit their egg intake,
people who ate 1 egg daily were no more likely to develop heart
disease than those who ate less than 1 egg a week. Eggs are
capable of raising one’s total and LDL cholesterol. As a result, the
amount of eggs eaten should still be limited for those with known
high cholesterol levels. This is especially true if they are known to
already have coronary artery disease. But for those who eat an
otherwise healthy low-fat diet, an occasional egg may not be as
bad as once thought.

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Sodium
The body actually needs less than one-fourth teaspoon of
sodium each day. It appears reasonable to avoid excess salt in the
diet, especially if blood pressure levels are borderline or elevated.
The average American takes in about 3,400 mg. of sodium chloride,
also called salt, each day. That is the equivalent of 1-1/2 teaspoons
of salt. This is much more than the body needs. About 75 percent
of the salt we get comes in the form of prepared or processed food.
Another 12 percent occurs naturally in foods. A little over 5 percent
is added at the table. Restaurant meals are often high in sodium.
People often forget the high salt content of pretzels, potato chips,
popcorn, peanuts, crackers, and soy sauces. Light salt or sea salt
is not an acceptable substitute for table salt. Excess salt intake is
a major cause of high blood pressure in certain people. Lowering
salt intake can definitely be associated with a decrease in blood
pressure. Salt is also a problem for the obese and those who tend
to retain fluid, causing swelling, also called edema.
Carbohydrates
More than half of our total daily calories will come from
carbohydrates.There are 3 types of carbohydrates: sugars, starches
and fiber. Carbohydrates provide the fuel that the body needs in
order to function. It is best if most of our carbohydrates come from
starches and fibers. Some examples of these carbohydrates would
be whole grains, breads, pastas, cereals, potatoes and corn. Diets
where most of the carbohydrates come from sugars leads to high
blood fat levels. Some of examples of sugary carbohydrates are
candy, jelly, sodas, pastries and cookies. Especially good foods to
eat are tinned soya beans and baked beans, red lentils, spaghetti,
sweet potatoes, All-Bran and white rice. These foods lead to a
lower rise in blood sugars.
People often refer to “good carbs” and “bad carbs.” Good carbs
are digested slowly and cause only a gradual rise in the blood
sugar. It is always best to include in our diets the good carbs over
the bad carbs. Examples of both are as follows:
Bad Carbs Good Carbs
Sugar Whole-grain cereals
Honey Whole-wheat bread
Jelly Bran

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Living Healthier and Longer –  What Works, What Doesn’t

Sodas Brown rice


White rice Bulgur wheat
White bread Whole fruits
French fries Barley
Crackers Lentils
Potatoes Oatmeal
Pastries Nuts
Protein
The average American eats far more protein than is needed.
The body’s daily protein requirement is .36 grams per pound of body
weight. This means a person weighing 150 pounds needs 54 grams
of protein each day. As with too many calories from carbohydrates,
excess calories from protein can end up as additions to our fat
stores. Also, it is recognized that a high protein diet is often a high
fat diet. Examples of common sources of protein include:
• 1 cup milk 8 grams
• 1 egg 7 grams
• 1 oz. hard cheese 7 grams
• 3 oz. meat, poultry or fish 21 grams
• 1 cup yogurt 8 to 11 grams
Soy
Soybeans are legumes which is a pod or a bean. Soybeans are
rich in fiber and free of cholesterol. They have monounsaturated
and polyunsaturated fats and omega-3 fatty acids. Soybeans also
have all 8 essential amino acids. Soy is a good substitute for meat
in the diet. Diets containing soy and soy nuts are associated with
slightly lower cholesterol levels. These diets are also good for the
blood vessels. Soy is also good for the body because it can have
estrogen-like effects and antioxidant capabilities. Soy foods are
available as tofu which is made from the liquid extracted from
processed soybeans, soy milk, soy nuts, meat substitutes and soy
butter. It is a good idea to have some soy products as part of your
daily diet.
Nuts
Nuts can be a valuable addition to a healthy diet. Though nuts
contain between 14 and 20 grams of fat per ounce, it is a good
type of fat. The fat in nuts is monounsaturated and polyunsaturated

146
Living Healthier and Longer –  What Works, What Doesn’t

and free of cholesterol. About 80 percent of the calories in most


nuts come from fat. Studies have shown that a person can reduce
their LDL cholesterol by 8 to12 percent when certain nuts were
substituted for saturated fats in the diet. These nuts include
almonds and walnuts. Some suggest feeling more full and satisfied
when you eat nuts. Nuts are valuable sources of Vitamin E and
other vitamins, minerals, and antioxidants. Because they are high
in calories, nuts are best eaten dry roasted. It is also best to eat 1
to 3 ounces of nuts a few times each week.
Butter/Margarine Substitutes
Often called “designer” margarines, 2 products, Benecol™
(pine tree wood pulp based) and Take Control™ (soy based) are
good tasting, and very low in saturated fat. Both also have little, if
any, cholesterol. If you eat about 2 grams every day of one of these
products, you should lower you LDL by about 10 to 15 percent.
Both of these products make it so that most of the cholesterol
moves through your body rather than staying in it. Sterol and stanol
enriched products can also be found in orange juice, granola bars,
rice milk, low-fat cheese, chips, a variety of other food items, and
even a vitamin preparation.
Olive Oil
Olive oil is a valued and tasty replacement for butter and meat.
It is important to remember, though, that olive oil is high in calories.
There are about 120 calories per tablespoon.
Coffee
Coffee probably is not much of a health risk if you do not drink
more than 5 cups a day. People who have special sensitivities to
caffeine products should be careful with their coffee drinking. A
recent Italian study of over 10,000 heart attack survivors showed
that after an 18 month period, those who drank more than 4 cups of
coffee daily had no more heart attacks, strokes or sudden deaths
than those who drank no coffee.
Recommendations
1. Follow a dietary program that allows you to maintain desirable
weight.
2. Reduce meat and fat in your diet.

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Living Healthier and Longer –  What Works, What Doesn’t

3. Eat at least 6 portions of fruits and vegetables each day.


4. Whenever possible, substitute unsaturated for saturated fat.
5. Consider adding soy products to your diet.
6. Watch out for and avoid trans fats.
7. Avoid cooking meat at high temperatures or for lengthy periods.
Doing either of these can allow the meat to develop cancer-
causing chemicals.
Further Reading
National Institutes of Health (NIH)
National Institute of Diabetes and Digestive and Kidney Disease
Diet and Nutrition
Health.nih.gov
Centers for Disease Control and Prevention (CDC)
Nutrition Topics

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Exercise
If we could give every individual the right amount of exercise,
not too little and not too much, we would have found the safest
way to health.
-Hippocrates
Facts
1. Among people ages 55 and older, 38 percent report essentially
sedentary lifestyles.
2. It has been estimated that about 12 percent of all deaths in the
U.S. are related to lack of regular physical activity.
3. Regular strenuous leisure time exercise in middle-aged men
can decrease the risk of cardiac arrest by up to 65 percent and
that of sudden heart attack by up to 30 percent.
4. It is estimated that 50 year olds with high levels of physical
activity live 3.5 to 3.7 years longer than those with low physical
activity.
5. Exercise can reduce total deaths and cardiac deaths by 20 to
25 percent in patients with coronary heart disease.
6. Routine exercise programs have proven valuable for a variety
of mental and emotional problems.
7. Estimates suggest that only about 38 percent of women
exercise regularly.
8. Only 26 percent of U.S. adults engage in vigorous leisure-time
physical activity (lasting 10 or more minutes) 3 or more times
per week.
9. About 59 percent of adults do no vigorous physical activity at
all in their leisure time.
10. One study suggests that exercise may even be protective
against the more serious type of macular degeneration.
11. Only one-third of patients with coronary heart disease do the
recommended physical exercise that they require.

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Each year in the U.S., as many as 250,000 deaths are attributed


to lack of regular physical activity. Many studies have shown that
physical activity reduces the risk of many diseases such as:
• Heart disease.
• High blood pressure.
• Cancer.
• Osteoporosis.
• Diabetes mellitus.
• Stroke.
The exact manner in which exercise exerts its many beneficial
effects is unknown. Many new studies are pointing to cellular,
vascular and biochemical changes leading to long term benefits of
exercise. Exercise has been associated with lower blood pressure
and improved blood fat tests as compared to sedentary people.
Exercise:
• Increases HDL cholesterol levels.
• Lowers triglyceride levels.
• Sometimes decreases LDL cholesterol levels.
• Helps control weight.
• Reduces blood pressure.
• Helps relieve stress.
• Improves the work capacity of the heart.
• Improves blood flow to the heart.
• Improves muscles’ use of sugar.
Exercise also appears to be able to delay onset of heart
disease and, should a heart attack occur, improve survival rates.
In one study, the risk of a heart attack was reduced by as much as
50 percent in active compared to sedentary men.
In a London study of middle-aged conductors of double-decker
buses, conductors who constantly ran from the lower to upper
decks and down again had smaller waist sizes and developed
much less coronary artery disease than sedentary bus drivers.
Exercise also appears to be able to reduce risks of dangerous
blood clots in the body and heart irregularities. Exercise can also
improve functional work capacity and help control body weight.

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For many years, physical inactivity had been recognized as


a contributor to development of coronary artery disease. More
recently, however, a sedentary lifestyle has been noted as a major
risk factor for coronary artery disease, along with other risk factors,
including:
• High blood pressure.
• Hypercholesterolemia.
• Cigarette smoking.
Though earlier studies were conducted with male subjects,
other studies suggest that physical activity also offers cardiovascular
protection for women. One study found a 44 percent reduction in
risk of heart attack associated with regular exercise in women.
Studies have also suggested that elderly subjects who exercised
developed disability at a much slower rate than those who did not.
Those in the exercise group also had fewer deaths.
The benefits of exercise are not limited to the heart. Patients
with peripheral vascular disease can significantly improve their
walking ability by taking part in exercise programs. Studies show
that exercise protects against:
• Colon cancer.
• Development of noninsulin-dependent diabetes (type 2)
• Osteoporosis.
• Mental health disorders.
• Breast cancer.
• Symptomatic gallstone disease in men.
Exercise is not only important in preventing, but is also useful in
treating osteoporosis, along with other therapies. Weight-bearing
activities such as walking, jogging and climbing stairs, weight lifting
and back strengthening exercises all have value.
The problem of lack of exercise is particularly important in
the U.S. where it includes 20 to 30 percent of the population. This
statistic indicates that 35 to 50 million Americans are at a two to
fourfold increased risk for cardiovascular deaths. Only about 22
percent of American adults meet or exceed recently recommended
exercise guidelines. About 54 percent are involved in some
physical activity but not enough to meet the guidelines; 24 percent
are sedentary and do little if any exercise. In the latter group, it has

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been estimated that as much as 35 percent of excess coronary


artery disease could be eliminated if these people became more
physically active.
The question is how much exercise is enough?
Recommendations from the Centers for Disease Control and
Prevention and the American College of Sports Medicine are that
every adult in the U.S. accumulate about 30 minutes of moderately
intense physical activity, preferably every day. This can be
accomplished in one effort or from several shorter bouts of activity
during the course of a day. A brisk walk (at a rate of 3 to 4 miles per
hour) is a good standard. Walking has an added advantage (over
swimming or cycling) in that it is a weight-bearing exercise and
thus is able to increase bone density, mostly in the legs and spine.
Other activities, such as dancing, climbing stairs, and cycling can
be substituted according to personal desires and preferences. The
goal is to expend at least 200 extra calories each day by exercise.
However, the health benefit derived from exercise can occur even
as low as 100 calories per day (walking 1 mile, climbing steps for
10 minutes).
Some studies show that significant health benefits are
achievable at exercise levels that exceed current minimum
guidelines such as running up to 50 miles/week. There are certain
risks and a variety of injuries that can occur with such vigorous
exercise programs. Because of proven benefits of a moderate
amount of physical activity, experts recommend that most adults
pursue moderate-intensity exercise programs.
Recent studies also suggest some hope for those who cannot
fit a structured exercise program into their lives. In these studies,
people were able to accumulate adequate periods of moderate-
intensity activity during the day by, for example, taking longer
walks on the way to office meetings, walking around airports while
waiting for flights, walking around soccer fields at their children’s
games, parking the car farther from the office.
Studies that have shown a reduced incidence of breast cancer
related to exercise appear to require 4 or more hours a week of
vigorous exercise such as involvement in competitive sports for that
benefit to occur. Moderate exercise such as walking or bicycling
for similar periods of time was not associated with reduction in risk
for breast cancer.

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Lifting weights is also valuable, even for people in their 90s.


Weight training programs can improve strength and balance in
these people, increase muscle mass, and even result in improved
walking capabilities. Benefits accrue from weight-lifting sessions
at least 2 days a week, with such sessions consisting of 10 to 15
repetitions of 10 sets of a variety of exercises.
Many commercially available books and pamphlets can provide
specific amounts and/or durations of favorite activities required for
specific benefits (for example, 20 minutes of jogging burns about
200 calories). Current exercise recommendations are considered
minimum suggestions.
It appears that, within reason, the more exercise performed,
the better and the lower the risks of disabilities and death from
coronary artery disease. One study suggested that men in the
60-80 age group who walked approximately 2 miles a day lived 5
years longer than those who walked less than 1 mile a day. The
large Harvard Alumni Health Study has shown that, at any given
quantity of energy expenditure, death rates were significantly
lower with moderately vigorous than with less vigorous physical
activities. The lowest death rates were in those who burned about
300 calories a day.
A report from Stanford University suggests that older persons
ages 50 to 72 who engage in vigorous running and other aerobic
activities have lower death rates and slower development of
disabilities than members of the general population. Exercise and
strength-training sessions have been shown to be beneficial even
for those ages 75 and older. It is the hope that such activities for
this population will result in:
• Improved:
• Ambulation.
• Balance.
• Coordination.
• Fewer falls.
• Better ability to maintain independent lifestyles.
Exercise is important for maintaining good balance, walking
being one of the best exercises for achieving that goal. As people
age and become less active, they lose muscle strength in the legs,
which is needed for maintaining balancing skills.

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Some have expressed concerns about possible development


of cardiac problems during vigorous exercise; however, about 96
percent of heart attacks occur during rest, with only 4 percent
related to vigorous exertion. Also, of those who have heart attacks
during vigorous exertion, the majority had been sedentary or were
among those who exercised infrequently. Those who exercised
regularly had an overall lower risk of heart attack.
Yoga
Asian yoga is a mystic and ascetic Hindu discipline of
meditation, breathing and prescribed postures. The practice of
yoga was believed to help its practitioners achieve inner peace and
tranquility, not help them meet their daily exercise goals. A more
westernized view of yoga indicates that benefits might be derived
from its exercise, stretching and relaxation components. While
there are a lot of anecdotal claims of benefits of Asian yoga, we
are unaware of any disease processes reversed by yoga, though
many (unsupported) are claimed. Some people, however, indicate
mental and emotional well-being, stress reduction and a positive
effect of Asian yoga on the quality of their life. About 18 million
people in the U.S. practice some form of yoga, some of which is
rigorous exercise. Yoga has become quite commercialized and is
thought to be a 20+ billion dollar business. TIME magazine points
to a study that showed that dedicated yoga practitioners show no
improvement in cardiovascular health, and that a typical 50 minute
class of the popular hatha yoga variety, burns off fewer calories
than are in 3 Oreo cookies. Different varieties of yoga, however,
can involve much more vigorous exercise. The TIME article also
points out the fact that 13,000 Americans were treated over the
past 3 years for yoga related injuries.
Recommendations
1. Walk briskly for at least one-half hour 6 to 7 days per week.
2. Continue an exercise program throughout your life.
3. If you have medical problems, disabilities or other limitations,
seek a physician’s advice and guidance in initiating and
developing any exercise program.
4. If you are able, choose a more vigorous physical activity
program for its added benefits.

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5. Even if you are unable to increase activities to desired or


recommended levels, any increase is beneficial and can
reduce risks of coronary heart disease.
6. Seek activities that you enjoy; you are more likely to stick with
them.
7. The benefits of exercise lie mostly in the aerobic category
(activities that increase your heart rate and make you breathe
hard).
Further Reading
Fries JF, Singh G, et al. Running and the development of disability
with age. Ann Int Med. October 1994.

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Sleep
Sleeping is no mean art. For its sake one must stay awake
all day.
-Neitzsche
Facts
1. Up to 5 percent of middle-aged men have sleep apnea.
2. Automobile accidents occur about 2 to 3 times more often in
people with sleep apnea (episodes of absence of breathing).
3. The incidence of heart attack is about 5 times greater in
patients who snore and have sleep apnea.
4. People with sleep apnea are at about a 3 times greater risk for
stroke.
5. Studies have shown that cigarette smokers are significantly
more likely than nonsmokers to report problems going to sleep
and staying asleep and daytime sleepiness.
6. Fifty-five percent of vehicle accidents in which drivers fell
asleep involve people under 25 years old.

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Sleep occupies a significant portion of the average day. At


some time or other, most people have complaints of difficulty falling
asleep and staying asleep or not feeling rested after sleep. Some
people feel excessively sleepy during the day without realizing that
something might be wrong with their sleep.
Transient problems with sleep, often associated with various
identifiable factors, are recognized and usually managed by
people. Chronic problems, however, often are undiagnosed and,
thus, left untreated; because their importance is unrecognized,
These problems do not get reported to physicians.
It is a common thing for people to fall asleep while driving
and become involved in traffic accidents. Probably most of these
victims are healthy people who are sleep-deprived due to lifestyle
or work schedules, though many of them may have long-standing
sleep disorders such as sleep apnea. Sleep apnea interferes with
sleep on a regular basis and causes subsequent loss of daytime
alertness and increased risk of automobile accidents. Also, some
people may be taking medications that have sedating effects or
that disrupt routine sleeping patterns.
Patients must discuss sleep problems with their physicians.
Sleep complaints suggest several important causes, including:
• Psychiatric illnesses (often depression).
• Major medical illnesses, especially those involving the:
• Thyroid gland.
• Heart.
• Lung.
• Illnesses associated with pain (such as arthritis), as well as
problems related to the medicines used for its treatment.
A large variety of nonprescription and prescription drugs can
interfere with sleep; these include:
• Nonprescription (over-the-counter):
• Pseudoephedrine.
• Phenylpropanolamine.
• Diphenhydramine.
• Chlorpheniramine.
• Caffeine in drugs (e.g., such as Anacin®, Excedrin® and
Empirin®, etc.).

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• Prescription:
• Antidepressants (amitriptyline, doxepin).
• Propranolol.
• Metoprolol.
• Clonidine.
• Bronchodilators (inhalers).
• Phenytoin.
• Progesterone.
• Corticosteroids.
• Methyldopa.
• Nonsteroidal anti-inflammatory agents.
This side effect of sleep disturbance may occur only in some
people or under certain circumstances. Alcohol, caffeine, and even
some medications thought to help sleep can cause problems with
sleep for certain people. Caffeine can be a particular problem for
some who are especially sensitive to its effects, which can remain
in the body for up to 20 hours. For such people, even a single cup
of coffee in the morning could prove to be a problem. Some people
may have to avoid caffeine completely, even that found in tea, colas
and chocolate. The average cup of regular coffee has 75 to 100 mg
of caffeine. Few coffee drinkers realize that decaffeinated coffees
at some chains can have as much as one-third the caffeine as that
in a cup of regular coffee.
Sleep problems are even more common in the elderly and
become more prominent with advancing age. Older people with
sleep problems can be bothered during the day with:
• Fatigue.
• Impaired thinking.
• Decline in motor skill capabilities.
• Decreased alertness.
These effects are problematic when anyone drives a car or
works with potentially dangerous machinery. Reasonable estimates
suggest that about 15 to 20 percent of all motor vehicle accidents
are attributable to sleepiness. In the U.S., this would amount to up
to 7,000 fatalities per year.
Fatigue has been recognized as the leading cause of trucking
crashes. Impairment in performance caused by sleep deprivation

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has been compared to impairment caused by alcohol. Sustained


wakefulness for 17 hours can decrease performance about as
much as 2 (1½ oz.) drinks of alcohol.
Good medications, when used appropriately and under a
doctor’s care, can be helpful in treating insomnia. One must be
concerned with the half-life of such medications (i.e., the time it
takes for the medicine to be cleared from the body); shorter half-
life drugs are less likely to have carry-over sedation that affects
daytime functioning. Also, toxicity of the drug is important because
of the higher risk of overdose with some preparations. Commonly
used and effective drugs for problems sleeping include:
• Estazolam (Pro Som).
• Eszopiclone (Lunesta).
• Flurazepam (Dalmane).
• Quazepam (Doral).
• Ramelteon (Rozerem).
• Temazepam (Restoril).
• Triazolam (Halcion).
• Zaleplon (Sonata).
• Zolpidem (Ambien).
Such drugs should be used only for short periods because
of the risk of developing dependency and withdrawal symptoms
when discontinuing their use. They should not be used for chronic
insomnia because of their potential addictive qualities. These
medicines can also mask underlying medical problems. Alcohol
should not be consumed when sleeping agents are being taken,
and these agents should be avoided if sleep apnea is suspected.
Some people find non-prescription sleep-aids helpful. Available
aids include:
• Diphenhydramine-containing compounds:
• Nytol.
• Sleep-Eze.
• Sominex.
• Tylenol PM.
• Anacin PM.
• Excedrin PM.

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• Doxylamine:
• Unisom.
These products contain a sedating antihistamine and, as with
use of prescription drugs, must be used with care. Even if taken at
night, they can cause daytime drowsiness, which can make driving
and other tasks risky. Also, tolerance can develop rapidly to the
sedative effects of antihistamines. Melatonin, though commonly
touted as a sleep aid, does not have sufficient data to support its
use in that role. There also is not enough data about melatonin’s
potential complications, toxicity, and optimal dosage.
The most serious sleeping disorder is sleep apnea, a relatively
common disorder seen in about 2 percent of women and 4
percent of men (about 2 to 5 million people in the U.S.). In sleep
apnea, people stop breathing up to hundreds of times each night
during sleep. An excess of 10 such events per hour are generally
necessary to establish diagnosis of sleep apnea. These people
are often unaware of their problem and often do not suspect any
sleep problem.
Sleep apnea tends to be more common in the elderly. It occurs
in 25 percent of people ages 60 and older. It also is associated
with obesity and high blood pressure. Certain airway obstruction
problems may be found in such people.
Symptoms of sleep apnea include:
• Snoring.
• Daytime sleepiness.
• Early morning headache.
• Memory changes.
• Thought deficits.
• Depression.
These symptoms often are overlooked, though loud snoring,
choking noises, and disruptions of breathing noted by sleeping
partners may be the best clue to sleep apnea.
As occurs with other sleep disorders, sleep apnea patients
have a higher frequency of automobile accidents. More important
problems, however, result from poor oxygenation of the blood
during periods of disrupted breathing. These problems are mostly
complications of the more severe cases and include:

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• Heart attack.
• Stroke.
• Sudden death.
• Hypertension.
Complicating the ability to diagnose sleep apnea (breathing
stops) is the fact that symptoms often are misinterpreted as anxiety
or depression or the results of aging. Additionally, many physicians
are unfamiliar with the disorder and the varied and confusing forms
that it can manifest.
There are specific, effective, and often lifesaving treatments
for sleep apnea and the diseases that may be associated with
it. Continuous positive airway pressure (CPAP) is the most
recognized form of treatment, but several general measures can
prove helpful:
• Weight loss, if overweight.
• Smoking cessation.
• Abstinence from alcohol.
• Sleeping in a non-supine position.
• Use of a humidifier or nasal steroid if signs of rhinitis
problems.
• Oral appliances and a variety of surgical procedures can also
be considered.
Recommendations
1. Recognize that sleep disorders exist and can have serious
consequences.
2. Recognize that lifestyle factors (smoking, alcohol, drugs) can
interfere with sleep.
3. Seek your partner’s observations of your nighttime snoring or
breathing habits.
4. Be suspicious of any medications you take as possible causes
or contributors to sleeping disorders.
5. If you are suspicious of sleep apnea, avoid sleeping on your
back; elevating the head of the bed may also help.

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6. Any suspicion of a sleep disorder should be brought to the


attention of a physician who is knowledgeable about and
interested in the condition.
7. Lack of response to therapies, suspicion of repeated sleep
disorder-related accidents, or a picture suggesting sleep apnea
or its complications should trigger a request for an evaluation
at a recognized sleep disorder center which performs a sleep
study.
Further Reading
National Institutes of Health (NIH)
National Heart, Lung and Blood Institute
National Institute of Neurological Disorders and Stroke
Sleep Disorders
Health.nih.gov
Wolkove N, Elkholy O, et al. Sleep and aging: 2. Management of
sleep disorders in older people. Canadian Medical Association
Journal. May 8, 2007:1449-1453.
Centers for Disease Control and Prevention (CDC)
Sleep and Sleep Disorders

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Vitamins and Supplements


Life loves to be taken by the lapels and told, “I am with you,
kid. Let’s go.”
-Maya Angelou
Facts
1. Vitamins and minerals can be classified as dietary
supplements.
2. Many Americans take vitamin supplements, though most do
not need them.
3. Vitamins taken in excess of the Recommended Daily
Allowances can be harmful.
4. Mineral requirements can easily be met with a balanced, varied
diet.
5. Studies do not show that a healthy person who takes extra
nutrients has increased energy, reduced fatigue, or added
disease protection.
6. The American Dietetic Association tells us that food is the
best source of nutrients. It also tells us that eating a well-
balanced diet provides us with a nice balance of nutrients. No
combination of vitamin or mineral supplements can do that.
7. Antioxidant supplements, including Vitamin E, are without
enough scientific support for their routine use. They do not
decrease cardiac deaths and could possibly be harmful, as
has been the result of the use of beta carotene in certain
settings.
8. Studies suggest that up to one-half of Americans are vitamin
D deficient.

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Millions of Americans take vitamin and mineral supplements,


responding to suggestions by supplement manufacturers that their
products can prolong life, increase energy, prevent cancers and
heart disease, improve sexual prowess, and ward off disease.
Guidelines for vitamin and mineral requirements are set by
the Food and Nutrition Board of the National Research Council
and termed Recommended Dietary Allowances (RDAs). These
recommendations exceed the needs of most healthy people but
avoid the excesses that can be potentially harmful.
Most adults in this country should not require vitamin and
mineral supplements because their diets generally provide
adequate nutrient intake. Essential nutrients can be obtained from
balanced and varied diets that contain:
• Lots of fruits and vegetables.
• Grains.
• Some dairy products.
• Lean meat.
• Skinless poultry.
• Fish.
Diets including the above may also be safer than taking vitamin
and mineral supplements. Also, obtaining necessary nutrients from
the diet avoids problems related to excess vitamin and mineral
intake. It also provides the various known and unknown materials in
foods that assist and/or enhance the actions of vitamins, minerals,
and other materials found in foods.

164
• Skinless poultry.
• Fish.
Diets including the above may also be safer than taking vitamin and mineral
supplements. Also, obtaining necessary nutrients from the diet avoids problems related
to excessLiving
vitaminHealthier
and mineraland Longer –  
intake. What Works,
It also provides What
the various knownDoesn’t
and unknown
materials in foods that assist and/or enhance the actions of vitamins, minerals, and
other A reasonable
materials found in vitamin
foods. and mineral preparation, set by the FDA,
is shown below:
A reasonable vitamin and mineral preparation, set by the FDA, is shown below:
Vitamins Daily Value set by FDA Minerals Daily Value set by FDA
Vitamin A* 5,000 IU Calcium 1000 mg
B Vitamins Potassium 3500 mg
Thiamine (B1) 1.5 mg Iron 18 mg
Riboflavin (B2) 1.7 mg Phosphorus 1000 mg
Niacin (B3) 20 mg Iodine 150 mcg
B6 (Pyridoxine) 2 mg Magnesium 400 mg
B12 (Cobalamin) 6 mcg Zinc 15 mg
Folate (Folic acid) 400 mcg Copper 2 mg
Panthothenic acid 10 mg Selenium 70 mcg
Biotin 300 mcg Chromium 120 mcg
Vitamin C 60 mg
Vitamin D 400 IU
Vitamin E** 30 IU
Vitamin K 80 mcg
*Based on a conversion of 1 Retinol Activity Equivalent=3 IU; **Based on a conversion of 1 Alpha-Tocopherol Equivalent=1.5 IU

Significant problems can result from excessive doses of: 141


• Vitamin A – avoid more than 5,000 IU daily.
• Vitamin C.
• Vitamin D.
• Vitamin E.
• Folate.
• Vitamin B6.
• Niacin.
• Selenium.
• Zinc.
• Calcium.
• Iron.
Some people do require daily multiple vitamin/mineral
supplements. For those who need them, the supplements are
safe if they contain no more than 150 percent of RDAs for each
component. People most likely to benefit from daily multiple
vitamin/mineral supplements include:
• Dieters with fewer than 1,200 calories daily.
• People with malabsorption syndromes.
• Elderly people who:
• Miss meals.
• Appear malnourished.

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• Have poor diets.


• Have poor appetites.
• People with specific vitamin or mineral deficiencies due to a
diagnosed disease.
• Alcoholics.
• Smokers.
• Pregnant and nursing women.
• People taking drugs that distort the appetite.
• Strict vegetarians.
• People with kidney failure, especially if on dialysis.
• Elderly people with poor sunlight exposure, who need vitamin
D.
• Most postmenopausal women, who need calcium
supplements.
• Menstruating women, who may need iron supplements.
• People taking orlistat (Xenical®) for weight reduction.
Strict vegetarians need Vitamin B12, zinc, iron, and calcium.
All vitamin supplements with the exception of Vitamin B12
are chemically produced by a manufacturing process that yields
both the desired natural form of the vitamin supplement as well
as undesirable chemical products which, in high doses, can be
harmful. Thus, the safety factor that results from getting the true
natural forms of vitamin supplements as they are found in foods
becomes obvious.
Unfortunately, diets of many elderly Americans may not provide
the desirable amount of certain beneficial vitamins. Because of
this, inexpensive, multivitamin tablets are seen as valuable for
this population. Often the best buy is from a reputable, generic
manufacturer, but consumers must be certain that the USP
designation is on the label. Remember that it is best to take your
multivitamin preparation with a meal. It is also best to purchase a
reputable brand name vitamin because unfamiliar, cut-rate brands
may not contain the desired ingredients in the most effective
forms.
Although age-related changes in elderly persons can bring
about this potential need for vitamin supplements, fortified food
products can also provide specific needed vitamins.

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Many older Americans have atrophic gastritis with low acid


production. This makes it difficult for these people to absorb
vitamin B12 and contributes to deficiency problems. Additionally,
this population’s aging skin is less efficient in converting UV light
to Vitamin D, which also contributes to deficiency. Elderly people,
who often don’t drink enough milk and are not exposed to sunlight,
will need vitamin D supplements. Vitamin D supplements in the
elderly appear to reduce the risk of falling, may improve bladder
function and possibly pulmonary function. Vitamin D deficiency
even appears to increase the risk of heart problems.
Vitamin C supplements and certainly beta-carotene
supplements are probably not needed by people who eat
reasonable diets. The average American diet, for example, offers
about 17 IU of vitamin E, while the RDA is 30 IU. The American
Heart Association does not recommend vitamin E supplements.
It does not believe that vitamin E reduces the risk of death from
coronary artery disease.
Past interest had been generated by the possibility that beta-
carotene and vitamins C and E may help prevent cancer and heart
disease because of their antioxidant qualities. At present, however,
the best recommendation is that more of the natural foods that
contain these antioxidants (such as fruits, vegetables, and grains)
be included in the diet. The American Heart Association does not yet
find enough evidence to recommend antioxidant supplementation
for the general public.
Women of childbearing age need 400 mg of folic acid in the
form of supplements or fortified foods in order to prevent neural
tube birth defects.
Thus, adequate blood concentrations of antioxidant vitamins
that are associated with improved health status can be acquired
by appropriate dietary intake. High doses of antioxidants can be
associated with significant health problems. One study of vitamin
E supplementation showed an unexpected increase in risk of
death from hemorrhagic stroke. Another study with beta-carotene
supplementation showed an unexpected increase in deaths from
lung cancer and coronary artery disease. In many studies in which
increased antioxidant intake was shown to be correlated with
reduced disease risks, the intake was from antioxidant-rich foods
rather than vitamin supplementation.

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There had been some recent interest in lycopene, a


phytochemical with potent antioxidant properties that is found in
tomatoes and especially cooked tomatoes. Lycopene was thought
to reduce the risk of certain cancers, but new data has been less
supportive of that conclusion.
Many claims, mostly undocumented, are made in the lay
literature about the far- reaching benefits of fish oil supplements.
Omega-3 fatty acids are essential nutrients. Presently, there is
not enough evidence to recommend their routine use as a health
food. Dietary sources include fatty fish (salmon) and to a much
lesser degree, flaxseed oil, nuts and seeds. Only one fish oil
supplement, Lovaza, has been approved by the FDA and has
proven very effective in reducing elevated triglyceride levels. In
spite of all the hype, there is no evidence that fish oil supplements
prevent cardiovascular diseases in the general population. We all
recognize that vegetarians, who are without fish or fish oil in their
diet, have a low incidence of coronary artery disease. Their value
in patients with coronary artery disease has yet to be defined as
they cannot be made in our body and must be acquired from food.
Our best advice would be to eat a fatty fish meal twice weekly if
possible.
The authors often see patients who take pills or powdered
preparations that are “concentrates” of fruits and vegetables.
These are marketed aggressively to patients who wish to be
certain they receive all important nutrients in their diet. Such
products, however, often do not provide valuable fiber or some
nutrients that are readily found in the food items they represent.
The convenience of these products is hardly worth their lesser
value and often great cost.
Despite numerous and varied claims for mineral supplements,
healthy people eating an appropriate number of calories in varied
diets with plenty of fruits, vegetables, and grains can easily achieve
the recommended intake of minerals. These minerals include:
• Calcium.
• Selenium.
• Iron.
• Zinc.
• Chromium.

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• Iodine.
• Phosphorus.
• Cobalt.
• Copper.
• Fluoride.
• Manganese.
• Molybdenum.
Taken in excess, individual minerals or combinations of them
can cause problems, including toxicity. Toxicity is not expected
from eating natural foods that contain these minerals.
The exception to this rule is calcium. To protect against
osteoporosis, increased incidence of fractures in the elderly,
and associated increased deaths, calcium supplements may be
required. The elderly, due to dietary deficiencies and/or lack of
sunlight exposure, may be deficient in calcium and vitamin D. Most
forms of milk, skim to whole milk, contain about 300 mg. of calcium
per 8 oz. serving, and are good sources of dietary calcium. For
those unable to take in enough dietary calcium, supplements
(such as calcium carbonate or calcium citrate taken 2 or 3 times
daily with meals) are beneficial. Daily vitamin D recommendations
for both men and women are:
• 19 to 50 years old – 200 IU/day.
• 51 to 70 years old – 400 IU – 600 IU/day.
• Ages 71 and older – 800 IU -1000 IU/day.
Even higher doses may be beneficial in the elderly who are
ill or are taking steroids. Vitamin D supplementation, along with
calcium, in the elderly has the potential to reduce the rate of hip
and other fractures and also helps prevent osteoporosis, partly
because it stimulates calcium absorption from the intestine.
It is amazing what people are willing to take which they believe
will achieve healthier and longer lives, avoid problems associated
with natural aging, and restore qualities and feelings associated
with youth. Manufacturers of supplements, health foods, and
natural products claim benefits for which there is no supporting
evidence, no FDA-approvals, and usually no scientific basis. Often
these items are expensive and by themselves can be dangerous
or prove to be especially toxic when combined with other drugs

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or products. Additionally, there is inadequate knowledge about


problems associated with long-term ingestion of these items.
Recommendations
1. Obtain vitamins and minerals by eating a balanced diet that
includes at least 6 servings of fruits, vegetables, and grains
daily.
2. A simple, inexpensive multiple vitamin/mineral supplement
based on RDAs benefit certain groups.
3. Avoid vitamin/mineral supplements in dosages greater than
RDA recommendations.
4. You may need calcium supplements, depending on your age,
gender, and dietary calcium intake.
5. A reasonable and effective way to obtain necessary antioxidants
is to eat a variety of fruits and vegetables of different colors
(green, orange, red, and yellow)
6. It is best not to purchase supplements from your health care
“professional” or from his or her office.
Further Reading
Vitamin supplements. The Medical Letter. July 18, 2005:57-58.
Barrett S, Herbert V. The Vitamin Pushers. Prometheus
Books:1994.
National Institutes of Health (NIH)
Vitamin and Mineral Supplements
Office of Dietary Supplements
Health.nih.gov
Centers for Disease Control and Prevention (CDC)
Vitamins and Other Micronutrients

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Aspirin
The desire to take medicine is perhaps the greatest feature
which distinguishes man from animals.
-William Osler
Facts
1. For those who have had a heart attack, a daily aspirin could
reduce the risk of having another by 30 percent.
2. If you feel like you are having a heart attack, call 911 and then
chew a 325 mg, plain (never enteric coated) aspirin.
3. An 81 mg dose of aspirin is probably all that is needed for most
indications.
4. For certain populations, a daily low dose aspirin could reduce
the chances of a heart attack or a stroke by 25 percent.
5. A variety of herbals and dietary supplements can interfere with
the beneficial actions of aspirin.
6. Ibuprofen can interfere with the action of aspirin, do not take
together.

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Aspirin is an important drug with many uses. Potential beneficial


effects of aspirin intake in people with heart disease, stroke, certain
blood vessel problems, diabetic patients, and people with kidney
diseases suggest a role for this drug in health maintenance.
Though aspirin has many potential beneficial effects, its
widespread usage is limited by a variety of significant side effects
that include:
• Peptic ulcers.
• Gastritis.
• Hemorrhage in the:
• Upper gastrointestinal tract (stomach bleeding).
• Urinary tract.
• Bowel.
• Brain.
• Allergic reactions (occasionally).
Even low doses of aspirin (81 mg) can cause gastric discomfort
and, though rare, gastrointestinal or brain hemorrhage. Though the
desired effects of aspirin are seen across a wide range of doses,
side effects increase with higher doses. Aspirin is a common cause
of skin bruising but no reason to terminate its use. A recent study
suggests that there is no significant difference in the rates of upper
gastrointestinal bleeding with use of regular aspirin or the more
expensive enteric-coated or buffered form.
Aspirin can also be a problem for those with uncontrolled
hypertension and for alcoholic subjects because of hemorrhagic
strokes and gastrointestinal bleeding, respectively.
Aspirin is effective for those with coronary artery disease and
those who have had or are at increased risk for heart attack. It
is especially useful in lowering risk of death (by 50 percent) and
in patients in the process of having heart attacks. The American
Heart Association estimated that 5,000 to 10,000 lives could be
saved each year if people took an aspirin (preferably chewed at
the first sign of symptoms). The aspirin prevents blood clots from
forming in the coronary artery by making blood platelets less sticky.
It is also known to have numerous nonplatelet-related effects, and
its anti-inflammatory ability appears to be a factor in the treatment
and prevention of coronary artery disease.

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Following a heart attack or medical condition that enhances


risks for heart attack or stroke, a daily aspirin (325 mg) or even
a baby aspirin (81 mg) is of proven benefit. Taking aspirin after a
heart attack lowers rates of death and recurrent heart attack by 20
percent. Patients with angina pectoris or coronary bypass grafts
also benefit from aspirin.
Use of aspirin in middle-aged or older men who, because of risk
factors, are at great risk for a first heart attack, may be beneficial,
but potential side effects may negate the desired value. In men
without symptoms or risk factors for coronary artery disease,
aspirin complications may negate the desired value. In fact, in
men without symptoms or risk factors for coronary artery disease,
aspirin may prove more harmful than beneficial. Because of its
potential adverse effects, aspirin is not approved for decreasing
heart attack risks in healthy people. If it is used, probably low-dose
(1 baby aspirin) each day taken with food will provide benefit while
minimizing risks.
Studies have shown a benefit of aspirin in reducing risks of
stroke in patients with symptoms (transient ischemic attacks) but
not as much benefit in asymptomatic people unless found to have
significant carotid artery narrowing.
Recommendations
1. Take aspirin (dose as recommended by your physician) if you
have coronary artery disease and especially if you have poorly
controlled symptoms, such as chest pain (angina) or have had
a heart attack.
2. Take aspirin (under a physician’s guidance) if you have
symptoms or signs suggesting an impending stroke (TIA) or
after a completed stroke.
3. Avoid aspirin if you are already taking other blood thinners,
have or are prone to peptic ulcers, or have other potential
bleeding problems.
4. Use the lowest dose of aspirin that is known to be effective for
the condition under treatment.
5. For those resistant to the effects of aspirin, have excessive
side effects or are allergic to aspirin, clopidogren (Plavix),
though expensive, can be substituted.

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6. For those with gastrointestinal side effects from aspirin, a


proton-pump inhibitor like omeprazole (Prilosec) can be
utilized.
7. The American Diabetes Association recommends a daily
low dose aspirin for all patients with type 1 or type 2 diabetic
patients who are over the age of 40, or even younger if
prominent cardiovascular risk factors exist.
8. The National Kidney Foundation recommends a daily aspirin
for people with kidney disease and especially those patients
on dialysis.
9. If you take aspirin regularly, do not stop suddenly due to a
possible rebound effect that can increase the risk for a heart
attack or stroke.
Further reading
U.S. Food and Drug Administration (FDA)
Aspirin

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Aging
He that would pass the latter part of life with honor and
decency, must when he is young, consider that he shall one
day be old and remember when he is old that he was once
young.
- Samuel Johnson
Facts
1. U.S. population is growing older.
2. There is no magic potion or medicine to reverse aging.
3. Medicines for treating high blood pressure, increased “bad”
cholesterol and heart disease are effective in the elderly.
4. Lifestyle goals to avoid obesity, excessive alcohol intake
(greater than 1-2 glasses per day), and smoking cessation are
equally important in the elderly.
5. Much that is considered “aging” is due to muscle atrophy.
6. Daily exercise can prevent heart “deconditioning” and muscle
atrophy in the elderly.
7. Depression and sexual dysfunction are common in the elderly
and are treatable.
8. Polypharmacy (multiple medications) leading to unnecessary
costs and side effects is common in the elderly.
9. Undetected hearing, visual, and dental problems are common
in the elderly, decreasing quality of life, and are treatable.
10. Cancer increases with age and thus routine screening for
breast, prostate, skin, and colon cancer is important.
11. Immunization (influenza, pneumococcal, tetanus, shingles) is
important in disease prevention in the elderly.
12. Social interaction and keeping one’s mind busy with reading,
crossword puzzles, and various other productive activities
enhance mental health in the elderly.

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The population in America is growing older and, by 2020, 20


percent of the population will be over 65 years of age. Moreover,
life expectancy at age 65 averages 17 years. Currently, the fastest
growing segment of our population is those over 75 years of age.
Thus, the approach to living a long and healthy life for the elderly
is of critical importance to our country’s future.
Successful aging is a challenge which involves both lifestyle
and genetic factors. While our genetic composition, as determined
by our mother and father’s gene banks, may predict predisposition
to diseases, prevention of disease necessitates lifestyle changes
and/or medications. Thus, the elderly should focus on the lifestyles,
as outlined in this book, which will provide them with a longer and
healthier life.
The important lifestyle changes for the elderly are similar
to those recommended for other Americans with appropriate
alterations as specified by the individual’s physician.
• High blood pressure increases with age and treatment is
important, as is statin treatment for “bad” cholesterol.
• Excessive alcohol intake can cause hypertension and
undetected alcoholism is not uncommon in the elderly.
• Smoking cessation in the elderly, in spite of decades of
tobacco abuse, can be associated with improved lung and
heart function. While daily physical exercise is equally or
more important in the elderly, the intensity and duration of the
exercise is best prescribed by one’s physician. At a minimum,
30 minutes of walking daily is advised. Modest weight lifting
can avoid muscle atrophy which can predispose to falls and
accidents. Aerobic exercise (e.g., walking, biking, treadmill)
has a beneficial effect on cardiovascular function.
• Mental exercise is equally important, whether it be reading,
crossword puzzles, bridge, or other card games.
When the physician adds an additional medication for an elderly
patient, he/she should ask whether any existing medications can
be discontinued. The cost and side effects of polypharmacy in
the elderly are major problems which can decrease quality of life.
Several studies indicate that the daily use of aspirin (81 mg) may
help prevent stroke, cardiovascular disease, dementia, and some
cancers. Alternative medicine therapies have been unproven in
approaches to prevent aging, and may be harmful.

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The products listed below not only have no anti-aging value,


but they can also be associated with significant toxicity. Billions
of dollars are wasted on these useless anti-aging products, each
year.
Unproven Anti-aging Products
• Hormones:
• DHEA.
• Testosterone.
• Estrogen.
• Growth Hormone.
• Melatonin.
• Vitamins A, C, E and D.
• Antioxidants.
• Nutritional supplements.
• Fetal stem cell injections
Depression may be frequently missed in the elderly and just
considered “withdrawing associated with aging.” Mood, eating
and sleep disorders may be clues to depression in the elderly.
Psychotherapy and antidepressant medications can be very
effective in the elderly.
Sexual dysfunction is also frequently ignored in the elderly.
As described elsewhere in this book, effective medications are
available to treat erectile dysfunction in elderly males.
There are immunizations that are mandatory and effective
for the elderly including influenza, pneumococcal, and zoster
(shingles). Tetanus vaccine also may need to be repeated as
recommended by the patient’s physician.
Early detection of cancers can be life-prolonging and thus
appropriate screening is recommended. Visual and auditory aids
can enhance the quality of life for the elderly.
Equally important in the elderly is social involvement with others
– friends, children, grandchildren. Isolation fosters depression,
non-compliance, alcoholism, psychosomatic disease, paranoia,
and even suicide in the elderly.

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Recommendation
It is too late! Ah, nothing is too late
Till the tired heart shall cease to palpitate.
Cato learned Greek at eighty; Sophocles
Wrote his grand Oedipus, and Simonides
Bore off the prize of verse from his compeers,
When each had numbered more than 4-score years . . .
Chaucer, at Woodstock with the nightingales,
At sixty wrote the Canterbury tales;
Goethe at Weimar, toiling to the last,
Completed Faust when eighty years were past.
These are indeed exceptions; but they show
How far the gulf-stream of our youth may flow
Into the arctic regions of our lives . . .
For age is opportunity no less
Than youth itself, though in another dress,
And as the evening twilight fades away
The sky is filled with stars, invisible by day.
- Henry Wadsworth Longfellow

Further Reading
Schrier RW. Geriatric Medicine. W. B. Saunders Company:1990.
Rowe J, Kahn R. Successful Aging. Pantheon Books:New
York:1998.
Michel J-P, Newton J, Kirkwood T. Medical challenges of improving
the quality of a longer life. Journal of the American Medical
Association. February 13, 2008:688-690.
Berger J, et al. Aspirin for the primary prevention of cardiovascular
events in women and men: a sex-specific meta-analysis of
randomized controlled trials. Journal of the American Medical
Association. 2006;295(3):306-313.
National Institutes of Health (NIH)
National Institute of Neurological Disorders and Stroke
Health.nih.gov

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The Physician
A physician can sometimes parry the scythe of death, but
has no power over the sand in the hour-glass.
-Hester Lynch Piozzi
Facts
1. A quality physician could prove to be one of the most important
pieces in a long and healthy life.
2. The physician and the patient must work as a team.
3. The physician is the “coach” and the patient is the “player”. The
game is making your living longer and healthier.
4. The author of a TIME Magazine article said, “Doctors hate to
tell you to lose weight as much as you hate hearing it.” TIME
reported on a study by the Mayo Clinic which found that up to
80 percent of physicians avoid talking to their patients about
being obese.
5. A physician’s silence can put your health in danger.

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There is little doubt that good physicians who have good


relationships with their patients can influence the patient’s life.
Patients who work with good doctors will have a higher quality,
longer life.
Much care should go into selection of personal physicians.
People want physicians with whom they work well. They also want
a doctor they can work with for many years. Personal physicians
usually are internists or family physicians. Patients must take time
to find physicians they like and trust. People also should find a
doctor with whom they have good personality matches.
Sometimes recommendations from friends and relatives, or
especially other trusted physicians, can help people find a doctor
who works for them. Patients should look for physicians who, from
the beginning, seem interested in them and their problems. People
should also find a doctor who is interested in helping them get and
stay healthy. Physicians should be willing to spend a reasonable
amount of time with patients during visits. A good visit with a doctor
is one where you feel that your problems have been heard.
Obviously, patients should expect to be cared for by quality
physicians. The physician should also have an excellent reputation.
Patients should feel free to check qualifications of a doctor they
are considering.
Some people may want to choose a doctor who is on a list
like “Best Doctors in America”. These physicians often work at
major university medical centers. It is important to understand that
many of the doctors at the university do not see many patients.
Usually these doctors have to teach and do research as well as
see patients. In recent years, however, many of these doctors are
starting to spend more of their time treating patients.
When looking for the right physicians, people might consider
their own special needs. They should also think about the specialty-
related interests and skills of the doctors they are considering.
For example, a diabetic patient may want to find an internist with
subspecialty interests in endocrinology. Keep in mind, though,
that primary care physicians can make referrals to a specialist for
special problems. Your primary care doctor does not need to know
every specialty. They need to know other good physicians so they
can make a good referral.

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Patients should see whether their doctor keeps reading about


new medical practices and research. Things are always changing
and we are always learning new things about health. Ask your
doctor if you have read about new health information. As you ask,
you will be able to see if your doctor is also learning about these
new approaches. Remember, though, that the media may report
on something that is interesting but may not be helpful. Also, the
media does not always give the whole story. Good physicians,
however, will look for information and figure out how it applies to
their patients’ illnesses and needs.
There are a number of ways in which a physician’s care can
improve the quality and length of life. Good physicians will:
• Make sure the patient gets the right immunizations. This will
help the patient avoid a sometimes serious or life-shortening
illness.
• Keep watch over the patient to discover diseases at early
stages. This means the doctor will do screens and tests looking
for the early signs of a disease. Diseases are easier to treat at
the early stages.
• Upon hearing patients' symptoms, quickly look into problems.
When the problem is uncovered, the doctor will start therapies
right away. The doctor will continue to work with the patient to
make sure the therapy is working effectively.
• Avoid tests or procedures the patient does not really need.
• Avoid dangerous tests or procedures.
• Use tried and tested medicines and treatments. A good doctor
will also know about the possible side effects and complications
of what they recommend.
• Be concerned about what could go wrong if certain drugs are
used together. The doctor should know everything you are
taking so they can make sure there is no dangerous mix.
• Choose the best available specialist to help care for the
patient.
• Help their patients select the best places to get medical care.
This means doctors should be able to tell patients which
hospitals, care centers, or emergency units they should use.
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• Help their patients find the best therapy and rehabilitation


centers for their needs.
• Help their patients find programs so they can change their
diets. Doctors can also help patients find programs to help
them adopt healthy behaviors.
• Tell their patients when they are doing something that puts
their health at risk. This means doctors should regularly talk
about issues such as:
• Smoking.
• Following an unhealthy diet.
• Drinking too much alcohol.
• Deciding not to have safe sex.
• Choosing not to exercise.
• Make sure patients know about their cardiovascular risk
factors.
• Be interested in the cost of evaluating and treating the patient.
Doctors should keep in mind that the patient may not be able
to do something that is too expensive.
• Be interested in all their patients' problems. Having anxiety,
depression, or dementia makes it hard for patients to follow
the doctor’s recommendation. They can also make a disease
worse. These conditions can lead to bad outcomes such as
suicide or an accident.
• Be advocates for the patient. Doctors should work on their
patients' behalf when there is a problem with insurance.
• Guarantee that their practice has someone patients can call
for nights, weekends, and when the doctor is on vacation. This
person should be qualified to help patients. This person also
needs to be able to meet patients' healthcare needs.
It is important that the patient and the doctor work well
together. They should also take the time to understand each other.
A high quality relationship between the doctor and patient helps
the patient really benefit from having a doctor. Patients sometimes
want to have more visits or exams than the doctor feels are needed.
Patients may also want tests, procedures, medicines, or therapies
the doctor feels may be a problem. The doctor should explain to the

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patient why they disagree. Doctors might not agree with the patient
if they feel some things are inappropriate, or dangerous. They may
also disagree if they think it is expensive with little benefit. Today
especially, physicians try to keep people out of expensive hospital
settings when reasonable alternatives are available. Doctors
should still be willing to discuss all the different medical choices
with their patients.
As patients age, what they need from the doctor can change.
Patients may eventually need some form of home care. This can
be:
• supportive or custodial home care.
• assisted living programs.
• nursing home care.
• rehabilitation programs.
• hospice care.
Physicians, by themselves or through team efforts, should be
able to direct patients towards the best programs for them. The
doctor should also keep the program in mind when thinking about
future health care. Doctors also need to think about the role of
family, friends, and community support activities in the life of their
patient.
Recently, studies have begun to look at the connection
between a person’s spiritual beliefs and decisions about their
health. These studies have shown that it is important for doctors to
take patients’ spiritual and religious beliefs into consideration. As
a result, physicians are starting to understand the value of working
with the patients’ spiritual and religious views when providing care.
For example, some doctors have expanded the part of the patient
exam (history) where they ask about a person’s background.
Recommendations
1. Take the time and effort to find the best physician match for
your needs. When looking for that person, use the information
suggested in this chapter.

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The Patient
The patient must combat the disease with the physician.
-Hippocrates
Facts
1. At least one-third of patients cannot name the medications
that they take.
2. Forty-three percent of patients do not take long-term
medications as prescribed.
3. Thirty-eight percent of patients fail to follow short-term
treatment plans (such as taking antibiotics).
4. Up to 21 percent of prescriptions given to patients are never
filled.
5. Seventy-five percent of patients do not follow lifestyle
recommendations (diet, exercise, etc.).
6. Fifty percent of patients in post-heart attack rehabilitation
programs abandon them within a year.
7. Only 30 percent of patients follow dietary recommendations
after 1 year.
8. Of patients taking digitalis for heart failure, only 10 percent
have their prescriptions filled often enough to be receiving the
proper dose.
9. About half of all patients leave the doctor’s office not knowing
what they have been advised to do.
10. One study found that patients with heart disease who took less
than 80 percent of the prescribed medication (beta-blockers)
had 4 times the number of cardiac events (heart attacks and
strokes) as those who were fully adherent.
11. Up to 20 percent of patients do not present their prescriptions
to a pharmacy within 1 month of issue.

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Many of these above listed facts were noted in the September


1994 Johns Hopkins Medical Letter and explain why many
physicians feel frustrated with problems of patient compliance.
Today, the problem is even worse. Adult patients are not compliant
for a variety of reasons, discontinuing medications on their own
because of:
• Real or suspected side effects.
• Drug costs.
• Uncertainty of effectiveness.
• Vacations.
• Confusion about dose or time of dose.
• Just plain forgetfulness.
Doctors, at times, contribute to the problem by:
• Not giving patients clear instructions for taking medications.
• Not warning patients about significant or bothersome side
effects.
• Making dose or time schedules too complicated.
• Not recognizing medication cost factors.
• Failing to instruct patients as to the purpose and importance of
medications.
• Not dosing medications based on age, gender, kidney and
liver function, other medications and diseases to be treated.
Physicians may at times fail to recognize a drug's side effects
that become manifest when added to other drugs on a patient's
program. Patients, on the other hand, take supplements, non-
prescription drugs, herbs, and various other pills with unknown
components in varied forms and dosages without telling their
physicians. Some of these drugs can be harmful in and of
themselves, in combination with other medications patients take
on their own (such as aspirin or sinus medications), or when
used alongside prescribed medications. Unfortunately, computer
systems used in pharmacies are not capable of screening for
potential drug interactions with all herbal products.
It is becoming apparent that patients must become assertive
with regards to their medical care. Patients who are passive,
unquestioning and seemingly unconcerned about their medical
problems are at a disadvantage, possibly receive less time and
attention from the physician and the clinic staff, and give the false

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impression that their condition is not as serious as it actually is.


Patients should learn as much about their illnesses as possible.
Resources such as books and pamphlets, especially those
recommended by your physician, and quality Internet sites have
potential value for patients to learn much about their medications,
how they work, how they should be used, their side effects and
potential complications. Patients who become more involved in
their care tend to feel more confident, are less anxious about their
illnesses, and are more likely to comply with treatment regimens,
especially regimens that are complex or more uncomfortable.
Most physicians generally understand that patients, especially
older patients, have spiritual needs that must be met. Studies have
shown that certain strictly observant religious groups have reduced
deaths and decreased rates of some diseases. Other studies have
shown that prayer has a beneficial therapeutic effect in a large
number of patients. A high percentage of people questioned on
the subject felt that prayer sometimes influences recovery from
illnesses, even though only half of those questioned described
themselves as religious.
Unfortunately, such concepts are often not communicated
between physician and patient. At a relatively early point in the
patient-physician relationship, patients should mention their
spiritual or belief areas so that physicians can be prepared to
help satisfy patients’ spiritual needs when and if the time for such
arises.
Recommendations
1. Know the medications you take and why you are taking them.
2. Ask your doctor about side effects of prescribed medications
you are given.
3. Have your doctor write down instructions.
4. Keep a list of your medications and instructions with you at all
times.
5. Ask your doctor about less expensive alternatives for
expensive medications, or if splitting the pills will make them
less expensive.

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6. Inform your doctor about your suspected medication side


effects.
7. Take a list of your current medications at least yearly to
your doctor and do so more often if you take numerous
medications.
8. Take a spouse, relative, or friend with you to your doctor when
you discuss confusing or complex treatment programs.
9. If possible, choose a single pharmacy and personal pharmacist
who is interested in providing information to you as well as in
filling your prescriptions.
10. A pill container divided into daily compartments holding each
day’s medications is helpful for the patient, particularly the
elderly.
11. When you visit your physician, bring with you a list of your
problems/concerns, and list them in the order of your
concern.

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Alternative Medicine -
Alternative to what ????
Our body is a machine for living. It is organized for that, it is
its nature. Let life go on in it unhindered and let it defend itself,
it will do more than if you paralyze it by encumbering it with
remedies.
—Leo Tolstoy, War and Peace
Facts
1. As many as 17 percent of adults report using herbal treatments
at least once in the past year.
2. About one-third of all Americans use some form of alternative
medicine.
3. Less than one-third of patients who use some form of alternative
methods tell their doctors about it.
4. People can have a dangerous reaction to an herbal remedy.
Remember, even though these are called “natural,” it does not
mean they are harmless.
5. Most studies that show herbals remedies work are paid for by
the company that makes the product.
6. Most alternative therapies have not been thoroughly tested
yet. As a result, we cannot say for certain that these therapies
are effective or safe. People are paying a lot of money for
something that has not been shown to work yet.
7. There is very little good data on the toxicity of herbals. It is not
clear whether or not these herbals hurt your body.
8. St. John’s wort has the most documented interactions with
other drugs. Tell your doctor if you are taking St. John’s wort.
9. There was a large study to see if those who used herbs pay
attention to well-done studies that show the herbs do not work.
About two-thirds of adults who use herbs do not pay attention
to these studies.
10. A placebo is a pill or therapy that does not really do anything to
the body. Sometimes, though, someone might get better even

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though they are getting a placebo. This is called the placebo


effect. The pill or therapy works because the person getting it
believes it will work. R. Barker Bausell’s talks about this in his
2007 book Snake Oil Science: How We Know That the Placebo
Effect Exists.
11. Almost all positive responses to alternative medicine treatments
are due to the placebo effect. People felt better because they
thought the treatment would work.

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Traditional medicine can also be called familiar, science based,


or conventional medical practices. This type of medicine has been
shown to extend and improve life. Some of the successes of
traditional medicine are:
• Offering cures for bacterial infections.
• Creating medicines. These medicines have helped treat and
control heart disease, metabolic illnesses such as diabetes,
and viral diseases such as AIDS.
• Creating therapies for inhibiting or slowing the growth of
cancers.
• The use of immunizations to keep people from getting serious
illnesses.
People feel comfortable with traditional medical practices
because they have been well tested. Most of these practices have
been studied and found to work. Those who practice traditional
medicine know that new tests are always being done. We are
comfortable with the fact that something new may be learned. We
are willing to use this new information to change a treatment. We
may even stop doing something that we once thought was effective.
Just because something has been done a certain way for a long
time does not mean that we would choose to continue it if we see
data saying it did not work. Doing new tests to see what works
has been very successful. The successes of conventional medical
practices have lead to people living longer. These successes have
also led to controlling or getting rid of certain diseases that reduced
the quality of our lives.
Everyone dreams of living a long healthy life without having to
worry about whether they smoke, eat or drink too much. They look
for the pill, herb, or magic potion that will allow us to be healthy
without eating a healthy diet and exercising. Forget it. The silver
bullet does not exist. It will never exist. That being said, a lot of
people continue to hope that the “pill of the day” that they are
using, will be “the one”. The search for a quick and easy way to be
healthy has gone on since ancient times. History shows that people
have looked at everything from magic potions to snake oils. Today,
people are looking to herbs and supplements. To go along with
these are a group of practices called Alternative Medicine. They
include a wide-ranging group of hundreds of approaches that have
not been supported by research. The more common ones are:

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• Acupuncture. • Homeopathy.
• Herbal medicine. • Magnet therapy.
• Massage therapy. • Spiritual healing.
• Reflexology. • Iridology
• Aromatherapy. • Naturopathy.
• Therapeutic touch. • Reiki.
Some definitions are probably in order. Those who support
alternative medicine often called it complementary. They believe
it can work with traditional medicine. This is a difficult idea for
conventional medical scientists. Another commonly used term is
CAM. CAM stands for complementary and alternative medicine.
Integrative medicine is phrase used to suggest that alternative
and traditional medicine can be used at the same time. There are
many different definitions for alternative medicine or CAM. The
best that I have found is that suggested by R. Barker Bausell.
Bausell is a research biostatistician who worked with a center for
complementary and alternative medical research. His definition of
CAM is as follows:
CAM therapies are physical, mental, chemical, or
psychic interventions such as acupuncture, homeopathy,
naturopathy, chelation, folk medicine, herbs, megavitamin
therapy, nutraceuticals, chiropractic manipulation, massage,
biofeedback, hypnosis, hatha yoga, tai chi, qi gong, and any
sort of energetic, psychic or spiritual healing used for treatment
of specific medical conditions or disease symptoms. They are
practiced in the absence of both scientific evidence proving their
effectiveness and a plausible biological explanation for why they
should be effective, and their practice continues unabated even
after (1) there is scientific evidence that they are ineffective and
(2) their biological basis is discredited.
Until recently, alternative medical practices were not taught in
medical schools. Instead, medical students were told that these
practices existed. Students could talk about these practices and
debate about their effectiveness. Medical students were also taught
to recognize potential complications related to their use. Recently
however that has changed. Because of the hefty financial rewards
for the CAM therapist, the hospital, the medical center and the
medical school, these CAM practices have crept into legitimate
conventional medical programs. CAM practices are often disguised

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as “research”, the desire to address the “needs” of patients, the


need to satisfy important politicians and powerful interest groups
and a vague notion that providing CAM is politically correct.
There are no recent figures on how much the public spends on
CAM therapies. Estimates from 1997 suggest that the U.S. public
spent between $36 billion and $47 billion. We believe that people
spend a lot more today. Up to 15 percent of that money spent
on CAM therapies is for herbal products. These products offer
little medical help. Since 1991, hundreds of millions of tax dollars
have been spent by the National Center for Complementary and
Alternative Medicine (NCCAM). This group is part of the National
Institute of Health. This money has been spent without anyone
being able to show that any alternative treatments work. Such funds
might have been better used if they were given to conventional
scientific research programs.
The problem with most alternative therapies is that they are
highly questionable practices that have not been thoroughly tested.
We do not have good data to say these approaches work. Instead,
alternative medicine practitioners defend their therapies by relying
on stories from a few people. They might also use a theory that has
not been tested yet. The research used to support this approach is
often from poor quality journals that often lack critical peer review.
People who practice alternative medicine often feel that scientific
studies do not apply to their particular therapy.
Alternative therapies are often closely tied with certain “catch
words” and phrases. Some examples are included in the list
below.
• natural.
• holistic.
• time tested.
• complementary.
• alternative.
• stimulating the body’s ability to heal itself.
• mind/body interaction.
• mind over matter.
• power of positive thinking.
• attacking the cause of disease.
• treating the whole patient.

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• safer non-toxic alternative.


• belief in the importance of body, mind and spirit in health.
Some alternative medicine therapists see their role as taking
care of people who “failed” in traditional medicine. There are in
fact patients who use alternative medicine because of a bad
experience with traditional medicine. These patients may have had
a problem with the doctor or with the medical setting. Most people,
however, use alternative medicine as another way to try and stay
well. They may have gotten the idea to try alternative medicine
from one of many sources. These include word of mouth, books
or magazines, radio and television, or the Internet. We have often
seen older people begin taking supplements they do not need.
These are people who are in excellent health and have always had
a healthy lifestyle. When someone asks these patients about their
good health, they often give credit to the supplement, not their
many years of living a healthy lifestyle. Others who have not seen
the years of good living will just accept that the pill is what led to
this person’s good health.
What makes it hard to know if something is working, is that the
person might feel they are getting better when they are not. This
is true for all forms of treatment. At some point alternative, folk
medicine or faith healing methods can seem like they are working.
This is why traditional or scientific medicine demands something
be tested on a lot of people using a high quality study before
deciding what works. There are many reasons something might
seem to work that really does not. These include:
1. The placebo effect. Sometimes we think something is working
because we expect it to.
2. The healer effect. Some of today’s most notable alternative
medicine healers are passionate, forceful people. They are
very easy to like. They are able to charm audiences with their
seemingly endless knowledge. They seem to know a lot of
facts even though some of the information they provide can
not be supported. These people often make money from sales
of the approach or product they are selling.
3. The co-operative effect. At times therapies that are not
tested are associated with behaviors that have been shown
to help. For instance, a therapy that has not been tested may

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be prescribed along with a change in diet, and exercise. Even


though the diet and exercise are what helps, the person might
believe it is the unproven therapy.
4. The psychological effect. A therapy may work because we
see it as better fitting other things we believe. We assume it
works because we feel the other beliefs are true. This effect
can assume many forms. For example, it is commonly thought
that traditional medicine rejects religion or spirituality. People
may feel the alternative medicine works because it supports
their religious or spirituality ideas.
5. The pattern of disease effect. Often a disease is self-limiting.
At some point the disease will stop by itself or a patient’s body
finally gains control of the process. Even though the person got
better on their own, they may think they were cured by whatever
treatment they were doing when the disease stopped.
6. The misdiagnosis effect. A patient may be thought to have
a disease he does not really have. This can happen because
there was not information to tell what the patient had. It is also
possible that at the time there were no good tests to find out
what was wrong. Regardless, the patient gets better even
though the particular therapy did not help.
Alternative Medicine Therapies
Homeopathy
Homeopathy targets symptoms of disease. This approach
takes extremely small amounts of substances that treat similar
symptoms in healthy people when taken in large amounts.
Homeopathic products are so watered down that they really do not
have a measurable effect. They have not proven to be effective for
any clinical condition. Homeopathy has been called “The ultimate
hoax.” It should not be used.
Acupuncture
Acupuncturists claim to be able to treat a large number of
diseases. Yet, there is no evidence to show that it can reverse any
disease process. The majority of studies of acupuncture do not
show effects beyond a placebo response. Professor E. Ernst from
a Complementary Medicine program analyzed acupuncture. He

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states, “some findings are encouraging but others suggest that its
clinical effects mainly depend on a placebo effect.”
Acupuncture is based on the claim that the body’s vital energy
flows through channels connected to body organs and functions.
Those who study acupuncture believe disease is the result of an
unbalanced or blocked energy flow. Twirling needles in the skin at
certain specific sites is supposed to reverse both of these. Recent
studies however have shown that the acupuncture effect can
occur no matter where the needles are placed. This contradicts
centuries’ old beliefs. Those who value acupuncture try hard for
newer and better explanations for the “effect” of acupuncture. They
argue that acupuncture helps produce endorphins. At this time,
however, nothing appears more logical than acupuncture has a
placebo effect.
Acupuncture and many other Oriental medical practices are
becoming less popular in China. This is because China’s economy
has improved. People in China are also becoming better educated.
As a result, people in China are looking for higher quality medical
care. The Los Angles Times notes that, the number of traditional
doctors trained in China has fallen by nearly half since 1949. There
are about 270,000 traditional doctors in China. In that same period
the number of Western-trained doctors has jumped twenty-fold.
There are now more than 1.7 million in China. Traditional Chinese
medicine may still exist because the Chinese Government has
given it a protected status.
Chelation Therapy
Chelation therapy is used to treat coronary artery disease,
atherosclerosis, peripheral vascular disease, and a host of other
major and minor illnesses. This therapy is done by putting a
synthetic amino acid, EDTA, and other substances into a patient’s
bloodstream. This is done thorough a needle in their arm.
Chelation therapy proposes to reverse the swelling and disorder
in the walls of the arteries. There is no research to suggest that
this therapy does this. The therapy can, however, have serious
side effects.

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Therapeutic Touch
Proponents of therapeutic touch say that a therapist can change
a patient’s “energy field”. This change allows the patient’s body to
heal. Energy fields, however, have never been documented. Also,
recent studies show that this therapy has no value.
Ayurvedic Medicine
Ayurvedic medicine is closely associated with Deepak Chopra.
He has written several books. Here are some quotes from his
books.
• “When your actions are motivated by love….the surplus energy
you gather and enjoy can be channeled to create anything that
you want, including limited wealth.”
• “They say you have to give up everything to be spiritual, get
away from the world, all that junk. I satisfy a spiritual yearning
without making (people) think they have to worry about God
and punishment.”
• “….by consciously using our awareness, we can influence the
way we age biologically….You can tell your body not to age.”
Chopra promises “perfect health” to those who follow his advice.
He says patients need to use Ayurvedic methods to harness their
consciousness as a healing force.
Chopra does quite well financially from the products he offers.
He sells books, tapes, herbs and aromatic oils. Critics have
accused him of substituting superstition for medicine. We do not
recommend Ayurvedic methods or treatments.
Herbal Medicines
People have begun to use herbs in addition to diets to help
people stay healthy. Herbs are also very popular. Herbal medicine
is the most common form of alternative treatment in use. Problems
have come up because herbal medicine is accepted more and
more by the public. There is a large variety of herbal medicines now
available. Also, more people are practicing alternative medicine
and thus more people are prescribing herbs.
Herbs are processed or unprocessed plant parts, extracts
or essential oils. They reach the public in a variety of forms. You

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can get herbs in tablets, capsules, teas, elixirs, and powders. The
herb may be in pure form or mixed with various other unknown
substances. Because of the many different ways you can get them,
herbs have a large variety of active chemicals. What is mixed with
the herb and how much is often unknown and changes from batch
to batch. This means that you can use the same type of pill from
a company and have it be different in every bottle. Herbs can also
have both toxic and helpful materials. Sometimes they have both.
Herbs also have been known to contain recognized prescription
compounds.
It is hard to get complete information for most herbs. What is in
the herbal medicine, how pure it is, and how safe it is, is often not
easily found. It is also usually not clear how soon the herb needs
to be taken. The steps taken to make sure the herb supplement
is high quality is also not known. Finally, there is usually very little
information on how the herb interacts with other herbs, prescription
medicines and foods. Available information about herbs is often
only to help sell the product. As a result, the information is slanted
and not clear in its claims. This information is not based on sound
scientific evidence.
In the United States, medicines are regulated. This means
there are rules about what information is needed to decide if the
medicine is safe. There are also rules about what you have to tell
people about the product. Most herbal products are considered
unpatented dietary supplements. This was done because of a very
large lobbying effort by the health food industry. The lobbying led
Congress to pass the Dietary Supplement Health and Education
Act (DSHEA). This law said that herbs were not medicine but
something you took to help with nutrition missing in your diet. This
classification allows manufacturers of herbal products to side-step
FDA rules. As a result, herbal products are not examined as closely
as other drugs. It also prevents the FDA from removing worthless
herbal ingredients from the marketplace.
If herbs were viewed as drugs, as they often in fact are, the
FDA would oversee them. The FDA looks over drugs that are
being used to make sure they are safe and that they work the
way the say they do. The FDA also pays attention to which drugs
interact with other substances. Finally, the FDA says which dose
or amount of the drug is safe. This all has to be decided before the

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FDA will allow a drug to be available to the public. Once the drug
is being used by the public, the FDA still monitors their safety and
effectiveness. This process does not occur with herbal products.
The Dietary Supplement Health and Education Act, called the
DSHEA, also weakens the FDA’s ability to protect consumers.
Because herbal medicines are not under the same rules as other
drugs, the herbal industry does not have to prove the drug does
what they claim. Often, information about what the herbal drug
can do are only suggestions about what the drug might do. They
do not tell you that the drug was well tested and found to work.
In summary, the DSHEA requires no proof of efficacy or safety
and sets no standards for quality control for products labeled as
supplements.
Herbal products are made and used all over the world.
This presents other problems. It is well recognized that herbal
preparations vary considerably from country to country. This makes
it harder to figure out if herbs work since something made in China
may be very different than something with the same name made in
the US. There are many things that can effect how the herb works
on your body. These include:
• the soil or climatic conditions of the area where the herb was
grown and picked.
• The way the herb was stored.
• the materials that are mixed in with the herb.
Chinese herbal preparations have been known to also have
toxic heavy metals in them. Some have had dangerous compounds
including pesticides in them.
Different countries also watch over product safety differently.
Quality control also varies from country to country. It has been
reported that the German government has lower standards for
herbal remedies than for conventional drugs. Herbal remedies are
quite popular in Germany.
There are also other things about the way the herbs are
prepared that are troubling. Studies have shown that what is
listed on the label does not always match what is in the herbal
preparations. Sometimes there is not even enough of the desired
herb to be effective. This makes studies of how well the herb works
very difficult. Some herbal preparations are such that the desired

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active ingredient is broken down by the body’s digestive system.


This means the desired herb never reaches the bloodstream.
Some preparations that seem like they will not be harmful, such
as green tea, can end up being harmful. Green tea has a high
amount of vitamin K. Vitamin K can present real problems for
patients taking the blood thinner warfarin. One common form of
warfarin is Coumadin®. Ginseng can reduce the blood thinning
effect of warfarin. Other herbs can boost the effect of warfarin.
These include: garlic, gingko biloba, licorice root, and feverfew.
Anesthesiologists have voiced concerns about patients using
herbal products prior to surgery. They have noticed major changes
in heart rates and blood pressures in some patients taking St. John’s
wort, gingko biloba, and ginseng. Anesthesiologists recommend
that patients stop taking herbal preparations at least 2 to 3 weeks
before scheduled surgeries.
Most of these problems with herbal remedies would have
been discovered and examined by the FDA. For this to happen
though, the herbal remedy would have to be under the same FDA
rules as other drugs. If that were the case, herbs would have to
be made the same way if they were called by the same name.
Manufacturers would have to follow the generally accepted
standards of effectiveness and safety for that preparation. Because
herbal products are often real drug preparations, they should be
treated as such. Herbs should be under the same FDA scrutiny as
other drugs.
As plants do contain chemicals which could potentially
prove to be effective medicines, they could prove valuable if they
can meet the FDA standards for approval. A recent example is
a product, sinecatechins (Veregen), which is a water extract of
green tea leaves from Carnellia sinensis, approved by the FDA
for the treatment of genital warts. A recent example of the extent
of the herbal problem is the popular cold remedy, Airborne, which
has made millions for its makers. It claimed to prevent colds and
protect people from germy environments. The Center for Science
in the Public Interest states that its vitamin, mineral and herbal
mixture has no credible evidence to support its claims. The makers
of Airborne, in a recent success story for the proponents of
evidence based medicine, have agreed to a $23 million settlement
of a class action lawsuit for false advertising.

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There was a story in the newspaper about a well-known


athlete who almost died after using an herbal remedy. After taking
the over the counter herb, the basketball player had seizures and
stopped breathing. According to the FDA, the product, gamma
butyrolacton or GBL, was supposed to be used to help one sleep
after strenuous physical activity. The product also was supposed
to help muscles recover more effectively.
In an effort to make some sense out of the pages and pages
of information on herbs, we have created a table. In the table we
have summarized the best available data on several commonly
used herbs. It is important that you understand that a lot of the
information on herbs is not complete. The information is also rarely
supported with good data. We will point out some of the suggested
uses and the claims made for these preparations. We will attempt
to point out the possible effectiveness of these herbs. We will only
do this, however, if there is high quality data to support their claims.
For the data to be high quality, it must come from a study in the
U.S. that looked at how the herb affected humans and not just
animals. The study should have been large enough to adequately
test the drug. These studies should have taken place over a long
enough period of time so as not to distort the outcome. Appropriate
studies will have been reviewed by people who can make sure the
study was done correctly. We will incorporate quality studies of
both positive and negative findings. We will attempt to arrive at a
consensus opinion as to the proven effectiveness of a particular
herbal preparation. It would be even better if the studies were
repeated by other quality researchers who had similar findings.
We will point out the presence and degree of toxicity of herbal
preparations if they are known. It is impossible though to consider
all potential complications of using herbs with other medicines. It
is also hard to know about the toxicity of unrecognized compounds
mixed with the herbal preparations. Some of these preparations
can interfere with the effectiveness of other important prescription
medications. In other cases, the herb can make the drug more
powerful. This means the person would have too much of the drug
in their body. The herb can also make another drug more toxic.
The other downside to using herbs is that someone might wait to
get treatment for a cancer or illness that would do better if treated
early. The best thing you can do is to talk to your doctor about
your problems and the methods that you would like to use to treat

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it. Finally, we will give our best recommendation as to whether


these herbs should be incorporated into your health maintenance
or life-sustaining/advancing program. If toxicity data are unknown
or unavailable, we will note that with a question mark. We are
considering only usual dosages and not overdoses.
Some may argue that we have said too many negative things
about individual herbal products. In the past, in fact, similar barriers
might have prevented some of these herbs and supplements from
being available for public use. We would hope, however, that the
public is capable of learning from the past. You should expect and
even demand a thorough overview of products that are available
for you. Be careful about anything you would put into your often
defenseless body systems.
Many alternative medicines claim to improve the “immune
system.” These claims are often based on animal studies. The
researchers are guessing the medicine will help the immune
system based on a change in a laboratory test which may or may
not be relevant. Though interesting, we cannot guess how these
medicines affect humans. Another source of these claims are data
which seem to show changes in some marker for the immune
system in humans. Though these changes are real, these are only
laboratory tests. Similar changes can be brought about by such a
simple thing as exercise. The actual significance or value of these
changes and their meaning for short or long term health itself is
unknown.
In spite of the many promises, alternative medicine practices
are not short-cuts to living longer and healthier lives. In fact,
according to Professor Bausell, “There is no compelling, credible
scientific evidence to suggest that any CAM therapy benefits
any medical condition or reduces any medical symptom (pain or
otherwise) better than a placebo.” Of course, should any of these
CAM therapies be found to be effective, that therapy becomes part
of conventional medicine.

201
medical condition or reduces any medical symptom (pain or otherwise) better than a
placebo.” Of course, should any of these CAM therapies be found to be effective, that
therapyLiving
becomesHealthier and Longer –  
part of conventional What Works, What Doesn’t
medicine.

Medicinal Toxicity
Use/Claims Effective Recommendation
Herbs Mild Serious
Androstenedione Boost athletic No Yes Yes Avoid
performance
Chamomile Sedative; Anti- No Yes Yes Avoid
Inflammatory;
Wound healing
Chaparral Blood purifier, No Yes Yes Avoid
Cancer cure
Chondroitin, Arthritis relief No Yes ? Questionable
Glucosamine value; better
Sulfate treatments
available, studies
in progress
Chromium Fat burner; No Yes Yes Avoid
Picolinate Muscle builder
Cholestin Treats high Yes, as Yes Yes Best to take
cholesterol “statin” quality controlled
FDA-
Approved “statin”
Co Q10 Enhances No Yes Yes Avoid
energy levels;
Cardiac support;
Prevents aging
Creatine Performance No Yes Yes Further studies
enhancer needed; won’t
benefit most
potential users
Dong Quai Regulate No Yes Yes Avoid
menses; ease
cramps
DHEA Anti-aging No Yes Yes Avoid
remedy; Energy
booster; Retard
memory loss
Echinacea Wound healing; No Yes Yes Avoid
Infections; Colds
Ephedra Weight control; No Yes Yes Avoid
Energy booster;
Asthma
treatment
Feverfew Migraine Yes Yes Yes More studies
Prophylaxis needed
Garlic Preventing heart No Yes Yes Good with food
disease; preparations
Lowering serum
lipids; Fighting 173
infection
Ginger For nausea and Yes Yes ? Possibly useful;
motion sickness more studies
needed
Gingko Biloba Improve mental No Yes Yes Avoid
function; Slow
aging; Vascular
health
Ginseng Treatment of No Yes Yes Avoid
atherosclerosis;
Relieve
symptoms of
aging; Senility
and cancers;
Aphrodisiac,
etc., etc.
Goldenseal Antidiarrheal;
202
Unknown Yes Yes Avoid
antiseptic
Green tea Cancer Yes More studies
prevention needed
lipids; Fighting
infection
Ginger For nausea and Yes Yes ? Possibly useful;
medical condition motion
or reduces any medical symptom (pain or otherwise)more
sickness better than a
studies
placebo.” Of course, should any of these CAM therapies be found to be effective, that
therapy
Living Healthier
becomes part
and Longer –  
of conventional
What Works, What Doesn’t
medicine.
needed
Gin gko Biloba Improve mental No Yes Yes Avoid
function; Slow
Medicinal aging; Vascular Toxicity
Use/Claims
health
Effective Recommendation
Herbs Mild Serious
Ginseng
Androstenedione Treatment
Boost athleticof No Yes Yes
Yes Yes Avoid
atherosclerosis;
performance
Chamomile Relieve
Sedative; Anti- No Yes Yes Avoid
symptoms
Inflammatory; of
aging;
WoundSenility
healing
Chaparral and
Blood cancers;
purifier, No Yes Yes Avoid
Aphrodisiac,
Cancer cure
Chondroitin, etc., etc.relief
Arthritis No Yes ? Questionable
Goldenseal
Glucosamine Antidiarrheal; Unknown Yes Yes Avoid better
value;
Sulfate antiseptic treatments
Green tea Cancer Yes More studies
available, studies
prevention needed
in progress
Kava kava
Chromium Relieving
Fat burner; Yes
No Yes Yes Better studied
Avoid
Picolinate anxiety;
Muscle builder drugs available
Cholestin Sedative
Treats high Yes, as Yes Yes Best to take
Melatonin Helps with sleep Questionable
cholesterol “statin” Yes Yes More research
quality controlled
and jet lag; Anti- (sleep) needed; no anti-
FDA-
aging aging use “statin”
Approved
Saw palmetto
Co Q10 For symptoms
Enhances Questionable
No Yes Yes ? Better meds
Avoid
due
energyto prostate
levels; available
enlargement
Cardiac support;
Shark cartilage Cancer
Prevents aging No Yes ? Avoid
Creatine treatment;
Performance No Yes Yes Further studies
maintains
enhancer needed; won’t
healthy joints benefit most
St. John’s Wort Natural Yes Yes Yes More long-term
potential users
Dong Quai antidepressant
Regulate No Yes Yes and better studies
Avoid
menses; ease needed. Better
cramps drugs available for
DHEA Anti-aging No Yes Yes significant
Avoid
remedy; Energy depression
Valerian Sleep
booster;aidRetard Yes Yes Yes Better agents
memory loss available
Yohimbe
Echinacea Treatment
Wound healing;of Inconclusive
No Yes Yes Take only with
Avoid
male erectile
Infections; Colds physician
Ephedra dysfunction
Weight control; No Yes Yes supervision
Avoid
Energy booster;
Recommendations: Asthma
treatment 174
1. If you are using
Feverfew Migraine herbal remedies,
Prophylaxis
Yes tell your
Yes physician.
Yes More studies
needed

2. If you are thinking about using an alternative medicine practice,


look for a sound study that tested it. See if the practice was
173
found to be effective.
3. Research to see if any herb you might take has toxic side
effects. Also, check to see if the herb can cause problems
when taken with blood thinners.
4. Before using alternative remedies for any problem talk with
your doctor. Your doctor will help you decide if you need
medical attention.

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5. Before you take an herb, talk with your doctor. It is possible the
herbs you take could react negatively with another medicine
that you are already taking.
6. In their book, The Vitamin Pushers, Barrett and Herbert
strongly suggest that “The most prudent course of action is
to forget about using herbs for medicinal purposes.” We agree
with their advice.
7. Avoid using any form of alternative medicine that has not been
proven to work.
Further Reading
Barrett S, Herbert V. The Vitamin Pushers. Prometheus
Books:1994.
Bartecchi CE. The Alternative Medicine Hoax. Garev Publishing
Int.:2003.
Bausell RB. Snake Oil Science: The Truth About Complementary
And Alternative Medicine. Oxford University Press:2007. Excellent
review of many alternative medicine, CAM treatments by a non-
physician, bio-statistician.
Cracking down on health fraud. FDA Consumer Magazine.
November-December, 2006.
Ernst E. Acupuncture: a critical analysis. Journal of Internal
Medicine. 2006:125-137.
Friedrich MJ. Exercise may boost aging immune system. Journal
of the American Medical Association. January 9, 2008:160-161.
Gardiner P, Phillips R, Shaugnessy AF. Herbal and dietary
supplement drug interactions in patients with chronic illnesses.
American Family Physician. January 1, 2008:73-78.
Jaroff, Leon. What will happen to alternative medicine? Time
Magazine. November 8, 1999:77.
Relman A. A trip to stonesville. The New Republic. December 14,
1998.
Sloan RP. Blind Faith. St. Martin’s Press:2006.

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Living Healthier and Longer –  What Works, What Doesn’t

Swartzberg JE. Dietary supplements: the wellness reports.


Berkeley School of Public Health. University of California.
http://www.quackwatch.com. Excellent source of information on all
alternative medicine therapies.
For information about herbal and dietary supplement drug
interactions:
• http://nccam.nih.gov
• http://www.medscape.com/druginfo/druginterchecker
• http://www.herbmed.org

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Living Healthier and Longer –  What Works, What Doesn’t

IN SUMMARY
I could not at any age be content to take my place in a
corner by the fireside and simply look on. Life was meant to be
lived. Curiosity must be kept alive. The fatal thing is rejection.
One must never, for whatever reason, turn his back on life.
-Eleanor Roosevelt
Current scientific data provides a great deal of information on
how to live a long and healthy life. Better yet, the things we must do
to achieve this goal are not so difficult or unpleasant that we would
need to wonder if they are worth the effort. In fact, many healthy
principles were taught to us by our mothers, who admonished:
• Don't smoke.
• Eat your fruits and vegetables.
• All that greasy food isn't good for you.
• Don't sit around. Go out and play!
• Let's do some work around here.
• You're getting fat. Don't eat so much junk.
• Why do you have to drink (alcohol)?
• Drink your milk.
• Don't ever let me hear that you are using drugs.
• Get your sleep. Don't stay up all night.
• What did the doctor tell you to do?
• Why don't you find yourself some nice friends?
• Buckle-up.
• Leave the magnets on the refrigerator where they belong.
In this era of great medical advancements, physicians feel
compelled to modify somewhat the wonderful words of wisdom
passed on to us by our mothers. They might rephrase the messages
to say:
• Don't smoke or use any tobacco product. Avoid second-hand
smoke.
• Eat at least 6 servings of fruits and vegetables each day.
• Eat a diet low in fat, especially trans-fats, saturated fat and
cholesterol.
• Know your blood pressure and be sure that it is normal.

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• Exercise. Walk (or do some other aerobic activity) at least one-


half hour each day.
• Keep your weight as close as possible to ideal for your height
and build.
• Work closely with your physician on cancer screening, blood
pressure control, and immunizations.
• Avoid more than 1 or 2 alcoholic drinks daily.
• Stay away from all illicit drugs.
• Maintain a supportive social network – friends, family.
• Demand proof of efficacy before using any alternative medicine
therapies.
If you follow this advice, either your mother's or your physician's,
you will live a longer and healthier life.
Further Reading
We have made every effort to provide further reading
information, inexpensively, for those seeking more. This can be
done by addressing the web sites of several excellent government
sources – CDC, NIH, FDA, etc. Other outstanding sources of
information on topics related to living a healthier and longer life are
available, though at some extra cost. These excellent resources
include:
Harvard Health Letter. 10 Shattuck St., Boston, MA 02115.
Harvard Heart Letter. 10 Shattuck St., Boston, MA 02115
Berkeley Wellness Letter. The University of California, P.O. Box
420235, Palm Coast, FL 32142.
Health after 50. The Johns Hopkins Medical Letter. 550 North
Broadway, Suite 1100, Johns Hopkins, Baltimore, MD 21205-
2011.
Mayo Clinic Health Letter. 200 First Street SW, Rochester, MN
55905.
Tufts University Health & Nutrition Letter. 53 Park Place, New York,
NY 10007

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Living Healthier and Longer –  What Works, What Doesn’t

WHAT WORKS – WHAT DOESN’T


In this chapter, the authors have chosen to suggest those
strategies – programs, activities, and drugs, which are best
suited to help you live a healthy and longer life. Regarding drugs,
usually drug classes will be mentioned as specific drugs need to
be determined by the patient’s physician according to the specific
needs of the patient. The need to balance effects with potential
side effects, the patient’s age, the person’s weight and history
of allergies to drugs or drug classes must be considered. Also
important to the consumer is knowing which, of all the media and
Internet hyped treatments and drugs, don’t work and might be
harmful, or just a waste of money. More detailed information will
be found in the respective chapters or in the references provided
at the end of each chapter.
CORONARY HEART DISEASE
What works:
• Diet, Mediterranean diet desirable, alcohol limitations.
• Diet, weight reduction to ideal weight if overweight.
• Exercise.
• Blood pressure control.
• No smoking or contact with second-hand smoke.
• Efforts to manage stress.
• Strict cholesterol control.
• If diabetic, strict blood sugar control.
Drugs:
• Statins, niacin, fibrates.
• Beta-blockers.
• ACE inhibitors, Angiotensin receptor blockers (ARBs).
• Aspirin.
• Nitrates.
What doesn’t work:
• Illicit and recreational drugs.
• Any herbal preparation.

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Living Healthier and Longer –  What Works, What Doesn’t

HIGH BLOOD PRESSURE


What works:
• Diet, DASH diet desirable.
• Diet, weight reduction to ideal weight if overweight.
• Sodium (salt) restriction.
• Exercise.
• Close blood pressure control, with goal of 130/80 mm Hg or
less.
• Smoking cessation.
• Alcohol restrictions.
• Efforts to manage stress.
• Cholesterol control.
• Home blood pressure measurements.
Drugs:
• Thiazides, beta-adrenergic antagonists, calcium channel
antagonists, angiotensin-converting enzyme inhibitors
(ACE-I), angiotensin receptor blockers (ARBs), direct-acting
vasodilators.
What doesn’t work:
• Numerous medicines that raise the blood pressure such
as appetite suppressants, cocaine, female hormones, pain
medicines cold remedies, anabolic steroids, etc.
• No herb or alternative medicine treatment is of any value in
lowering significant blood pressure elevations.
STROKE
What works:
• Good blood pressure control.
• Diet, weight reduction, if overweight.
• Avoid smoking and second-hand smoke.
• Control cholesterol levels.
• Control diabetes if present.
• Periodic cardiac evaluations looking for rhythm problems,
artery occlusions.
• Thorough evaluations of TIAs.
• Exercise.

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Living Healthier and Longer –  What Works, What Doesn’t

Drugs:
• Aspirin or clopidogrel (Plavix).
• Statin drugs for many.
What doesn’t work:
• Illicit and recreational drugs.
• Herbs or other supplements.
• Alternative medicine treatments for post stroke debilities.
CANCER
What works:
• Diet, weight reduction if necessary.
• Routine screening for cancers.
• Avoiding cigarettes and second-hand smoke.
• Checking homes for radon.
• Attention to family histories.
• Avoiding excessive exposure to ultraviolet radiation.
• Exercise.
• Alcohol restriction.
• Avoiding unnecessary diagnostic X-rays.
Drugs:
• Numerous anti-tumor drugs, radiation therapy and surgery.
What doesn’t work:
• No herb or supplement has been shown to prevent, treat, or
improve cancer.
• No alternative medicine therapy has been shown to prevent,
treat or improve cancer.
DIABETES
What works:
• Diet, weight loss if necessary.
• Good blood sugar monitoring and control.
• Good diabetic education.
• Exercise.
• Not smoking, avoiding second-hand smoke.
• Blood pressure control, less than 130/80 mm Hg.
• Good cholesterol control.

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Living Healthier and Longer –  What Works, What Doesn’t

• Close watch for cardiac, kidney, and eye complications.


• Close follow-up with a skilled physician.
• Frequent evaluation and care of the feet.
• Yearly eye exams.
Drugs:
• Aspirin.
• Exenatide.
• Oral antidiabetic drugs.
• Insulin.
• Statins.
• ACE inhibitors.
• Anti-hypertensive medicines if needed.
• Erectile dysfunction medications if needed.
What doesn’t work:
• No herb has any value for diabetic patients.
• No supplement other than a daily, standard multiple vitamin is
of any value.
• Thiazolidines could be a problem in older diabetic patients
due to increasing sodium and water retention causing heart
failure.
• Selenium is not helpful and could cause problems.
BONE DISEASE
What works:
• Diet.
• Exercise.
• Not smoking.
• Limiting alcohol.
• Knowledge of family osteoporosis history.
• Checking for low testosterone in men.
• DEXA scanning of certain age groups or suspects.
• Reasonable amount of sun exposure.
Drugs:
• Adequate calcium in diet or supplements taken properly.
• Vitamin D3.

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Living Healthier and Longer –  What Works, What Doesn’t

• Bisphosphonates and human parathyroid hormone.


• Adequate Vitamin K in diet.
What doesn’t work:
• Glucocorticoid therapy for other problems.
• Certain medications, anticonvulsants, heparin, etc.
• Proton pump inhibitors for long periods.
• No herbal preparation is of any value.
DEMENTIA
What works:
• Exercise.
• Knowledge of family history.
• Search for reversible causes.
Drugs:
• No treatment has been proven to stop Alzheimer’s Disease.
• Acetylcholinesterase inhibitors are of limited value.
• NMDA-receptor antagonist of some value.
• Possibly some value for statin drugs.
What doesn’t work:
• Excess vitamins, minerals or other supplements.
• No herbal has proven effective.
INFECTIONS
What works:
• Immunizations.
• Education of at-risk groups or people.
• Avoidance of risky lifestyles.
• Simple cleanliness activities like hand-washing.
• HIV screening tests for most people.
• Avoiding illicit or recreational drugs.
What doesn’t work:
• No alternative medicine treatment or herbal preparation has
proven effective for an infectious disease, or HIV/AIDS.

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Living Healthier and Longer –  What Works, What Doesn’t

SEX
What works:
• Correcting complicating diseases.
• Treating emotional or psychiatric disorders.
• Tests for low testosterone in males.
• Search for medications that can cause sexual dysfunction,
there are many.
• Alcohol restriction.
• Improving cardiovascular situation.
• Not smoking.
• Education of involved individual or couples.
Drugs:
• Phosphodiesterase inhibitors.
• Testosterone therapy for some men.
• In some cases, antidepressants.
What doesn’t work:
• Yohimbine – too many complications.
• Herbs or other supplements have no effect unless they contain
phosphodiesterase inhibitors.
• Most aphrodisiacs have only a placebo effect.
INJURIES/ACCIDENTS
What works:
• Seat belts and helmets.
• Avoiding alcohol and illicit drugs.
• Not smoking.
• Sleep disorder evaluation.
• Vision and hearing evaluations.
• Considering problems from prescription medications.
• Assuring safe environments at home.
What doesn’t work:
• Elderly people taking anti-anxiety medications.
• Driving after drinking or using mind-altering drugs.
• Not overseeing medication taking by the elderly.
• Demented elderly with drivers licenses.

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Living Healthier and Longer –  What Works, What Doesn’t

POLYPHARMACY AND ILLICIT DRUGS


What works:
• Knowing the name and dose of your drugs, what they do, and
potential side effects.
• A knowledgeable, helpful pharmacist.
• Help from family members for elderly patients.
• Education about illicit drugs.
• Seeking help from physician or counselor.
• Supportive family and friends.
What doesn’t work:
• Trying to overcome drug addiction without help.
SMOKING
What works:
• High tobacco taxes.
• Non-smoking ordinances.
• Quitting “cold-turkey”.
• Education.
• Exercise.
Drugs:
• Varenicline (Chantix).
• Bupropion (Zyban).
• Nicotine replacement therapy.
• Nortriptyline.
What doesn’t work:
• Hypnosis.
• Herbs or supplements.
• Acupuncture or other alternative medicine treatments.
CHOLESTEROL
What works:
• Diet.
• Exercise.
• Knowledge of family history.
• Not smoking.

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Living Healthier and Longer –  What Works, What Doesn’t

• Moderate alcohol drinking.


• Knowing lipid levels and attaining goals.
• Check for drugs and diseases that can elevate lipids.
Drugs:
• Statins.
• Niacin.
• Ezetimibe, though further supporting information needed.
• Fibrates.
• Omega-3 fatty acids.
What doesn’t work:
• Herbs or supplements.
• High dose vitamins.
OBESITY
What works:
• Diet/calorie reduction along with a multiple vitamin.
• Exercise.
• Knowing body shape and waist measurement and resulting
risk.
• Education and a supportive physician
• Thin friends and associates.
• Bariatric surgery.
• Legitimate weight-loss organizations.
Drugs:
• Orlistat.
• Physician prescribed appetite suppressants such as
phentermine and sibutramine.
• Psychotherapy.
What doesn’t work:
• Enviga (a drink).
• Herbs or supplements.
• “Fad” diets.
• Rimonabat.

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Living Healthier and Longer –  What Works, What Doesn’t

ALCOHOL
What works:
• Moderate drinking always.
• Education.
• Treatment of associated depression.
• Psychotherapy.
• Balanced diet with vitamin and mineral supplements.
• Alcoholics Anonymous.
Drugs:
• Disulfiram, naltrexone, acamprosate, and topiramate.
STRESS AND DEPRESSION
What works:
• Physician help and/or counseling.
• Early detection by friends or family members.
• Exercise.
• Family support.
• Knowledge of family history.
• Pets.
• Belonging to religious community or other support groups.
• Electroconvulsive therapy – rarely needed.
Drugs:
• Anxiolytic agents – many.
• Antidepressants – Selective serotonin re-uptake inhibitors,
tricyclics, tetracyclics, lithium.
What doesn’t work:
• Alcohol.
• Herbs or supplements.
IMMUNIZATIONS
What works:
• Obtaining all the necessary immunizations at the appropriate
ages, and keeping them current.
• Special immunization needs related to travel.

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Living Healthier and Longer –  What Works, What Doesn’t

What doesn’t work:


• Herbs or supplements do little to prevent or reverse flu or viral
problems or stimulate immune system.
DIET
What works:
• Diet, as suggested in this text.
• Education.
• Exercise.
• Simple vitamin, mineral preparation.
What doesn’t work:
• Fad diets.
• Herbs or supplements.
• Antioxidants other than what is in foods.
• Megavitamins.
• Trimspa, Cortislim, or Xenadrine.
EXERCISE
What works:
• Exercise as much as possible within the guidelines suggested
in this text.
• Exercise daily throughout life.
• Aerobic exercises.
• Do exercises that you enjoy.
What doesn’t work:
• Anaerobic exercise.
• Many forms of yoga.
SLEEP
What works:
• Look for sleep apnea.
• Don’t smoke.
• Moderate alcohol intake.
• Look for medical or psychiatric problems that can interfere with
sleep.
• Look for the many drugs that can interfere with sleep.

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Living Healthier and Longer –  What Works, What Doesn’t

• Reducing coffee/caffeine intake.


• Treatment of depression if present.
• Weight loss if obese.
Drugs:
• Many effective short term sleep aids, see text.
What doesn’t work:
• Herbs or supplements.
VITAMINS AND SUPPLEMENTS
What works:
• A single daily vitamin/mineral supplement contents as set by
the FDA.
• Always best to get vitamins/minerals from food.
• Obtain vitamins from a quality manufacturer.
• Extra vitamin D as suggested in the text.
• Some people with special needs, pregnant, vegetarians.
What doesn’t work:
• Megavitamin formulas.
• Purchasing vitamins or supplements from your health care
provider.
ALTERNATIVE MEDICINE
What works:
• Nothing has been scientifically proven to work over and above
the placebo effect, or placebo like effect.
• No alternative medicine therapy has been scientifically shown
to cure any disease.
• Though herbs are plants and do contain chemicals and
compounds, and likely could have some chemical effect in
our bodies, most have not been shown to relieve or cure any
disease process.
• Education.
• For some people, alternative medicine therapies, such as
yoga, provide a form of relaxation and a feeling of control of
their bodies.

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Living Healthier and Longer –  What Works, What Doesn’t

What doesn’t work:


• Taking herbs with other prescription medications.
• Not telling your doctor what you are taking.
• Having a disease and not utilizing conventional medicine
treatment.
• Not being skeptical about media and internet claims for a
variety of physical and mental problems.
• Taking herbs prior to surgery.
AGING
What works:
• Following the principles laid forth in this text can surely help
one to live a healthy life and avoid problems, habits, mistakes
and well meaning therapies that could potentially shorten
one’s lifespan.
Drugs:
• None.
What doesn’t work:
• All the hormones, vitamins, nutritional supplements,
antioxidants and “secret” formulas that claim to extend life.

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Living Healthier and Longer –  What Works, What Doesn’t

About The Authors


Carl Bartecchi and Robert Schrier are a unique physician
team that has worked together for nearly 3 decades in several
health care and educational areas. Dr. Bartecchi, a pre-eminent
practitioner of internal medicine for more than 30 years, has
been recognized nationally, having received both the prestigious
American College of Physicians’ Ralph O. Claypoole Memorial
Award and Colorado’s Distinguished Internist Award of the
American College of Physicians. Bartecchi is also Distinguished
Clinical Professor of Medicine at the University of Colorado School
of Medicine.
Dr. Schrier is Professor of Medicine at the University of Colorado.
He was Chairman of the Department of Medicine at the University
of Colorado for 26 years. For his contributions as Chair, in 1996
he received the Robert H. Williams Award from the Association of
Professors of Medicine as the outstanding Chairman of Medicine in
the country. He is a Master of the American College of Physicians,
and has received the John Phillips Award, the highest honor of that
124,000 member organization of internal medicine specialists. He
is also an Honorary Fellow of the Royal College of Physicians, and
has received many prestigious awards and honors from national
and international medical associations. Dr. Schrier has authored
over 900 publications in respected medical journals.
Although educating physicians and patients has been the
continual focus of Bartecchi and Schrier, this text, Living Healthier
and Longer – What Works, What Doesn’t, is written for the lay
public in response to patients’ requests and the need for medically
sound and substantiated data. The text includes the best scientific
and practical information available for people who desire to make
reasonable efforts to extend the quality and length of their lives.

220
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