Professional Documents
Culture Documents
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
and
Longer –
What Works,
What Doesn’t
and
Quotations sourced by
Barbara Lindley Schrier
MFTP PUBLICATIONS
Pueblo, Colorado
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
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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
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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.
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Leading Causes of Death in the U.S.
Leading Causes of Death in the U.S.
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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.
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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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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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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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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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• 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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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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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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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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• 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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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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• 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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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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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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• 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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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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• 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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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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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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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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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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(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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• 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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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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People who weigh 20 percent more than ideal body weight are
considered obese.
Obesity Shape
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Height/Weight Chart
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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
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.
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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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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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• 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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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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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.
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
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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
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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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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
protein, carbohydrate, and fiber oftoa standard
help youserving.
learn more
Manyabout a type
publications areof food.
also Thistoinformation
available help you learnismore
put about
out by industry
a type of food.or
This
information is put out by industry or government.
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.
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• 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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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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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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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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• 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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• 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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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
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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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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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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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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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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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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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• 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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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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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
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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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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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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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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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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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We are here to give you health information or tell you about
community resources to help you get healthy! Take a moment
We are here to give you health information or tell you about community resources to help you get healthy!
Would you like more information?
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1. Gender 2. Age
Ƒ Female Ƒ Male Ƒ 16 or younger Ƒ 18-30 Ƒ 31-50 Ƒ 50-65 Ƒ 66+
3. Was this book helpful to you?
Ƒ Yes! Ƒ Somewhat Ƒ Not at all
4. I’d like more information about:
Ƒ Coronary Artery Disease Ƒ Dementia Ƒ Smoking Ƒ Exercise
Ƒ Hypertension Ƒ Infections/HIV Ƒ Cholesterol Ƒ Sleep
Ƒ Stroke Ƒ Sexuality Ƒ Obesity Ƒ Vitamins/Supplements
Ƒ Cancer Ƒ Injuries/Accidents/ Ƒ Diet Ƒ Aging
Ƒ Diabetes Domestic Violence Ƒ Stress/Depression Ƒ Alternative Medicine
Ƒ Bone Disease Ƒ Polypharmacy Ƒ Immunizations
Please place this form in an envelope for mailing.
Living Healthier and Longer – What Works, What Doesn’t
Comments:
Pueblo, CO 81003
151 Central Main Street
Pueblo City-County Health Department
BUSINESS REPLY MAIL
Pueblo, CO 81003
151 Central Main Street
Pueblo City-County Health Department
BUSINESS REPLY MAIL
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Living Healthier and Longer – What Works, What Doesn’t
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