Why do my feet tingle?

Peripheral neuropathy is a common condition, affecting some 6% of adults 45 or older.

What is it, what causes it and what can you do about it?

Our nervous system consists of the central nervous system (CNS) – the brain and spinal cord – and the nerves that carry sensation to and commands back from the CNS. These nerves are the peripheral nervous system.

The peripheral nerves can be thought of as the body’s wiring system. There are sensory nerves that bring sensations of touch, temperature and pain to the CNS, motor nerves that carry commands from the CNS to our muscles, and autonomic nerves, that regulate bodily functions not usually under conscious control such as heart rate, breathing and gastrointestinal function.

Many things can damage nerves, some of which happen no matter what we do while others are under our control.

If sensory nerves are damaged, we may be unable to feel hot or cold or where our feet are, or we may feel numbness or tingling, or we may feel pain for no reason.

If motor nerves are involved, you will notice muscle weakness.

Autonomic neuropathy can have many effects, including drop in blood pressure when you stand up.

Because the nerves to the feet are the longest peripheral nerves, they are most susceptible to damage and usually the first to suffer. Hence, we usually notice abnormal sensation in the feet rather than higher up. The fingers may be next.

What causes peripheral neuropathy? The commonest known cause is diabetes; the longer and more poorly controlled is the diabetes, the more likely to result in neuropathy. Another common cause is excess alcohol. Vitamin deficiency, particularly of B12 and other B vitamins, is a very treatable cause. (Oddly enough, excess B6 can also cause neuropathy!) Chemotherapy often results in neuropathy.

There are numerous diseases, too many to list, that have peripheral neuropathy as one of their symptoms.

Finally, there is that great wastebasket of “we do not know.” One of the commoner causes of peripheral neuropathy is simply aging, with no specific disease found after thorough testing.

What can you do? If you notice any of the symptoms listed above, bring it to your doctor’s attention. Verifying the presence of neuropathy is usually easily done by physical exam. If it appears likely, you should probably see a neurologist for a more thorough exam and testing.

To minimize the likelihood of developing neuropathy, eat a healthy diet with lots of fruits and veggies to get your B vitamins and minimize your alcohol intake. If you have diabetes, work with your doctors and nurses to keep it under good control.

Do not dismiss it (or let your doctor dismiss it) as simply aging. Only after treatable causes are excluded is this an acceptable conclusion.


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Are you taking a daily aspirin?

Should you be taking a daily aspirin?

First, a little bit of (easy) basic science: we cut ourselves all the time, and nature has given us protection against bleeding to death every time this happens.

The first line of defense is our platelets, small blood particles that go to the site of disrupted blood vessels and plug any small holes, like the little Dutch boy at the dike.

The second and more permanent way bleeding is stopped is that proteins in our blood form clots.

These protective forces can cause harm. Platelets attracted not to a hole in an artery but to an irregular surface such as a cholesterol plaque can block off the artery, causing a heart attack or stroke.

(Unneeded clots can also cause problems – we will discuss that another day.)

Aspirin works to prevent platelets from clumping together. This effect is rapid and effective: a single dose of 81 or 162 mg (“low dose”) aspirin paralyzes all the circulating platelets. Platelets turn over rapidly; you get an entirely new set every 7 days, so a single dose will be effective for a few days only.

Many decades ago, it was shown that daily low dose aspirin started within 24 hours of a heart attack dramatically reduced the risk of another heart attack and stroke. This effect is called “secondary prevention:” preventing a recurrence, and nothing has changed this benefit. If you have coronary disease, you should be on aspirin unless you are at very high bleeding risk.

The problem comes when the prescription of aspirin moves from this valid use to broader use. It seems logical that if aspirin taken after a heart attack prevents another one, taking aspirin before a heart attack should prevent a first one, so-called “primary prevention.”

Aspirin taken this way DOES decrease a first heart attack or stroke, but only by a very small amount. This benefit is typically outweighed by the increased risk of bleeding that comes with aspirin use.

The higher your risk of heart attack or stroke and the lower your risk of bleeding, the more the evidence says to take aspirin. If you have multiple risk factors such as hypertension, high cholesterol, smoke and have a positive family history, and particularly if you have a high coronary calcium score, the more likely you would benefit from daily low dose aspirin.

If your coronary risk is only moderate and if you have had a bleeding ulcer or other serious bleeding, you are better avoiding aspirin.

In between? The old fallback: talk to your doctor!

No known major coronary risk? The risks almost certainly outweigh the benefits.


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How much water do you need?

It depends!

Water truly is life – we can go without eating for weeks and survive but get very sick if we do not get adequate water for a few days.

You are doubtless familiar with “rules” such as the need to drink 8 glasses of water a day. The problem with relying on such simple rules is that the real answer truly is “it depends.”

A man who is 6’5” and weighs 205 lbs. needs more water than a woman who is 5’4” and weighs 110.

It is currently sunny and pushing 90 degrees F. Walking up to get the mail left me sweating. We clearly need more water under these conditions than we do when it is 65 and shady.

People doing physical work outdoors in the heat need more water than those sitting at desks in air-conditioned offices.

“Water” includes most other liquids such as herbal tea and fruit juice – but not caffeinated drinks or alcohol, which tend to pull water out of the body.

Finally, and perhaps less obvious, we do not get water only by drinking. Many foods, particularly fruits and vegetables, contain significant amounts of water. Our habitual diet will change the amount of water we need.

Then how do you know how much water to drink? A simple reliable way to assess this is to look at your urine. If your urine is dilute – clear to pale yellow in color – you are adequately hydrated. If your urine is closer to apple juice than lemonade in color, you are dehydrated and need to drink more.

If your urine is very dark, you ought to seek medical attention, as you may need intravenous fluids.

Do not depend on thirst as your sole indicator. If you are thirsty, you are probably somewhat dehydrated, but lack of thirst is not as reliable as the color of your urine.

So: drink up!


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A shot in the knee?

A lot of us develop osteoarthritis (“wear and tear arthritis” – though the process is not that simple) as we age.

If it is truly disabling, surgery may be the only way to reduce pain and increase mobility, but there are many less invasive options. Do any of them work?

Let’s get one myth out of the way first. Many people see an orthopedic surgeon and are told “your knee(s) are bone-on-bone, and nothing will work but surgery.” This is very often an exaggeration. There may be complete loss of cartilage in a portion of the knee, but rarely does this involve the whole knee. If it is on one edge, a brace may give great relief. The decision to have surgery should almost never be based on an X-ray.

The most time-tested non-surgical approach is an injection of a cortisone-type product into the knee, usually accompanied by a local anesthetic. This injection generally starts working in 2 days, and the effect may last 3-4 months. I had patients who got these shots 3-4 times a year for several years with good relief.

Like any treatment, cortisone shots do not work for everyone, and there is a worry that the drug may hasten deterioration of cartilage. The treatment is universally covered by Medicare and commercial insurance plans.

Hyaluronic acid is a lubricant that mimics the body’s natural joint fluid and injecting it into the knee is another “standard” procedure that is covered by insurance. Since most of the product leaks out of the joint within a few days, it is unclear how it works, and recent studies have suggested that it has largely a placebo effect.

Newer treatments are available that are considered experimental and typically NOT covered by insurance.

One is injection of platelet-rich plasma (PRP), drawn from your own blood, centrifuged to separate the PRP from the rest of the blood and injected into the knee. These seem to work by reducing inflammation and may provide relief for as long as a year. Be prepared to pay several thousand dollars out of pocket if you go this route.

Widely advertised is the use of stem cell injections, which can theoretically grow new cartilage. The jury is still out on this, but most studies show benefit lasting only 3-4 months. The cost, in the thousands, will almost certainly not be covered by insurance.

The newest kid on the block is radiofrequency ablation (RFA) of the pain nerves in the knee. This treatment has been shown to give pain relief for up to six months. It is minimally invasive and has few side effects, but is often not covered by insurance, at least not without prior approval from your insurance company.

Knee replacement surgery is generally, but far from always, successful. If you opt for this surgery, know that you must be committed to doing a lot of physical therapy for many months to get the best result.

Do not forget weight loss! Whether through use of the newer drugs or old-fashioned diet, significant weight loss will usually help your knees.


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Do you feel safe at home?

Domestic violence has been a plague throughout human history, but only in recent decades has it come to the forefront of medical and legal concerns.

Domestic violence or "intimate partner violence", is a pattern of behavior in any relationship that is used to gain or maintain power and control over an intimate partner. Abuse can be physical, sexual, emotional, or psychological.

While domestic violence most commonly involves a male against a female, the victim can be of any gender or age.

How common is domestic violence? Nearly 3 in 10 women (29%) and 1 in 10 men (10%) in the US have experienced rape, physical violence, and/or stalking by a partner and reported it having an impact on their functioning. In the United States, more than 10 million adults experience domestic violence annually.

Since the abuser is a spouse or companion, and often repeatedly apologizes and promises to stop, the victim is often reluctant to call the police, and the pattern continues.

If there are children, the victim may be even more reluctant to separate, and the children become emotionally (if not physically) traumatized.

Once thought of as a problem among lower socioeconomic classes, we now know that domestic violence is prevalent in every community, and can affect anyone regardless of age, socioeconomic status, sexual orientation, gender, race, religion, or nationality.

If you are the victim, or you know someone who is a victim, what can you do? First, know that it is NOT your fault. Disagreements among spouses or other domestic partners are normal and common, but never justify violence.

If you feel you are in immediate danger, call 911 and get help getting away from your abuser.

Find someone you can trust and seek their help. This may be your physician, pastor, or a close friend or relative. You almost certainly cannot solve the problem yourself.

For anonymous, confidential help, 24/7, call the National Domestic Violence Hotline at 1-800-799-7233 (SAFE) or 1-800-787-3224 (TTY). Almost every state has 24/7 hotlines and most offer immediate help with shelter and legal resources.

If you suspect a friend or relative may be a victim, you can help. Be aware of clues such as bruising, cut lip or emotional withdrawal. Listen – let them know you want to help – but do not offer concrete advice until asked. Believe them – you may find it hard to believe but know how common the problem is.

Reassure them that you believe them, that it is NOT their fault and that they do NOT “deserve” what is happening. Help the victim create a safety plan that can be put into action if violence occurs again or if they decide to leave the situation.

This should include a safe place to go in an emergency, or if they decide to leave, a way to let family or friends know what is happening and an "escape bag" with cash, important documents (birth certificates, social security cards, etc.), keys, toiletries, and a change of clothes that can be easily accessed in a crisis.

Domestic violence will probably never disappear, but you do not have to accept it.


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We are having a heat wave...

The U.S. and most of the world experienced unprecedented heat waves last summer, and this summer promises more of the same. The Northeast is set to experience it’s first official heat wave as I write. Extreme heat can cause serious health issues, including death, so prepare – prevention is much better than treatment.

The body is generally quite good at maintaining a normal internal (or “core”) temperature. We get rid of excess heat by increasing blood flow to the skin, where it can be removed by air flowing over us, and by increasing sweating, which dissipates heat as it evaporates.

In extreme heat conditions, these mechanisms may be inadequate, and our core body temperature rises. The heart feels the stress – it works much harder trying push more blood through dilated blood vessels.

The first sign of heat beyond the body’s ability to cope are cramps and “heat exhaustion:” dizziness, weakness, nausea, headache, and an unsteady gait. If the sufferer is moved to a cool environment, these symptoms will usually pass.

If the core body temperature exceeds 104 (40C), you may go on to experience “heat stroke.” This life-threatening condition begins with confusion and can go on to seizures, delirium, coma, and death if untreated.

While everyone can experience these heat-related emergencies, certain people are at higher risk: children and the elderly, those doing physical work outdoors and those taking medications that impair the body’s response to heat (such as diuretics – fluid pills - many psychiatric drugs and anticholinergics, used for some urinary and bowel problems).

How can you prevent heat-related illness? The most obvious is the most important: stay cool! Keep blinds down to lessen indoor heat; use your air conditioner, and if only 1 or 2 rooms have AC, stay in those rooms. If you do not have AC, use public places that do, such as the library or official cooling sites.

Avoid doing physical work in the heat of the day; if you MUST run or cycle, do it in the early morning. Hydrate! You are going to lose water by increased sweating, so push the water and electrolyte drinks.

If you are experiencing any of the symptoms noted above, stop physical activities and get to somewhere cool. If you do not improve, call 911. An emergency home remedy is to get in a cold tub or to put ice bags under the armpits, behind the neck and in the groin.

Check on any neighbors who may be at risk. Since an early sign of heat-related illness is confusion, they may not react properly.


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Symptoms and cancer

Most cancers eventually cause symptoms, but usually only when the cancer has been there a long time, and often when the optimal time for treatment has passed. This has led to the recommendation behind many “screening tests,” tests done in people with no symptoms.

Colonoscopy, Pap smears (often combined with HPV virus testing), mammograms and low-dose chest CT are among the recommended tests done routinely in people with no relevant symptoms.

Do symptoms have any role in cancer detection? Yes, in both directions.

Let’s start with men. Many men worry they may have prostate cancer when they begin noting urinary urgency and frequency, and feel that if they have no urinary symptoms cancer is unlikely. In fact, urinary symptoms reflect growth of the central part of the prostate, which surrounds the urinary passage out of the bladder, while most cancers begin in the outer part of the gland. So, counting on symptoms to prompt a search for prostate cancer is unwise.

Whether screening for prostate cancer saves lives remains controversial, but if you want to find it early, get tested regardless of any symptoms.

For both men and women, both kidney and bladder cancers are usually heralded by blood in the urine, though this may be small enough to only be seen when the urine is checked by a lab. Since a small amount of blood in the urine is common, and most often due to something else (infection and stones lead the list), there is tendency to overlook it. Don’t.

If your patient portal shows you that you have any amount of blood in your urine, be sure your doctor stays on top of it. At a minimum, get this rechecked. If it is still there, the next test is usually an ultrasound – both safe and harmless, so not to be feared.

Uterine cancer is becoming more common, for reasons not entirely clear. This cancer almost always announces itself early, with abnormal bleeding. If caught early, uterine cancer should be nearly 100% curable, but diagnosis is too often delayed because the bleeding is attributed to something else. Don’t accept a diagnosis of fibroids or endometriosis or hormone imbalance without at least discussing having a sampling biopsy. If you have been through menopause and then bleed, demand a biopsy.

Finally, for women, is ovarian cancer. This, like pancreatic cancer, is often found only after it has spread. It has been taught that early ovarian cancers do not cause symptoms, but a recent study found that 72% of women with early-stage cancer had one or more symptoms. The leading symptoms were abdominal and/or pelvic pain, fullness or bloating and urinary frequency. Most often these symptoms are not due to ovarian cancer, but do not ignore them. You know your body, and if these symptoms are new, persist and do not have another explanation, push your doctor to check for ovarian cancer, typically with a pelvic ultrasound. Catching it early may save your life.


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Here comes the sun - cover up!

After a cool rainy spring, at least in the northeast, summer has finally arrived, bringing promise of beach time, sailing, cycling and other outdoor activities.

As good as the sun is for the soul, it is hard on the skin. The sun’s UV (ultraviolet) rays age the skin, contribute to skin cancer and can cause painful burns. A good protective sunscreen lotion should be a key part of your outdoor gear.

There are 3 types of UV rays:

• UVA. These rays go into the skin more deeply than UVB rays. They play a major part in skin aging and wrinkling. They also contribute to the growth of skin cancer.

• UVB. These rays are the main cause of sunburn. They tend to damage the skin's outer layers. These rays also play a key role in the growth of skin cancer.

• UVC. These rays do not reach our skin. The Earth’s atmosphere absorbs them before they reach the surface.

Sunscreens are labelled with their SPF – skin protective factor – a measure of how much of the UVB rays, the rays that cause sunburn, they block. An SPF of 30 blocks some 97% of these rays. Going above 30 adds very little additional protection.

Since it is the UVA rays that most contribute to skin cancer, you should look for a product labelled “Broad spectrum,” indicating protection against both UVA and UBV.

There are two main types of lotion – chemical-based and mineral-based. Chemical sunscreens absorb UV rays while mineral sunscreens reflect them as well as absorbing them.

It has been found that the chemicals in sunscreens are absorbed and can be measured in the blood. To date, there is no evidence of harm, but this has only been studied recently. The zinc oxide and titanium dioxide in mineral sunscreens are not absorbed but can leave white residue on the skin and this may discourage use. The best sunscreen is the one you will use!

The ingredients in sunscreen degrade when hot, so leaving the bottle in a hot car or beside you on the beach is not a good idea. Keeping the sunscreen bottle in your cooler is wise.

Despite claims to the contrary, very few sunscreens are “waterproof.” Water resistant sunscreens will only work on wet skin for an hour or two and should be reapplied every 2 hours if you are sweaty and after you get out of the water if you swim.

Don’t forget to protect your ears, lips (with a sun-protective lip balm), feet and ankles and along clothing/swimsuit edges.

So…

Buy a broad-spectrum sunscreen with an SPF of 30 or higher, apply it liberally every 2 hours (sooner if you go in the water) and be sure to protect all exposed skin. Keep the bottle cool if possible. Do not forget the option of protection with a hat and light-colored clothing.




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FSA, TSA, HSA - two of these can help a bit with medical bills

Except for some government employees, generous health insurance is rare. As the cost of insurance has skyrocketed, employers are shifting more of the cost to their employees, often through higher and higher copays and deductibles.

Either a Flexible Spending Account (FSA) or a Health Savings Account (HSA) can lessen the blow.

Note that in general you will be offered one or the other, but rarely will both be possible.

FSAs allow you (and also your spouse if they are employed) to put up to $3200 pre-tax income each year into an account that can be used to pay for eligible health and medical expenses. This saves you paying income taxes on the amount you put into the FSA. Your employer may, but is not required, to put money into your account as well, up to the amount you put in through payroll deduction.

Note that you can only contribute to an FSA if you have employer-sponsored health insurance.

It is very important to remember that these plans are “use it or lose it.” You may be able to roll over any balance at the end of the year, but if you do not spend these funds on eligible expenses, the money goes back to your employer. Also, if you change employers, your FSA does not travel with you.

Before deciding to contribute to an FSA, look carefully at your out-of-pocket medical expenses for the last year or two – and take into account any expected expenses such as dental work or elective surgery.

If it is offered, an HSA is an even better deal, particularly if you can afford to put in significant sums. An HSA can be set up by your employer or, depending on the type of health insurance you have, yourself. The contributions lower your taxable income, just as with an FSA, but there is no deadline for spending the money. You can let it accumulate, tax-free, and, as long as you use the money for health expenses, pay no tax on withdrawals. An HSA is yours – if you change jobs, it goes with you.

The maximum contribution limit of an HSA is higher than to an FSA. Individuals can contribute up to $4,150 to their HSA accounts for 2024, and families can contribute up to $8,300. People 55 and older are allowed an additional $1,000. As with FSAs, employers may but are not required to contribute.

On what can you spend the money in these accounts? Copays and deductibles are eligible, as are dental bills, medical equipment, eyeglasses and most over-the-counter medications. You can even use the money to pay for needed home renovations if they are medically-justified.

Neither of these types of accounts will remove all the sting of exorbitant medical costs, but if Uncle Sam is willing to help, you should let him do so.


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Are you taking too many pills?

Americans take a lot of pills! About 20% of adults between 49 and 75 are taking 5 or more prescription medications daily. This gets commoner as we get older. Surveys found that 13% of young adults (30-49) take 4 or more prescription drugs daily, while 54% of those over 65 do so.

While many of these medications are beneficial or even life-saving, there is a lot that can go wrong. Many medications interact with each other in harmful ways. Many more are of only minimal benefit while carrying serious side effects.

The problems with over-medication are much worse in older adults. As we age, we accumulate more chronic illnesses, and these often lead to more drugs prescribed. With age, the kidneys and liver are less able to eliminate drugs and levels may pile up to dangerous levels. Older adults are more susceptible to many drug side-effects, including confusion and excessively low blood pressure.

Another potential issue is that as medicine has become overly specialty-oriented, multiple doctors may be prescribing medications that seem fine from their perspective without realizing that other doctors are prescribing medications that may be conflicting with the new one.

How can you protect yourself?

First, be sure your primary care doctor knows what you are taking. I would have my patients make a yearly “brown bag visit,” bringing in ALL of the medications they were taking, including over-the-counter pills. A common finding was that people were taking the same medication twice – one bottle had the brand name and the other the generic, and the pills looked nothing alike – so they were unaware of this double dosing. We also often found medications that I was sure they had stopped but which their pharmacy “auto-refilled” and they kept taking.

Whenever your doctor suggests a new pill, always ask if there are life-style changes you could try instead. It may be that you need the medicine now, but could come off it in the future if you do make those changes.

Ask if the symptom being treated (ankle swelling, dry mouth, high blood pressure, etc.) could be a side-effect of a medicine you are currently taking. Perhaps that symptom would be better treated by changing the culprit pill rather than adding a new one.

Be particularly cautious when adding a drug on the Beers list, a list of drugs felt by the American Geriatrics Society to have a poor benefit to harm ratio. It is easily found on-line. You may still benefit from the medication, but have a frank conversation with your doctor.

Almost any time a new medication is added, a good rule is “start low and go slow.” Begin with a low dose and raise the dose only after giving the initial dose a trial.

Modern medications can be life- and health-saving, but they can harm. Caution and common sense should prevail.


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I am Woman - hear me - Please!

Pediatricians are fond of saying that children are not just small adults – that their physiology and response to diseases are different. In the same way, women are not just men with different sex organs. Every cell in women is different than the corresponding cell in men, due to the difference in chromosomes.

Thus, women, as we have learned, often describe different symptoms when they are having a heart attack – and as a result, the diagnosis is often missed or delayed. Women have many more “auto-immune” diseases such as lupus and thyroiditis. Women obviously have unique diseases related to the menstrual cycle, such as endometriosis or polycystic ovary syndrome.

Women’s health issues are severely under-studied. Even though women make up 55% of patients hospitalized with acute coronary disease, they make up only 25% of participants in clinical trials of coronary disease.

Because women are considered at lower risk for coronary disease (even though as noted, they are over half the patients admitted with acute coronary symptoms), they are less likely to be prescribed statins, a proven life-saving therapy for patients with coronary disease.

Even though 70% of women take at least one prescription drug during pregnancy, only 5% of these drugs have been tested and shown safe during pregnancy.

Why this disparity? Throughout history, medical research and practices have primarily focused on men. This stems from outdated beliefs that women's health issues were either insignificant or simply variations of men's conditions. Many clinical trials specifically do not enroll women of child-bearing age, even those these same women may be given the treatments after the drugs are approved.

Women often complain of being “gas-lighted:” having their complains ignored. Unconscious biases among healthcare providers can influence the quality of care provided to women. These biases may lead to symptoms being dismissed, pain being downplayed, or concerns being trivialized, all of which can result in delayed or inadequate treatment. For the same painful conditions, women are less likely than men to be prescribed pain medication.

Certain health issues specific to women, such as menstrual disorders or menopause-related symptoms, are dismissed as "normal." This can lead to healthcare providers dismissing or minimizing these concerns, further perpetuating the cycle of inadequate care for women.

Addressing these issues requires a multi-faceted approach that includes raising awareness, advocating for gender-inclusive research and healthcare policies, providing education and training on gender-sensitive care for healthcare providers, and ensuring equitable access to healthcare services for all. By recognizing and actively working to dismantle these barriers, we can strive towards a healthcare system that provides equitable and compassionate care for everyone, regardless of gender.


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Protein - panacea or problem?

Protein is everywhere on the grocery and pharmacy shelves these days. There are protein shakes, protein bars, high protein cereals – you name it.

One reason for this emphasis on protein is that in the 1980s and 90s we were taught to fear fat, and in the 2000s we were told carbohydrates were bad – so that only leaves protein!

We do indeed need protein for health. There are a number of essential nutrients (specific amino acids) that the body does not manufacture and which come from dietary protein.

How much protein do we really need, and is too much bad for us?

The recommended amount of protein an average adult should eat is 0.8 grams per kilogram of body weight. Almost every adult in western countries gets this much or more. For an adult weighing 165 pounds, this translates to 60 Gm protein/day. If you are trying to maintain or gain muscle mass, or if pregnant or nursing, you should increase this by 25%. This would include most older adults, who often lose muscle with aging.

Protein is available from a variety of foods, with fish, fowl and meat the most obvious but far from the only or even the best source. Dairy products, eggs, beans and lentils and nuts provide quality protein, as does soy. What should you avoid? Fatty cuts of meat and most processed meats (cold cuts, sausages, bacon, hot dogs) are bad for your heart and best minimized. If you are choosing hamburger, go for the 90+% lean packages.

Since all of the foods providing protein also provide different additional nutrients that we need, balance is key. Fish provides omega-3 fatty acids; meat provides iron; dairy products provide calcium and vitamins; legumes provide fiber and minerals.

Can you eat too much protein? Clearly yes, for a few reasons. Protein is our only source of nitrogen and tends to make the body acidic; the kidneys eliminate these toxins. If you have any degree of kidney impairment, excess protein can over-tax the body’s ability to cleanse the blood. Excess animal protein can lead to kidney stones. If you increase your protein intake without increasing exercise you will probably take in too many calories and put on weight.

Most experts agree that the maximum an average adult should eat is 2 grams/Kg body weight. For our average 165 lb adult, this is 150 Gm/day. Take a look at your intake, and if you are way over this, probably wise to cut back.

And be sure to get your nutrition from a variety of sources. Protein, carbohydrates and healthy fats are all necessary for good health.


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Speak up - I did not hear you

Hearing loss as we age is universal. In young adults, hearing loss is rare and usually mild, but as we pass 60, it becomes both more common and more severe. Past 80, the vast majority have hearing loss, and it is usually at least moderate.

Most hearing loss is gradual and so often not recognized by the individual. Family are in a better position to notice – they may comment on why you have the TV or car radio up so loud.

Age-related hearing loss is almost always worse at higher frequencies. Because women have higher-pitched voices than men, this is a possible explanation for the “selective hearing loss” that lets men hear their buddies talk football while claiming to not hear their wives ask them to do something.

Hearing loss can have a major negative effect on quality of life. You miss out on conversations, feel “left out,” and may begin skipping events. Those with risk of dementia may experience a more rapid decline in mental acuity because of lack of interaction with others.

If this is a possible issue, get your hearing checked. The best way to do it is with an audiologist, who will have you in a sound-deadened room with headphones, and will check the hearing in each ear at different frequencies. Most health insurance plans will pay for this. A fallback is an on-line hearing test you can do for free. Not as accurate, but very convenient.

If your hearing loss is more than minor, you ought to get hearing aids of some sort. Traditionally, you could only get hearing aids from an audiologist, and they were very expensive. Starting in 2022, hearing aids became available over-the-counter, and so price options have expanded.

Price is important, because Medicare does not cover hearing aids, though some Medicare Advantage plans offer partial coverage, and for those under 65 many commercial plans also do.

How expensive? I went to a national chain site and the audiologist was recommending a set that went for over $8000.

If price is no object, go to an audiologist and you will get custom programming of the devices and free adjustment and tuning. A good option for those without insurance coverage but who want hand-holding during the process is to go to Costco (or another Big Box store), where you will get similar technology at about half the price, albeit with less customization.

If your health insurance has a hearing aid benefit, you will almost certainly have to use a vendor who is on their list, so check before you see anyone.

Finally, if you have no insurance coverage, and are on a limited budget, buy an over-the-counter device. The New York Times Wirecutter, Consumers Reports and Forbes have all published good reviews of these products, so browse them first. Recommended products came as low as $800/set.

If the budget is really tight, get a “PSAP,” a personal sound amplifying product. These have only volume controls and are clearly not perfect for anyone, but can be bought on Amazon or Walmart for as little as $50! Using one of these devices is much better than constantly saying “what.”


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How much will that cost me? On hospital pricing

Hospital pricing is notoriously difficult to understand. Until very recently, it was also impossible to find out how much a hospital was going to charge you for a test or procedure until you got the bill.

Starting January 1, 2021, each hospital operating in the United States was required to provide clear, accessible pricing information online about the items and services they provide both as a comprehensive machine-readable file with all items and services and in a display of shoppable services in a consumer-friendly format.

Initially this rule was largely disregarded, and those hospitals that did post prices did so in a way that only computer geeks could access. Gradually, more hospitals are complying.

Does this matter to you? If you have good health insurance, it may not matter that much, as your insurance company will have negotiated rates for most hospital services. If you are uninsured (still 10% of the U.S. population) or if you are among the many more with high-deductible plans, it matters a lot.

If you have a high-deductible plan, you may have to pay the entire charge for an MRI of your knee, and so if it is $800 or $2800 matters.

There are two things you need to know before “price shopping” for a test or procedure.

The first is that prices vary wildly, and with little correlation between price and quality. A recent study found that the hospital charge for uncomplicated vaginal childbirth varied from $1183 to $55,221 (that is not a typo!).

The second is that if you call the hospital billing department and ask the price, there will often be a major difference between what you are told and what is posted on the hospital website. In only 15% of hospitals that both posted prices on-line and gave them over the phone were the prices the same, and differences often exceeded 50%.

So…if you are uninsured or underinsured, take the time to price shop when you can – when it is not an emergency. Try the websites for several hospitals near you to get an idea of which are at the high end and which at the low end. Then, try calling the billing departments. If they quote you a lower price than the on-line price, get in in writing by email or post.

Two other cost-conscious suggestions:

When you are well, check which hospitals near you are in your insurance network – when you are ill this will probably not occur to you, and going to an out-of-network hospital can cost you dearly.

Just because your doctor says you need something does not guarantee that it will be covered. Always ask if prior authorization is needed before having the test or procedure.

The money you may save will be yours!


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But I read it on Facebook!

The Internet has led to democratization of information access. Information that was locked away in libraries or simply not readily available to most of us can now be found with a simple search.

Along with that, however, has come a flood of misinformation. When you do a Google search, the leading links may be pure gold or utter dross. How can you tell the difference?

If you were to open your favorite social media site and read that Frigidaire appliances were suddenly bursting into flames, would you immediately put your refrigerator out on the street? I doubt it – you would probably check this out on Consumer Reports or call your appliance store. You would also apply your common sense.

So, why is it that some of my patients would come to a visit and say they had stopped their cholesterol medication because they saw a post that the medicine caused dementia?

Anything can be posted on the Internet. Some flagrantly racist or other hate speech may (or these days may not) be taken down, but grossly misleading health information usually stays on-line.

When you search, the top hits are often sponsored links or sites that have carefully managed their description to get a high ranking, with minimal relation to the quality of the content.

How can you tell if a site is worth visiting? Focus on the messenger before looking at the message. The best place to look for scientifically valid and unbiased information are sites maintained by the National Institutes of Health. These will always have the domain nih.gov as part of their URL. Another great source of information is the National Library of Medicine, whose URL will contain medlineplus.gov.

If these do not give you what you want, go next to websites maintained by major medical centers such as the Mayo Clinic, Johns Hopkins or Mass General-Brigham. These will obviously lean towards attracting patients to their institution, but still have high quality content.

Avoid celebrity sites and those that are trying to sell products or services.

The quickest way to decide if a link is likely to be useful is to go first to those tagged .gov, then to those tagged .edu and third to those tagged .org.

When seeking health information, caveat emptor!


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Bird flu - time to panic?

Spoiler alert: No.

What is bird flu? It is an influenza virus, related to the seasonal flu viruses that plague us every winter but one which predominantly spreads among birds. The specifics are that is an H5N1 form of influenza. (Those letters and numbers describe certain proteins on the virus surface and vary quite a bit from year to year, epidemic to epidemic.)

This particular virus has reached pandemic status among birds – it has been found on every continent but Australia and has killed millions of birds. It seems to be spread by migrating wild birds but has been lethal to domestic fowl, leading to the culling of many flocks in Europe and America. The price of foie gras may go up.

The reason for the recent interest is that the virus can spread from birds to mammals. Foxes, cats, seals, dolphins and bears have been infected. Most recently, outbreaks of bird flu have occurred in dairy cattle in the U.S. Herds in at least five states have been infected.

Last week, the virus was confirmed to have infected a human: a farmworker in Texas. This is not new; scientists have known for some time that people who have direct contact with sick birds or mammals can be infected. To date, there have been no known cases of human-to-human spread.

The virus has been found in the milk from infected cows and eggs of infected chickens, but the virus is killed by pasteurization or cooking. It could potentially be spread by consuming raw milk or using uncooked eggs.

To become a serious threat to human health, the virus would have to undergo major mutations to allow human-to-human spread. Not impossible, but unlikely.

Also in our favor is that the few people proven to be infected with H5N1 have had very mild illness. The man in Texas had only conjunctivitis (“Pink eye”).

Finally, the antiviral drugs like oseltamivir (Tamiflu) work well to reduce symptoms, and are readily available.

So… stay away from raw milk for now, be sure to cook your eggs, and, most important, do not pick up or examine dead birds or animals, and warn your children not to do so. A veterinarian called to a north shore beach found that the dead birds were all infected. Let the pros handle it.


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Colon cancer - find it early!

Cancer of the colon and rectum is very common. Colorectal cancer will occur in over 150,000 Americans this year. It is the third-leading cause of death in men and the 4th in women. Because it is an “equal opportunity” scourge, it is the second-leading cause of death when combining men and women (just behind lung cancer).

Very troubling is the increasing incidence in younger people, a phenomenon that doctors cannot yet explain. We used to think that it was very rare in people under 50 unless you had an uncommon genetic risk, but colorectal cancer is being increasingly diagnosed in people in their 40’s or even 30’s.

When caught early, it is very curable. The secret is early detection.

The controversy is how best to detect it early and when to start looking.

Most cancers begin as polyps, some of which slowly develop into cancer. The hallmark of such pre-cancerous polyps is “atypia,” which can only be proven with microscopic examination. If all polyps are removed, the likelihood of ever developing cancer is minimal.

Clearly the ‘gold standard’ of early curable cancer detection is colonoscopy. After a good clean-out, allowing the gastroenterologist to see well, any polyps present can be removed and sent for examination. Ideally, everyone over 40 should have a colonoscopy (5 years ago I would have said over 50). If it is entirely normal, your next one can be in 8-10 years. If polyps are removed, that timetable will be shortened.

The problem is that no one LIKES having a colonoscopy. It is really not that bad. When you finish this post, Google “Dave Barry colonoscopy.”

No matter how much I or your primary care doctor urge it, not everyone will consent. There are other ways to detect colorectal cancer before symptoms develop, when it is often advanced.

The commonest test is to check for hidden bleeding in the bowel, which can herald polyps. Of the available tests for this, the current standard is the FIT (fecal immunochemical test), which has only about a 25% predictive value for cancer and advanced polyps when positive. A negative test does NOT guarantee you are in the clear, and to be useful the test must be done annually.

Another option is a stool DNA test, which is much more specific for advanced polyps and early cancers. On the horizon are blood tests that are fairly accurate.

Key to properly using any stool or blood test is to follow a positive test with a colonoscopy – sadly only half of people with such positive tests get one in a timely manner.

Buck up – listen to Dave Barry and just do it. The life you save will be your own.


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Kidney from a pig - is it really a big deal?

Your kidneys are critically important organs that clear toxic substances from the body and regulate your fluid balance. Kidney disease is very common, affecting millions of Americans. So-called “end-stage” kidney disease is kidney disease so advanced that without treatment, death is imminent. Presently, over 800,000 Americans are affected by this advanced stage of the disease.

It is very rare that kidney disease can be cured surgically or medically. Instead, you must either get a new kidney from a donor or go on dialysis. Dialysis is a technique in which the blood is filtered by a complex machine that tries to do what the kidneys are no long capable of doing. The technique was developed in the 1940’s but only became widely used in the 1970’s.

Dialysis, to be blunt, is no fun. You have to be connected to the machine 3 times a week and stay at the center for 3 to 4 hours each visit. About 1 in 7 dialysis patients, who have good home support, can do the procedure at home. While it is life-saving, patients on dialysis rarely feel really well.

A breakthrough in the treatment of kidney failure came in 1954 with the first transplantation of a kidney from a human donor to a patient with end-stage kidney disease. This was done by Dr. Joe Murray at the Brigham, and the donor was the recipient’s identical twin. The first transplant from an unrelated donor came 8 years later, in 1962.

Any time an organ is transplanted from anyone but an identical twin, the body recognizes the transplanted organ as foreign, and tries to eliminate it, the way it tries to eliminate bacteria. To prevent rejection of the new kidney, the body’s immune system must be suppressed, leaving the recipient at higher risk of infection.

When transplantation is successful, the recipient of the new kidney feels much better, physically and emotionally, as they can now lead a normal life rather than being tied to a dialysis center.

Why don’t all patients with end-stage kidney disease get a transplant? Simple: there are not enough organs available. Of the 800,000 with the condition, over 2/3 are on dialysis and fewer than 1 in 3 have had a transplant.

If the recent transplant, from a pig that was genetically engineered to have kidneys that were closer to human genes, is successful, the huge bottleneck that is availability of kidneys for transplant would be removed.

Can we declare success? Not yet. The two men who had pig hearts transplanted both died soon after the surgery. We hope the Boston man who got the recent transplant does well, but only time will tell. There are too many unknowns to predict the outcome. In addition to the problem of rejection of the new organ, pigs carry many viruses that humans do not, and one or more of these may cause problems.

If this volunteer is alive and with a functioning kidney in several years, a giant step will have been achieved.

The number one cause of chronic kidney failure is poorly controlled high blood pressure, so if you have hypertension, be sure to have it controlled with medication.


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Ultra-processed foods: what are they? Why should you care?

About half the calories consumed by people in high income countries such as the United States and Canada come from ultra-processed foods, and such a high consumption of these “Franken-foods” contributes to many health problems.

What are ultra-processed foods?

Most of our food is processed to some degree, if only with preservatives, and not all processing is bad. Pasteurized milk is “processed,” and is generally safer than unpasteurized milk. Iodine added to salt gives health benefits.

There are many ways to classify how foods are processed, but the most widely used system is NOVA, developed by academic food scientists in Brazil.

NOVA Group 1 includes unprocessed or minimally processed foods. The latter includes removal of inedible parts, drying, roasting, freezing, etc., with no additives.

Group 2 includes processed ingredients such as salt, sugar and oils that are used as additives.

Group 3 includes foods where the Group 2 ingredients are added to Group 1 food to increase their durability and enhance their flavor.

Group 4 foods are those that are ultra-processed, foods that are manufactured, often in several steps. Natural food products are fractionated into sugars, protein, oil and fats, starches and fiber. These component parts are then chemically treated, most often by hydrolysis or hydrogenation. The final food product is then assembled with various industrial techniques and colors, flavors and preservatives are added.

Common ultra-processed foods we may consume daily include carbonated soft drinks, packaged snacks, ice cream, flavored breakfast cereals, prepared pies, pasta dishes and pizzas, “nuggets,” hot dogs, sausages and powdered instant soups and desserts. Note that some of these may be labelled “all-natural” or organic.

Why should you care? High consumption of ultra-processed foods has been linked to such health problems as obesity, diabetes, high blood pressure, cancer and many gastrointestinal disorders.

Recent studies have shown that ultra-processed foods, usually high in both sugar and fat, trigger a similar brain response as do addictive substances like nicotine and alcohol.

What should you do? First, realize that U-P foods are not arsenic. Having a scoop of ice cream or some fries once in a while will not kill you. In moderation, they can be part of a healthy diet. The goal is to keep U-P foods to less than 25% of your daily calories.

Eat fresh or stewed fruit in place of store-bought pies and cakes. For breakfast, have oatmeal or minimally processed granola with fruit rather than sugary cereals. Cook more: bake chicken or fish rather than heating up prepared frozen dinners.

Look at labels. If a product contains 4 or more ingredients, some of which you cannot pronounce, put it back. If it is obvious where the food came from (eggs come from hens, apples from trees) it is generally OK. If the origin is unclear, try something different.

Don’t fall for hype – an “organic natural” packaged cookie might still be ultra-processed.


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Why do so many American women die from childbirth?

For most of human history, pregnancy and childbirth was the cause of many women’s deaths. In the modern era, this should be an extremely rare event, and in most of the developed world it is.

About 800 women in the U.S. die every year during pregnancy, delivery or the 6 weeks that follow delivery. Our maternal mortality statistics are our shame. Maternal mortality per 100,000 live births is 4.4 in Sweden, 8.0 in France, 9.2 in the United Kingdom and 7.3 in Canada, while in the U.S. it is 26.4.

Globally, maternal mortality has been steadily falling while in the U.S. it has been rising.

There is a clear racial disparity, with deaths from pregnancy much higher among Black and Native American women than among white, Asian and Hispanic women. For Black women, poorer care compounds their tendency to more of the hypertensive disorders of pregnancy. However, even white women die at a higher rate in the U.S. than in any of our peer developed countries.

Why is this? Doctors here are often too slow to recognize the importance of even mild high blood pressure in a pregnant woman and fail to treat it, leading to the dangerous condition called eclampsia. Because severe complications of pregnancy at any given hospital are rare, most hospitals do not have an organized plan to deal with severe hemorrhage after delivery or embolism of the amniotic fluid (large bubbles of amniotic fluid entering the mother’s circulation).

Experts who study maternal deaths estimate that about 70% of the deaths due to hemorrhage, infection or cardiovascular conditions are preventable. California adopted a comprehensive plan to lower maternal deaths, with “best practice” guidelines widely distributed to every hospital and obstetrician, and was able to cut its death rate in half between 2006 and 2013.

Additionally, many women die from treatable mental health problems, notably depression and suicide, that are missed, often because the new mother is not seen after delivery. While most women bring their infants in for a well-baby visit, many skip their own post-partum check, often because they do not want to take time off from work.

Most western countries provide ample paid time off for new mothers, no matter their occupation, while in the U.S. this tends to be a “luxury” afforded only to highly paid professionals. We should be advocating for 3 months paid maternity leave for ALL women.

Ask your local hospital if it has systems in place to deal with the infrequent but lethal emergencies that occur during pregnancy and delivery. Make sure any friends and relatives who deliver have adequate support. Offer to take them for post-partum checks.

We should be emulating Sweden and Canada, not Afghanistan and Swaziland.


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Who will care for me when I am old and gray?

Every day, 12,000 Americans turn 65. In 2022, 58 million were over 65 – 17% of the population – and estimates are that by 2040, seniors will make up 22% of the population.

While most people over 65 are healthy, as we age illnesses and frailty become increasingly common, and growing numbers need at least some care in their daily lives. How do they get that care?

Unlike many other western countries, the US has no organized program to help seniors who are unable to live and function independently. In many cases, particularly for those over 80, the choices come down to placement in a nursing home or a lot of help at home to allow them to avoid that dreaded option.

Many elders and their families are surprised to learn that Medicare does not pay for anything but short-term rehabilitation, either for nursing home stays or home health care. If you have a hip replaced, Medicare will cover a week or so at a rehab facility and a few weeks of home PT and visiting nurses, but if you are simply too frail and sick to live independently, you are on your own.

Long-term care insurance is available, but it is very expensive and frequently does not cover the full cost of nursing homes or extensive home care.

To get the care needed at home, home health aides are available but this “system” is full of problems. Such care is generally provided through agencies that hire and vet the aides. They charge the patient a lot and pay the aides very little. Most home health aides get minimum wage for very demanding work, resulting in a huge turn-over. Why lift and clean an elder when you can earn the same hourly wage at McDonalds?

In the end, it often falls to family members to provide needed care, difficult at best when families are scattered around the country and often trying to hold down a job while assisting their parent(s).

Medicaid will pay for nursing home care, but to be eligible, the recipient must spend down most of their assets and become impoverished. They cannot give away assets to their family – this is carefully scrutinized. Moreover, Medicaid rates are generally so low that you will not find many “upscale” homes willing to take you.

What can you do? Don’t get old. Seriously, one important factor is to stay as fit as you can to avoid the need for help. While exercise increases longevity, its more important benefit is to keep you independent longer.

If you can afford it, investigate long-term care insurance. Be very careful in reading the policy and assessing the likelihood that the policy will cover your needs.

While you are healthy, begin to make your home more “aging-friendly.” Get grab bars in the shower, railings on all stairs, better handles on doors and cabinets and put shelves lower.

Write to your state and federal legislators and ask them to start working on a plan, either at the state or national level, to improve the care we offer our frail elders. Part of any such plan must include better pay for home health aides to encourage people to make this a career.


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The heart risk factor no one knows about

Most readers of these columns, I assume, are aware of the relation between elevated cholesterol and coronary heart disease, and of the benefit of reducing high cholesterol with diet and medication. The statins have saved many lives, and newer agents have come to market for those who cannot take statins.

I do hope you are not among the third of Americans who do not know their cholesterol.

What I would like to discuss here is another heart risk factor, which has been prominently discussed recently in the cardiology community but has not received much attention more widely. This is lipoprotein(a), commonly referred to as Lp(a) and verbalized as “L p little a.”

Lp(a) is an LDL (low density lipoprotein) molecule with an apo(a) protein attached. It can be trapped in the arterial wall, causing atherosclerosis (“hardening of the arteries”) and it increases clotting.

We know a lot about Lp(a). It is genetically-determined; there is very little effect of diet on levels. This means that you don’t need to measure it on a regular basis – if it is high, it will stay high, and if it is low, it will stay low.

It is a major factor in causing coronary disease, independent of standard cholesterol values.

As of now, there are no medications available to lower it, but new medicines are on the horizon.

If we cannot treat it, you may ask, why measure it?

First, if it is elevated, your doctor can put you on cholesterol-lowering medication even if your standard cholesterol levels are normal and would not be treated. No one risk factor works alone, and even if we cannot yet lower a high Lp(a), we can still reduce your risk of heart attack by treating other risk factors.

Second, there is recent evidence that low-dose daily aspirin, which is now considered not appropriate for the general population, will cut in half the heart attack and stroke risk in people with Lp(a) over 50.

So, at your next visit, ask your doctor if they have ever measured your Lp(a), and request they do so if it has never been done.

Knowledge is power.


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Private Equity in Health Care

Those of you in the metro Boston news market have been regaled with the saga of the failing Stewart Health Care System, owner of nine hospitals in eastern Massachusetts. One eye-catching story described the $40 million yacht purchased by Stewart’s CEO, Dr. Ralph de la Torre, while Stewart hospitals were having equipment repossessed because of failure to pay their bills.

While a 190-foot yacht catches attention, it is only a symptom of a deeper problem.

Private equity (PE) firms’ business model is to buy companies as cheaply as possible, pull as much cash as they can from the company and then either resell it or declare bankruptcy. To be able to sell the business, they have to jack up profits by cutting costs and/or raising prices.

Private equity investment in healthcare is a recent phenomenon but one which is rapidly growing. These firms focus on specialties where lucrative procedures can be done and/or where patients have little choice. Many emergency medicine groups, pathologists and anesthesiologists now work for entities controlled by private equity. These groups were responsible for most of the “surprise” out-of-network bills that made headlines in the last few years. Knowing that patients rarely if ever have the option to select a physician in these fields, they would pull out of insurance contracts and then bill whatever they wanted.

Quality is secondary to the acquiring PE firm; profits come first. They can increase revenue by raising fees and/or encouraging their employed physicians to do as many well-paid procedures (such as catheterizations and endoscopies) as can be justified, even if not all are truly needed. They can cut costs by skimping on equipment and supplies that are not “revenue-producing,” even if they improve quality care. They can also substitute less-qualified, lower-paid personnel, such as aides in place of nurses.

Steward offers a textbook example. Cerberus Capital bought the troubled Massachusetts-based Caritas Christi hospital system, promising to turn it around. Soon after, they sold the land and buildings of its own hospitals to a real estate trust, pulling out $1.2 billion and saddling the hospitals with hundreds of millions in annual rent. That transaction allowed Cerberus to quadruple its investment and to pay its investors a $100 million dividend. They bought hospitals around the country, including Texas, Florida and Ohio. Many of these have since been closed, doubtless after the PE investors had pulled as much money out as possible.

So, Stewart’s CEO has a very expensive yacht and communities around the country are dreading the closure of what is often their only nearby hospital.

Tell your state legislators that private equity has no place in health care, certainly not without very strict guidelines and oversight.





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Do you want to live to be 100?

In 1521 Ponce de Leon arrived in Florida in search of the mythical fountain of youth; those who drank from it or bathed in it were said to be returned to their youth. Some 500 years later, the New York Times ran a lengthy article on a longevity guru whose disciples wear T-shirts emblazoned Don’t Die and who buy supposedly rejuvenating vitamins and supplements from him by the bushel.

What is real in our search for longevity? I assume that most of you, like me, are interested in healthy longevity – I would rather be well and active into my 90’s than live into my 100’s in a frail dependent state.

The maximum lifespan of any species, including our own, seems to be fixed. The longest documented human lifespan was 122 years, and the next oldest were 119. About 120 would seem to be as much as we can hope for.

In the famous Blue Zones, 5 scattered sites in Italy, Japan, Greece, Costa Rica and California, many people live healthy and active well into their 90’s, and much of what we know about healthy longevity came first from studying these populations, backed up by many other studies.

While heredity clearly plays a role – the best single predictor of a long life is having long-lived parents - only some 30% of your chance for a long healthy life comes from choosing the right parents. Much is under our control.

Diet is a critical factor. If longevity is very important to you, prepare to be hungry. There is incontrovertible evidence in mice and considerable data in humans that calorie restriction lengthens lifespan.

What you eat is important. Contributing to a long and healthy life is eating a plant-based diet, heavy in fruits and vegetables with little or no red meat. Get your protein from fish and nuts, and use olive oil in place of butter. This type of diet leads to less heart disease and less cancer.

Move. Regular exercise both leads to less premature death and better quality of life. While any amount of exercise is much better than none, more is better. Even walking 30 minutes a day will pay dividends, but exercising more and longer is even better. Do not forget strength. Aerobic exercise will do the most to extend life, but strength training prevents falls and injuries and strengthens the bones.

Don’t smoke. If you do, quitting now will do more to improve your health than anything else you can do.

Minimize your alcohol intake. There is soft evidence that moderate drinking may reduce heart disease, but it increases a variety of other disorders. One drink a day is probably a wash, but more is clearly bad.

Get enough sleep. Sleep is when we rejuvenate, and try for at least 8 hours a night.

Socialize. Spending time with friends and family and participating in group activities is very common in the Blue Zones and has been shown to be associated with less depression and better physical health.

See your doctor once in a while. Many chronic diseases that shorten life, including hypertension, high cholesterol and diabetes, have simple treatments that prevent premature death and worse diseases. A few preventive measures such as colonoscopy and immunizations have good data supporting their use.

Pills? Not many. As I wrote a while back, there is now data supporting the use of a daily multivitamin to stave off dementia. Softer evidence favors the amino acid taurine and the diabetes pill metformin; both are in early stages of testing and I do not take either. Most other supplements enrich their sellers but do not help you.

There are no quick fixes to let you live longer and better, but there are many things you can do.



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COVID - forgotten but not gone

Understandably, most of us have developed “Covid fatigue.” After what seems like years of warnings and behavior changes, we want to put it all behind us. Unfortunately, while we are tired of the virus, the virus is not tired of us.

The latest variant to appear, JN.1, is much more transmissible that its predecessor even though it has only a minor genetic change. It has rapidly become the dominant strain hitting the U.S. and much of the world. Fortunately, the last vaccine, aimed at an earlier variant, seems to be very protective against severe illness and death, even if not that good at preventing infection.

While not nearly as dramatic as the situation of 2-3 years ago, both case counts and deaths have been trending up. For the last period for which we have complete data, some 1500 Americans are dying of Covid every week – most, but not all, older and/or with severe underlying illnesses, and most not up to date on their vaccines.

Only 19% of adults 18 and older and 8% of children have received the current vaccine. Of those 65 and older, at highest risk of severe disease, only 38% have been fully vaccinated.

What should we do?

First and most important, get your booster! Vaccines only work when you get them.

Second, wear a well-fitted mask when you are indoors with lots of people. Think concerts, bridge games, indoor sporting events. While not a panacea, masks do cut down transmission of both Covid and other respiratory viruses such as colds and flu.

Finally, if you are sick, stay home. You do not want to be the one who recovers but finds out that you gave the virus to your elderly aunt who died. There will always be another event.

For those who do get sick, treatments are available that help. Paxlovid is under-used. In the older population, it cuts hospitalization and death by more than half. If you are very high risk, IV antibody treatments are even more effective.

We do not want or need to go back to the days of school closures and shuttered restaurants, but we can and should do these simple things that protect us all.



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Is the FDA protecting us adequately?

The high point of the FDA (Food and Drug Administration) showing its worth came in 1960, when Dr. Frances Kelsey refused to let thalidomide be marketed in the U.S. She prevented the U.S. from experiencing the epidemic of babies born with deformed limbs to mothers who were prescribed the drug for morning sickness in Europe.

Do we still have similar guardians? Recent years have seen a raft of drugs and devices of dubious value approved by the FDA.

Example: Zurzuvae was approved in August 2023 to treat postpartum depression. This is a major depressive disorder that begins during pregnancy or within 4 weeks after delivery. Standard recommended care is psychotherapy or the well-studied group of antidepressants called SSRIs (selective serotonin reuptake inhibitors). Zurzuvae works on the same brain receptors as benzodiazepines (think Valium, Xanax) and barbiturates, and so not surprisingly causes sedation, sleepiness and dizziness, and most people who take it for over a week suffer withdrawal symptoms when they stop.

Two studies of Z were done in women with severe postpartum depression, and in both it was compared to placebo, not SSRIs. It was superior, but the placebo group saw about 75% of the improvement seen in active drug users. The real test would have been comparison with a safer SSRI, not a placebo.

Moreover, even though only patients with severe depression were studied, the drug was approved for all patients with the disorder. I’d avoid it.

Example: In Dec 2019, the FDA approved the oral drug Olaparib for treatment of pancreatic cancer. This drug is priced at $12,000 PER MONTH. The study leading to approval showed a very modest improvement in survival: 18.9 months vs. 18.4, with no quality-of-life benefit. Statistically significant perhaps, but clinically? I’d also question using placebo rather than existing approved drugs as the comparison.

In addition to drugs, I could describe many devices of dubious value, but will only mention one in the interest of brevity.

In 2023 the FDA approved two devices that destroy nerves to the kidney to treat high blood pressure without medication. Two studies have been done. One showed no benefit and one showed statistical lowering, but by an average of 3 mm – less than the usual variation I would see between two measurements in the same visit. Is that worth the estimated $6000 that using the device will cost? Do we have data showing long-term benefit? (No!)

We should require that the pharmaceutical and medical device industries fund studies that clearly define which patients will benefit from new drugs and devices. We should then also require our regulators to protect the public by forcing new innovations to pass a proper bar before being allowed on the market. “Might help some people,” at high cost and with potential side effects is not a high-enough bar, not when lives are at stake.

Let the FDA know they need more Dr. Kelseys and fewer rubber stamps.



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Who makes the decisions about your health care?

If you have commercial health insurance or are one of the over half of Medicare enrollees who have a “Medicare Advantage” plan, decisions about your health care are not decided solely by you and your doctor(s). There is a third party in the room: your insurer, whose interests are financial rather than health.

As medicine became more complex and much more expensive, one response of health insurance companies was to try to decrease the use of expensive tests and treatments. They developed lists of tests, medications and procedures that could in some cases be substituted by older cheaper tests and treatments. When a doctor wished to order an expensive new approach, they had to justify why this was necessary.

If done properly, this was fair and reasonable. Every expensive new drug is not always better than a cheap old one. Every patient with back pain does not need a CT scan or MRI. The problem is that insurers went overboard.

The process works like this: your doctor sends a prescription to your pharmacy or asks their staff to schedule you for an imaging test. They then hear from the pharmacy or the radiology department that your insurance company requires “prior authorization.” The cost will not be paid until the insurance company agrees it is needed. The doctor’s office calls the insurer and are questioned by a clerk with no medical background using a checklist. Sometimes miracles happen, every box is checked and you get approval.

More often, your doctor is told that the request does not meet their criteria for necessity and will not be paid. There are now three choices: do it anyway and have you, the patient, pay the bill; forget about it and try a different approach; request an appeal of the decision.

For all but the very wealthy, paying out of pocket is very difficult. If there indeed is a good cheaper alternative the system has worked as intended. Most of the time the request is necessary for the best outcome and the doctor must appeal.

A survey found that the average doctor’s office devoted 14 person-hours a week to prior authorizations – time that costs the doctor money and takes away resources that could be better spent on care. Clearly the insurers hope that if they deny needed care, the doctor may sometimes decide it is not worth the time and effort to appeal.

Recent investigations by ProPublica and others have found that many insurance companies rely on biased algorithms to deny needed care. They have also documented that insurance company medical directors review 10,000 cases/year or more, and often make decisions without even looking at the patients’ charts. Moreover, many companies employ as medical directors doctors who have been driven out of practice by disciplinary action or numerous malpractice suits.

If your doctor’s suggestion is denied by your insurance company, what can you do? If you and your doctor agree that the denied service is truly best for you, insist on appealing. While the doctor’s office has to take the lead, you can add your voice to the process. Get the HR office at work to intercede on your behalf. Threaten to – and do if necessary – contact the state office of consumer affairs.

It is their money – but it is your life and health.



Prescription for Bankruptcy. Buy the book on Amazon