An Ounce of Prevention is Worth a Pound of Cure

Old truisms like this one persist because they contain wise advice.  Unfortunately, while we all know them to be true, we often aren't so good about implementing the advice.  Many of my patients do a very good job of researching their health problems.  Many put lots of energy into sorting out what supplements might be good for them.  However, relatively few of them adequately attend to the basic health screenings they should receive.  Fewer still come in to go over their lifestyle habits to prevent disease or learn how to improve the way they feel on a day to day basis.  In the rush of life we tend to overlook things until they force us to take notice.

I recommend that patients come in every year or two, even if they feel well, so that we can discuss their health habits.  Part of this review is going over their diet looking for problem areas.  If they have been in before, I will try to learn if they have been acting on my previous recommendations or if the recommendations should change.  Every year there are literally millions of new research findings published in medical journals.  As we learn more, I work to incorporate the best parts of what we have learned into my recommendations to patients.  As medical researchers have finally begun to research alternative medicines and dietary supplements, we are learning so much so fast that it is simultaneously wonderful and overwhelming.  My family can tell you of the mounds of medical journals I plow through every week.  I even keep a stock of them in my car so I can read whenever I have an opportunity.

This article is focused on the health screening that I recommend.  Please go to Fundamental Health Habits on my website to read about what I believe we all need to do on our own to be healthy and happy.

Beginning Before Birth

Prenatal care is preventive medicine.  It is the most purely wellness-oriented aspect of conventional medical care.  Prenatal care is also unquestionably one of the most successful aspects of conventional medical care.  It saves lives, leads to healthier children and saves money.  I would like to see more parents educated about diet, supplement and lifestyle interventions that appear to have great potential for improving the wellbeing of their coming child not to mention the soon-to-be delightedly stressed parents.

Childhood

Continuing through the life cycle, well child exams are a justifiably popular means of screening children for health problems.   Many problems, can be identified early and then treated before they become significant.  In some cases, like hip dislocations or strabismus, delayed treatment can make the problem very difficult to treat succesfully.

In addition, these visits provide a fantastic opportunity for health education.  New parents should receive support informationally and often emotionally in these visits.  Experienced parents can get help sorting how to deal with the new and different model now in their possession.  The physician learns about the new patient and his/her family while providing preventive health education.  In some cases it can be important to screen for anemia or environmental toxins (lead for example).

The nutritional needs of children are quite different from those of adults.  Also, dietary choices made in the formative years have life long repercussions.  US government data tell us that 30-70% of American children are deficient in some of the most common vitamins (E, C & A).  Despite this fact, very few pediatricians routinely inquire about their patients' dietary habits.

After completing the customary run of well child visits by age 2, I like to see healthy children every 2-3 years to go over their diet, conduct a physical examination and address any health related questions.  This becomes most important around the major growth spurts because overlooked chronic nutritional inadequacies often lead to disease or worse when the body lacks the nutrients needed to fuel its transformation.

Children increasingly participate in sports with a specialized dedication making them more susceptible to a variety of injuries.  For example, girls playing sports that involve explosive directional changes like soccer, volleyball, basketball and skiing have a major risk for serious knee injuries peaking in the mid teenaged years.  Children and adults for that matter who play contact sports (football, soccer, boxing, skiing, horse riding) are at risk for head injuries.  We now have exercise regimens proven to reduce the risk of knee injuries and computerized testing to follow subtle signs of brain injury guiding decisions about safe return to competition.

Teenagers - Yikes

As the officially designated source of societal debate, frustration, controversy and criticism teens have a heavy responsibility to challenge the assumptions of the rest of us.  Although I can understand the reasons for friction between parents and their teens, I enjoy working with them.  Maybe that has something to do with my lifelong role as an agitator.

In my experience it is very important for me to see my young patients again during this time of their life.  One reason is that they need to know that I am their doctor and, limited by threats to themselves and others, I can be a confidential source of information.  As their lives change, so do their risks and inevitably their responsibility for their own health.

I have mixed feeling about vaccinations but maybe the most important vaccination to consider is the hepatitis B vaccine.  It is usually administered to infants because of the "we've got them in our clutches" public health attitude.  Except when family members are hepatitis B carriers, children are not at risk for hepatitis B until they begin dating.

Just as with the rest of the lifecycle, prevention is better than treatment so this is a critical time for education about high-risk behaviors, diet and exercise.  The old fear about marijuana use leading to addiction to "harder" drugs may have some truth to it but we know for certain that cigarette smoking is clearly and strongly associated with subsequent drug and alcohol abuse.

On to Adulthood

Standard medical care starts out pretty well by uncharacteristically focusing on prevention, but then loses the plot neglecting labor-intensive health promotion counseling. This has always seemed odd to me because health care is largely about education, not just writing prescriptions hand-over-fist.

Once again, a thorough periodic examination of your diet, supplement usage, exercise patterns and other lifestyle elements is a great way to prevent disease while improving the quality of your life. Obesity is becoming epidemic in our high carbohydrate, low activity society. The health consequences are enormous and it is certainly easier to reign in on the problem when you discover your weight has just started to go up, than it is to drop serious poundage later on.

High blood pressure is often a consequence of excessive weight gain, although in many cases it appears in people whose weight is not markedly abnormal. Unlike the visibility of weight gain, most people have no idea that their blood pressure is elevated. People with hypertension don't feel any different until years of increased blood pressure have made their mark with heart disease or stroke or some other nasty problem. Checking your blood pressure annually is a good idea.

I should mention the growing discussion in the medical literature about when or if doctors should check patient's blood pressures. Because there are a significant number of people whose blood pressures are fine everywhere except the physician's office, too many people are incorrectly diagnosed with hypertension. Most of them are then placed on prescription medications that they do not need, and from which they suffer adverse effects. I usually check my patient's blood pressures periodically and, if elevated, I urge them to check it again themselves every morning for a week or two. There is a new generation of highly accurate, easy and maybe even fun-to-use blood pressure monitors, so checking it yourself is not a big deal.

Periodic blood screening for diabetes and lipid abnormalities (elevated cholesterol, serum c-reactive protein) is anything from a good idea to crucially important, depending upon your family history, weight and lifestyle habits.

Mens Health

Unfortunately, men tend to be relatively oblivious to preventive health care. That may explain why we tend to live a couple of years less than women. Just as women are more vulnerable to certain health problems, men have our own weaknesses.

Testicular cancer is the most common form of cancer in 15-34 year old males, and the second most common in 35-39 year old men. This cancer can be diagnosed easily. All it takes is a physical examination, and young men should learn to do this for themselves.

Annual digital prostate exams are a good idea after age 50, or even much younger if symptoms warrant. Blood testing using the PSA (Prostate Specific Antigen) test has its uses, but unfortunately, it is very prone to false positives. As a result, many men have undergone needless procedures, some of which have often led to serious long-term ill effects. As the years go by, the test is getting refined, which increases the accuracy and decreases the false positive rate.

Womens Health

Young women need to be concerned about cervical cancer screening. This preventable cancer is most common in young sexually active women. Regular PAP smears should start within 3 years of first intercourse. Bimanual pelvic exam is also important because it can help us diagnose ovarian cysts, ovarian cancer, uterine fibroids and a number of other problems. Examinations should be repeated annually until 30 or 35, and then every 3 years until age 65. Women who are at higher risk (DES daughters or granddaughters, multiple sexual partners, immunosuppression) should be screened annually. Women who have had a hysterectomy do not need PAP smears.

Mammograms are a controversial and confusing topic these days. Mammograms can detect breast cancers 1-3 years before they can be felt. But, there are many falsely abnormal mammograms, particularly in women under age 50. Maybe breast exams can help, especially if performed well. Then again, further adding to the confusion, one recent massive study in China found no benefit of breast self-exam, even when women had received instruction in proper examination techniques. How can that be when most breast cancers are still discovered by women examining their breasts intentionally or unintentionally?

So my recommendations are: First--stay tuned. New technologies are in development that promise more reliable information, everything from breast MRI to electrical impedance to ductal lavage with microfiberoptic equipment. Second--consider your family history and other risks for breast cancer (early onset of menses, no breast feeding, use of hormones, alcohol consumption, weight gain after menopause). Third--I think there is a role for breast self examination, but we just don't know what it is. The same can be said of professional clinical breast exams. You should consider mammograms every other year, especially if you are between the ages of 50 and 70, have a close family history of breast cancer or have a number of risk factors for the disease. One other note is that I do not think that breast thermography is a useful tool. It is just doesn't give enough consistent or meaningful information.

Ovarian cancer screening is another area of evolving controversy. At this time, the most useful predictive factor is family history. An American woman with no family history of ovarian cancer has a 1.2% lifetime risk of developing the disease. If one relative has had ovarian cancer, her risk goes up to 5%, and 7% if two relatives have had the disease. There is also a rare genetically inherited syndrome that increases the risk drastically - 40% lifetime risk.

The CA-125 blood test has gotten a great deal of attention as a screening test. The numbers from a large (22,000 women) study in the United Kingdom highlight the limitations of this blood test. Of the 11,000 women receiving the CA-125 test annually, 16 developed ovarian cancer. However, the blood test was not very good at finding them. Of the 468 women who tested positive, only 6 had ovarian cancer. The other 10 women with ovarian cancer had tested negative.

Another blood test of a tumor marker, lysophosphatidic acid, looks like it may be better, but it needs to be evaluated in screening studies to learn if it is adequately sensitive to use for screening.

Women who are at very high risk for ovarian cancer (family history, Northern European descent and never pregnant) might consider taking oral contraceptives, as they appear to significantly reduce the risk of ovarian cancer.

Osteoporosis screening is recommended for women at age 65, but I think it is a big mistake to wait until then. As bone density declines sharply following menopause, I recommend a DEXA bone density at the onset of menopause. That way you can take action to prevent osteoporosis, instead of getting backed into a corner having to consider prescription medication.

As We Age

As the time we have left gets shorter, the likelihood of significant health problems inevitably increases. Colon cancer is one of the best examples of a health screening success story. This is a very common cancer with good evidence that early treatment saves lives.

After age 50 every one should have an annual stool blood test (guaiac), looking for invisible blood in the stool. Also, either a sigmoidoscopy every 5 years, double contrast barium enema every 5 years or a colonoscopy every 10 years looks to be a good idea. A sigmoidoscopy is easier and cheaper, but it only looks at the last 30% of the colon. In my opinion, patients with a family history of colon cancer, especially in relatives under age 50, should start colon cancer screening even younger.

So called "virtual colonoscopy" is a fancy X Ray test (CT scan) of the colon. While this test identifies polyps like colonoscopy, the patient must then undergo regular colonoscopy to biopsy the polyps. In traditional colonoscopy, any polyp can be easily biopsied, and often the simple removal of the polyp is therapeutic, as the polyps then cannot follow their common natural history and become cancerous. I do not like the radiation exposure virtual colonoscopy requires.

I am skeptical about the new wave of body scans. They are marketed to the public as an accurate means of disease screening, but there are drawbacks. The radiation exposure is considerably less than years ago, but still considerable. We all have a variety of "defects", and you have to ask what good it does to find more of them. Sometimes even finding a cancer early only leads to interventions which make the patient suffer without leading to a longer or more enjoyable life. In some rare circumstances these scans might save a life, but what about the worry over something which might never have caused you symptoms, the risk of the radiation, your potential uninsurability after something is discovered, the cost .? I think this is more of an individual decision based upon your intuition, than it is a clear cut medical decision.

Years of exposure to the sun and environmental toxins can lead to skin cancer. I recommend an annual skin exam after age 40. In addition to the clinical features that tell us that a skin lesion is likely to be malignant, a new technology, well established for years in Europe, helps distinguish cancers from "funny looking" moles. This simple hand held device is a polarized light. I have found it helpful and very easy to use.

There are a few other tests that I think have a role in health screening.

Many patients experience low energy or immune dysfunction from low levels of iron without knowing it, because most physicians do not know to test the body's store of iron. It is very well established that physical abilities are hampered and patients have symptoms because of low iron, even when they are not anemic. The simplest blood test for body iron stores is ferritin. Among my patients, 20-25% of females in their 40's have low iron stores.

Thyroid deficiency is also very common. As laboratory technology has improved dramatically at measuring low levels of hormones, we can screen for low thyroid with a simple blood test. I do not agree with those who contend that morning body temperature is an accurate gauge of thyroid function.

When I worked as an emergency room physician years ago, I would often see patients with chest pain for which it was difficult to determine the cause. In the past few years, some rapid blood tests have appeared, improving diagnostic accuracy, but I still think it is a good idea for any adult who has had an EKG to carry a copy of it in his/her wallet. That way an ER doc can compare it to a new EKG if you have chest pain.

I believe that periodic eye examinations, including glaucoma screening, are a good idea.

The future promises many new blood tests for cancer markers, and a variety of health assessment tools using light to examine body tissues. We have a long way to go before we advance to the "Star Trek" physical, but as tools become finer they can tell us more while being less intrusive.

Finally

The subtlest instrument in our possession continues to be the power of human perception and intelligence. For this reason it is vital to consider your own unique family history, tendencies, strengths and weaknesses. Just so, it is important to seek the advice of someone who knows about health and has the experience to understand your qualities.

Mark Twain wrote that a man who has no vices may not live longer, but it will surely seem that way. I like the humor, but in my experience living in the right way is the best guarantee of living your life to the fullest in every sense of the word.

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How To Have A Healthy Baby

My best advice is to the prospective babies out there - "Look for healthy parents." Seriously, although having good health is in part the result of good fortune, it is mostly the result of good health habits. The effects of your health decisions are multiplied in your child.

For example, drinking an excessive amount of alcohol can have many detrimental health effects on adults; a pregnant woman who drinks even a very small amount of alcohol puts her child at risk of fetal alcohol syndrome. Fetal alcohol syndrome is the leading cause of mental retardation and birth defects in the United States.

Another widely known example is smoking. Smoking during pregnancy makes the baby smaller and more vulnerable to respiratory diseases. As if that weren't enough, children who are passively exposed to cigarette smoke (most often from their parents) have an increased risk of lung cancer, and their lungs will never develop as fully as children of nonsmokers.

While there is so much we could talk about in regards to raising healthy children, I want to focus here on the less obvious aspects of prenatal health. Many of these tips are dietary, but lets start from the top.

Facing the prospect of having a child is always a bit stressful. Even if the pregnancy was perfectly planned, in a stable family that is well prepared for the addition, the new family member changes everything. Most first-time parents, especially those who thought they were so busy before, discover how much free time they used to have. The second child throws a curve at his/her parents, because they usually believe they've learned enough from their mistakes that it will be a piece of cake the second time around. Ooops. Instead, they often learn that methods that were so successful with child number one, don't work at all with number two. Still worse, that stuff doesn't work with number one anymore either because she/he has changed with age and the introduction of a sibling.

Parents with three or more children, like an outnumbered army, usually surrender. In this case, they surrender any remaining hope of being perfect parents. Actually, in this seeming futility there is wisdom. We all fail as parents in some way, but if we try to do our best, our successes are enough to give our children a good start in their lives.

How can anyone deal which such hopeless responsibility, anxiety, confusion, excitement and joy? Well, no one said peace of mind came easily. Doing your best to develop emotional stability will help you and your family get through the wonderful dramas heading your way. I think the real reason yogis withdrew to caves to meditate was that is was just too tough to do it at home with the kids fighting, the spouse needing attention and the neighbors upset for one reason or another. Parenthood teaches and demands strength of character and equanimity.

Eating the right things is easy by comparison. We know that high B vitamin supplementation prevents neural tube defects. When I first learned this 25 years ago, the great majority of the medical community, who did not read the research, considered it a crackpot idea. Similarly, there are other promising research findings that are not well known as yet, but might turn out to be common medical knowledge 25 years from now. For example, new research shows that Vitamin D and choline are important neurologically to the developing fetus. A series of studies has found that children whose mothers took supplemental choline (also found in eggs and nuts) had significantly increased scores on intelligence tests. Danish researchers recently learned that women who ate fish markedly reduced the risk of delivering a premature or underweight baby. We think this is because of the omega-3 oils in the fish. We are learning more and more about the importance of diet in pregnancy.

The next suggestion requires some explanation. We all have a huge population of bacteria living in our bodies. Don't worry, most of them are friends and do good things for us. We call them "probiotics", because they help other living creatures, like us, for example. For a long time we've known that some of them help us by making certain vitamins, but recently we've started to learn a whole lot more about their positive effects on human health. These bacteria can get rid of chemicals that cause cancer. They reduce rates of diarrheal disease and severity of illness in those who do get sick. Some of the most intriguing information, though, pertains to their immunity mediating effects. Children who receive antibiotics in the first year of life have a 400% risk of subsequently developing asthma. Studies suggest that one of the ways antibiotics increase the risk of asthma is by changing the bacteria in our intestines. (To learn more, read about the hygiene hypothesis).

The first bacteria in the digestive tract spread out and make themselves at home. They are difficult to kick out later. So, it is an excellent idea to try to help the best bacteria get there first.

I am sure you have probably heard of acidophilus. Lactobacillus acidophilus is one of the hundreds of species of probiotic organisms we have identified. Over 15 years ago, dedicated researchers at Tufts University in Massachusetts collected bacteria from the digestive tracts of healthy people. They tested over 200 different species, looking for the best one ­ able to survive the digestive processes, strong enough to stick in the bowels, easy to grow and with lots of beneficial health effects. The species they selected is now known as lactobacilluss GG (GG = Drs. Gorbach and Gouldin). Since then, this species has been the subject of hundreds of research articles, and it consistently turns out to be as good or better than every other organism to which it has been compared. Undoubtedly, with time, we will learn that other probiotic organisms are better in certain circumstances; however, at this point lactobacillus GG is clearly "king of the hill".

I recommend that pregnant women take lactobacillus GG daily before delivery, and that parents give it to the newborn infant for the first month after birth.

We are suffering a puzzling increase in allergic disease, particularly asthma. In the past 20 years the rate of asthma in American children has tripled, despite many improvements in environmental risk factors. In addition to using probiotics, there is something else you can do to decrease your child's risk of developing allergic disease. Although many children with allergies are sensitive to animals, children who are born into homes with three or more animals rarely develop allergies. Similarly, children who grow up on farms rarely develop allergies. On the other hand, you need to consider the entire family. If other family members already have an allergy to cats, it would not be wise to try to help the baby by loading the house up with cats.

When babies are born, it is routine to prick their little heels to run several tests screening for a number of diseases which are important to identify right away. The most common of those problems is hypothyroidism which can cause mental retardation in the undiagnosed newborn. Adding to the potential for thyroid hormone deficiency related developmental problems is the environmental contaminant perchlorate. Perchlorates are used in a variety of products and now found widely spread throughout the environment. Unfortunately perchlorates block the iodine our thyroids need to function. Worse still, the chemical pathway women’s bodies use to concentrate iodine in breast milk for their newborn babies actually favors perchlorates over iodine. Consequently, breast milk concentrations of perchlorate are much higher than environmental exposure would predict and simultaneously, iodine levels are quite low. Taking even modest doses or iodine (150-200 mcg) can counteract this problem. All pregnant and nursing women should make certain they are either getting plenty of iodine in their diet or taking a supplement.

Taking supplements, eating well, getting enough sleep and all of the other good health habits are even more important during and for months before a pregnancy. Don't forget that dad has a part in all of this. If he wants a healthy baby, he should take care of himself as well. Taking care of the family, takes care of the baby.

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Natural Approaches To Menopause

As the generation with the highest interest in natural health ages, its female members are asking lots of questions about conventional management of the menopause. As you can see by my emphasis in the prior sentence, I share the sense that it is odd to turn a normal part of the aging process into a disease, which must be managed medically. Previous generations of women have felt this ambivalence as well, evidenced by the extremely small proportion of postmenopausal women who have traditionally taken their prescribed hormones for more than a year or two.

I believe that hormonal changes are not defects. (One of my favorite bumper sticker is the one, "They aren't hot flashes, they are POWER surges!") I believe that we should respect these changes as natural processes, and recognize that intruding with synthetic hormones is likely to lead to unanticipated adverse consequences. The natural levels of many hormones, including male and female sex hormones, decline with age. We know that boosting hormonal levels, including estrogen, progesterone, testosterone, growth hormone and DHEA, can be associated with increased risks of various cancers. Some scientists believe that declining levels of these hormones allows us to live into old age, because otherwise we would die of cancers or other hormone-driven illnesses.

However, for so many years my skepticism hid timidly trembling in a corner of my brain. All we knew scientifically pointed strongly in favor of postmenopausal hormone supplementation for women. These hormones appeared to reduce the risk of osteoporosis, heart disease and Alzheimer's disease, with little evidence of increasing risk of any health problems, including cancer. Studies of long-term health issues with many factors that alter the risk (diet, exercise, etc) are difficult to conduct and prone to misinterpretation. For example, in the past, many women who were unusually active in their devotion to their health also saw their doctors for hormone replacement, thus confusing study data, which suggested that hormones led to benefits (which were actually largely due to exercise). The latest scientific position paper on women's health issues concludes that hormone replacement therapy is not the best choice of therapy or prevention for any menopause-related symptom or condition except hot flashes.

Regarding the use of conventional hormones, as is nearly always the case, the circumstances of every individual patient must be considered. There are situations in which hormone replacement therapy is the best choice for a certain patient. That circumstance is not the norm, in my opinion. Even within the confines of conventional hormones, there are far too many options and different flavored approaches, to simplistically label hormones as good or bad.

Whenever we consider any chronic health condition, attending to fundamental principles goes a very long way towards achieving ideal outcomes. Exercising moderately reduces the risk of osteoporosis by 18%. Exercising vigorously reduces the risk still further - 44%. Creating and maintaining healthy bones by eating sufficient calcium and green vegetables, while moderating animal proteins and alcohol, will also reduce the risk of heart attack, diabetes, stroke and many other diseases. Those are highly desirable "side-effects."

Most women pass through "the change" with little difficulty. Sometimes professional help is needed. This transition also serves as a reminder that it is wise to periodically assess our habits, so that we correct mistakes to become as strong and resilient as we can be. I offer a variety of therapies that can be helpful with peri-menopausal symptoms. These include homeopathic medicine, herbs, nutritional supplements and lifestyle counseling. Just as with conventional medication, the risks of these therapies increase with their potency, so professional guidance is a good idea if you use these therapies for long-term health problems, or your problems are severe.

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