A few months ago, a patient who had recently been diagnosed with high blood pressure came to see me for the first time. She was concerned about her new diagnosis. In fact she was so concerned that she kept checking her blood pressure several times a day which made her even more anxious. Over a period of several months her anxiety became debilitating. She became depressed and noticed that her blood pressure kept going up. I remember the defeated look on her face when I first saw her. I changed her medication regimen to better control her blood pressure and explained to her that she should not get anxious about her blood pressure because the anxiety itself can cause her blood pressure to rise. Because she was a computer scientist I used the concept of a negative feedback loop to explain this phenomenon:

1. High blood pressure causes her to be anxious
2. Her anxiety keeps her checking her blood pressure more often
3. Her blood pressure is higher because of her increased anxiety
4. Go back to step 1

As you can see she was caught in this negative feedback loop which kept escalating. On her second visit, I showed her that the new regimen controlled her blood pressure beautifully. I also explained to her that this negative feedback loop needed to be broken. Even though she understood, it took her another month and another visit for her to be almost entirely cured of anxiety. When I saw her today she looked fantastic. She was much more at ease with herself. Once again I reminded her of the negative feedback loop she had created which we had broken. This time however, I also showed her a positive feedback loop which I asked her to practice for the next few months:

1. Continue taking medications but stop checking blood pressure
2. Anxiety over her blood pressure goes down
3. As anxiety goes down she has more time and energy to be physically active and enjoy Chicago
4. As her physical activity goes up she loses weight
5. As she loses weight her blood pressure goes down
6. Go back to step 1

I assured her that when I see her in three months we will be able to cut down on her medications for her blood pressure, anxiety, and depression. She was excited. Although there are medications for depression and anxiety, the best treatment is to understand the causes yourself and to turn the existing negative feedback into a positive ones. In most cases you cannot do this yourself because it is difficult to step back from your own situation. I would recommend talking to a counselor or your doctor.

The shoulder is a complicated joint. Unlike the knee which can only flex and extend, the shoulder has multiple degrees of freedom allowing it to move in almost any direction. Because of it’s complexity it is also easily injured, usually from heavy lifting or overuse.  The most common injury is  supraspinatus sprain, also known as impingement syndrome. The supraspinatus tendon is responsible for lifting the arm up laterally. Put your arms by your side and raise them all the way up. If you feel a click or pain, you have impingement syndrome.

There are two parts to treating impingement syndrome. First, relieve the pain by doing the pendulum swing exercise. The supraspinatus tendon runs through a narrow canal called the subacromial space. Hold a 5-10 lb weight in the affected hand, completely relax the arm, and let it hang as you make small circles. This widens the subacromial space and allows the tendon to move more freely without catching. I recommend doing this exercise several times a day for a minute or so each time.

Once the soreness subsides after a few days of the pendulum swing exercise, you should start the second part of the treatment which is to strengthen the shoulder muscles. This is important because the recurrence rate for impingement syndrome is high and stronger muscles can prevent frequent relapses. I recommend using elastic bands to do  resistance exercises. There are many such exercise videos online. This video shows the exercise quite well:

It is a common belief that stress somehow causes our hair to turn grey. However there is no scientific evidence linking stress to hair color changes. What we do know is that as we age, the activity of hair pigment cells, known as melanocytes, gradually declines until they stop making melanin (hair and skin pigment) altogether. Each of us has a genetically determined time when this process starts. Recently, researchers in Germany and the U.K. have discovered the exact mechanism by which melanocytes lose their activity, and it looks like the culprit is a free radical known as hydrogen peroxide. Hydrogen peroxide is a natural byproduct of the body’s metabolism. It is readily broken down into water and oxygen by an enzyme called catalase. In aging hair cells, the amount of catalase is significant lower, thus allowing hydrogen peroxide to accumulate, which then attack important enzymes. One of the enzymes it attacks is tyrosinase, a key enzyme that starts the production of melanin in the hair cells. As tyrosinase levels decrease, less pigment is produced causing our hair to turn grey.

So how do we prevent early greying of hair? Even though we’ve figured out the mechanism, there are no good treatment options at the moment. However I do have some general recommendations:

1. Because free radicals are the culprit, ingesting plenty of anti-oxidants (mainly vegetables) will definitely help your hair and skin look younger.
2. Smoking has been linked to premature grey hair.
3. Metabolic conditions such as thyroid disorders and vitamin B12 deficiencies have also been linked to grey hair. Anyone who has skin and hair changes should have a comprehensive blood test to rule out these conditions.

Rice is a staple food item in Asian meals and the main source of carbohydrates. As obesity continues to rise in the West, and we understand the primary role of simple carbohydrates as its main culprit, a question is why isn’t there appear to be a similar obesity problem in Asia where rice is consumed so much? First of all, even though Asians do eat a lot of rice, they also eat proportionally more healthier food items such as beans and vegetables. Second, there actually is an epidemic of obesity in Asia. Lifestyle also contributes to this growing problem. As Asian economies develop much like the West, Asians are becoming much less active and consuming more unhealthy snacks and processed food creating a rise in diabetes and cardiovascular disease. Statistics from India and China clearly confirm this. A third of children in China are currently overweight. What is different about the Asian body is that diabetes can develop with only slight weight gain as opposed to Caucasians and African Americans. Some anthropologists believe that because of the long history of famine in Asia  going back centuries, the Asian body cannot handle being overweight. In addition to increasing physical activity and cutting down on unhealthy snacks, my recommendation to Asians is to switch out white rice completely to brown rice. Like anything, a drastic change maybe difficult. So I recommend starting with 50/50 mix of white/brown rice and gradually increasing the proportion of brown rice.

A patient of mine who works for the TSA recently asked me about the safety of full-body scanners used at airports.  My initial thought was that they must be safe because it is the standard screening technology. However, the more research I did,  the more questions I had. 3D full body scanners use either high frequency radio waves or backscatter X-rays to reconstruct a person’s physical appearance. A person is exposed to X-rays for as long as eight seconds. X-rays can cause ionization as they travel through human tissue–a process whereby electrons are knocked off atoms that form the building blocks of our DNA. This creates harmful free-radicals that can cause cancer among other diseases. The amount of damage correlates with level of radiation, length of exposure, and overall health of the person exposed.

Most of us are exposed to some degree of radiation everyday, however the amount is quite insignificant. Our body repairs free radical damage quite well. The danger comes when you expose children, pregnant women or those with suppressed immune systems with frequent doses of radiation. Given enough exposure these people can develop cancer later in life. The problem is that this is very difficult to show – how would you show that someone’s cancer was related to his or her radiation exposure a long time ago? There are so many variables involved. Recently there have been reports of higher than usual incidence of illnesses among TSA workers at certain airports but the data is not clear as to whether this was related to their radiation exposure.

In general nothing good comes out of radiation but it is not clear at this point whether current imaging technologies are exposing us to harmful doses. What is clear is that the less exposure, the better for our health.

So what is the best medication in the world? We often hear of “miracle” drugs on the news that can cure diseases that were once thought to be incurable. An example of this would be certain monoclonal antibodies targeting specific cancers. What was once incurable has been shown to be treatable.  Although these drugs truly are “miracle” drugs, I do not consider them to be the best medicine in the world simply because they are too expensive and target a very narrow population. My criteria for the best medicine in the world is one that almost everyone can afford, that when used, will dramatically reduce morbidity and mortality of the vast majority of the population. The winner is clearly aspirin: this “boring” medicine that is so cheap and prevalent that no one bothers to look at it on the drugstore shelf has been proven time and again to have strong anti-oxidant and anti-inflammatory properties. It plays a significant role in delaying the progression of many types of disease– most importantly cardiovascular diseases such as heart disease and stroke. It has also recently been shown to reduce the incidence of many types of cancers. The main side effect is stomach upset especially if you have peptic ulcer disease. I usually recommend my healthy patients to start taking a “baby” aspirin (81mg)  daily starting at age 40.

When I do annual physicals for police officers and firemen I see a clear trend. New recruits in their 20s and 30s will usually have healthy weight levels, but as they age their weight goes up. It may not go up by a lot but five pounds every year will add up to 50 pounds in 10 years. In addition to not smoking, exercising, and eating healthy, I advise patients with a normal BMI (body mass index) to maintain their ideal weight as they age. This “boring” advice is probably the most important medical advice a doctor can give you. Patients should be aware that as they gain more weight, their risk of diabetes, high blood pressure and high cholesterol increases proportionally. This in turn increases risk of cardiovascular disease as well as multiple types of cancers. Maintaining a good weight may not always increase your life expectancy but will definitely increase quality of life as you age. I sometimes ask patients in their 40s who are healthy but overweight to picture two scenarios for themselves as they enter their retirement age: one where they remain overweight with multiple medical problems and are on several medications, unable to get around, and enjoy life with their grandchildren, and the other where they are active, full of life, and can continue to do everything they had enjoyed. So what really keeps a doctor away? An apple is good but not the correct answer. It is maintaining your ideal body weight. Have a good weekend.

High cholesterol is prevalent especially in the U.S. where incidence of obesity and diabetes is high. A class of medications called “statins” has been around for a long time and is used for this condition but these medications are not without side effects and recent studies showed that they may increase blood glucose levels. Many patients are looking to alternative methods of lowering their cholesterol. If your cholesterol level is mildly elevated it is worth trying out these alternative options prior to starting a statin.

First of all, I would recommend regular exercise: 2-3 times per week 20-30 minutes at a time. Ideally, a combination of resistance and aerobic regimen is the best. Reduce saturated fat intake and increase fruits, vegetables, and whole grains. Supplements such as vitamin B3 (niacin), flax seed, fish oil and omega-3 fatty acids have shown to reduce cholesterol levels. Artichoke leaf, green tea, and red yeast rice have also shown to be beneficial.

After a few months of exercise, dietary changes, and supplements I would recommend checking a fasting cholesterol level again and if it is still elevated consider taking a statin.

Recently we enjoyed watching the movie “Contagion” featuring Matt Damon and Gwyneth Paltrow. It was fun to see an  elementary school in our neighborhood featured in the movie. One of my patients asked me how likely this scenario was and my answer was that the scenario is already here. What made the virus in the movie so deadly was that morbidity and mortality were high once infected. It was a newly mutated strain usually found in an environment with close proximity of humans, pigs and birds (i.e. a place like HK). However in terms of the “contagiousness”, whooping cough is probably similar, if not more contagious. Whooping cough is a condition caused by Bordetella pertussis. It is highly contagious and causes severe uncontrollable cough. Treatment is usually 5 day course of Z-pack, and in general morbidity is low. Because most people recover fully, sometimes without even knowing that they’ve had the infection, there isn’t much media coverage. However there is an outbreak of whooping cough these days. Children are usually vaccinated against the virus however as it turns out, adults may be harboring the virus and infecting the children who may not be fully immunized. There is a relatively new vaccine called TDap (Boostrix) that is now recommended for all adults if it has been over 10 years since the last immunization. I recommend this vaccine especially if you have young children.

No one will deny that the healthcare system in the U.S. is in a state of chaos. There is waste of resources with little efficiency. I believe that the primary reason for this is the lack of price transparency at every level. Doctors who order tests and prescribe medications do not know how much they cost and patient do not know how much they will have to pay until months later when they get a bill. In the middle sits insurers, hospitals and clinics who have their own “proprietary method” of charging patients. The outcome of all this is high costs for consumers and more importantly, unpredictable prices in drugs and medical tests. Because of this unpredictability patients avoid going for medical checkups, which eventually adds to healthcare costs. Studies have shown that proactive, preventive healthcare save lives and reduce cost but this is difficult to implement when price uncertainty keeps patients away from doctors and hospitals.

Healthcare system has to change in such a way that before going to a doctor’s office, consumers know what tests they need and how much they have to pay. Even if you have insurance, deductibles and co-pays are going up every year so you have no idea how much you will owe after a visit until months later when you get a bill. In some ways you might be better off if you did not have insurance because your payment is more predictable. We have a discount program in our office so that patients without insurance get a discount based on their annual income. I try to seek out the cheapest places to get tests and medications. Sometimes I have to do the tests myself to give best prices. It is amazing how prices vary from one place to the next. A chest xray may cost $70 in one facility but $300 at a large “reputable” hospital 5 minutes away. The good news is that there are things individual practices can do to help save costs for patients.