Friday, March 30, 2018

Health Tip: How Do You Know If You’re Not Drinking Enough Water?

The body is made up of about 60% water, and daily intake is obviously vital for survival. You have probably heard that you need to drink 8 glasses of water per day, at a minimum. This is a general guideline that does not take into account your activity level, health status, the temperature/humidity of your environment, or your body size/gender. The actual amount you need may vary considerably day-to-day based on what you're doing or what the weather is like.

The Mayo Clinic website notes:

  • About 15.5 cups (3.7 liters) of fluids for men
There are also exceptions – people with heart disease, kidney disease, or those taking diu
retic medications ("water pills") should discuss their fluid needs with their physician. They may need to drink less than average for their health. Endurance athletes and pregnant women or those who are breast feeding will likely need more fluid than usual. People with swallowing difficulties must keep a close eye on their fluid intake to make sure they meet their minimum needs.

Given that there is no set rule about how much water is enough, I thought I'd give you a few pointers that you can use to determine (roughly) if your hydration status is within an acceptable range.

There are two simple tests you can do to check your hydration status:
  1. Pinch Test (skin turgor test). Clinicians use this test to get a rough estimate of how hydrated a patient is. If you pinch the skin on the back of your hand, it should snap back within a second, regardless of your age. If it takes longer for the skin to return to its flat position, that's known as "tenting" and it's a sign of dehydration. The longer the skin takes to flatten out, the more dehydrated you are. Check out this video demonstration to see how the test works in action. The goal for most healthy folks is to consume enough fluids to keep the pinch test <1 br="" second.="">  
  2. Urine Color Test. The concentration of your urine is related to your hydration status. The more concentrated (or dark) the urine, the more dehydrated the body. Drinking water (or other fluids) until the urine is a very light yellow or clear color is a reasonable goal for most healthy people.
Seven signs you may be dehydrated (these can be signs of other conditions too, so ask your doctor if you are concerned that it could be something else):
  1. Headache - When we are dehydrated, brain tissue can contract a little bit due to decreases in blood volume. This pulls on the attachment sites to the skull and may be experienced as headache.
  2. Hunger - Sometimes your body is thirsty, but this is perceived as hunger instead. If you've had enough to eat and still feel hungry, it's possible that you are actually thirsty. See if drinking water paradoxically satisfies your "hunger."
  3. Dry Mouth - The body conserves saliva when it is dehydrated, which can create a dry mouth sensation.
  4. Hard Stool -  Constipation can occur when we don't drink enough fluid.
  5. Muscle Cramps - When dehydration becomes more severe (such as after long bouts of exercise) it's possible to lose enough electrolytes and salt in your sweat that you get muscle cramps. Muscles need sufficient potassium, calcium, and sodium to contract and relax normally.
  6. Dizziness when standing up - If you notice a change in blood pressure when you go from lying down or sitting to standing (experienced as near-fainting, or dizzy spell) this could mean that you are dehydrated.
  7. Rapid Heart Rate - When your body is significantly dehydrated, your blood volume decreases and your heart has to work faster to pump around the smaller amount of blood available to carry oxygen to the tissues.
The bottom line is that water is essential for health, but the amount you need varies from person-to-person and even day-to-day. You can use the two simple tests to make sure that your hydration is roughly in a good range, and the seven warning signs may give helpful tip-offs when it's time to increase your fluid intake. Remember that certain food and beverages (other than water) can provide significant hydration, but keep an eye on unwanted calories, especially from sugar – otherwise over time you may gain more than just water weight.


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Friday, March 23, 2018

Health Tip: What does your poop tell you about your health?

There is a scene in Jurassic Park where a scientist (Laura Dern) digs through a massive pile of "droppings" to diagnose a sick triceratops. She wears armpit-high plastic gloves for her stool analysis, as a bemused onlooker (Jeff Goldblum) reminds her to "wash her hands before dinner."

Stool analysis can be helpful in diagnosing gastrointestinal disorders, but without laboratory testing, I would be hesitant to go too far with self-diagnosis. However, there are a few things that you may notice as a casual (adult) onlooker that could be medically important.
  1. Blood in the stool. Bright red blood in your stool is most commonly caused by hemorrhoids or a small anal fissure. However, it is occasionally associated with colon cancer, so bloody stool should not be ignored. The color of the blood gives an idea of where it came from. If the blood is bright red (i.e. "fresh") it is more likely to have come from the end of the intestinal tract (such as the colon, rectum, or anus) . If the blood is very dark, or even black or tar-like in appearance, it is more likely to have come from "higher up" such as the stomach or small intestine. When there is a lot of blood, the stool has a distinct odor, but that is hard to describe to a person without having encountered it frequently, so maybe we'll just leave that one to the imagination.
  2. Foul-smelling stool. This is a non-specific finding, because scent is rather subjective, and you know the old expression about everyone's poop being stinky. However, there are some colon infections that have a particular odor. Clostridium difficile (known as c. diff) is a soil organism that can overgrow in the colon after a person has recently been treated with antibiotics . C. Diff causes water diarrhea (many episodes per day, sometimes frothy or greenish) and has a uniquely pungent smell. A piercingly smelly bout of diarrhea should be discussed with your doctor, especially if you've had antibiotics recently, or a family member with a C. Diff infection. If you suspect C. diff, see your doctor right away as it can be harmful if left untreated. There are other causes of foul smelling stool (such as malabsorption syndromes or overgrowth of certain bacteria) but C. diff is the one you don't want to miss.

  3. Hard stool. Constipation is very common, and can be worsened by dehydration, medications (especially opioid pain killers), a low fiber diet, lack of exercise, and intestinal disorders such as irritable bowel syndrome. If drinking more water, exercising, and eating raw veggies and bran/prunes doesn't relieve the problem, then there are many over-the-counter solutions for constipation. Hard stool may be treated first with Colace (docusate sodium) and then with laxative solutions.

  4. Dark stool. Although dark stool may be caused by blood, remember that stool often reflects the color of the food you eat. Beets are notorious for causing bloody-looking stool, and iron tablets and Pepto Bismol (bismuth) turn stool dark as well.

  5. Bright green stool. Bile is produced by the liver and stored in the gallbladder. It is a kind of neon yellow color, and is used like soap to break down food in the top part of the small intestine. If your stool is bright green or yellow, you may just be seeing bile. Bile is more noticeable when you have diarrhea (so there isn't as much food to soak up the yellow bile pigment to create brownish stool), or when you have a stomach bug (viral or bacterial illness) that is making your food move through your intestines very quickly. Dark green stool is usually a sign that you recently ate chlorophyll-rich dark green veggies.

  6. Oily or greasy stool. If you see oil floating on the toilet water (and you're not taking Colace as a stool softener), it's possible that you are having absorption difficulties due to an intestinal or pancreas disorder. Greasy stool that is also very smelly is associated with malabsorption such as Celiac disease.
The bottom line is that stool infections are not possible to diagnose with a casual eye. Samples need to be cultured and examined under a microscope to determine if there is a parasitic or bacterial issue. Everyone's bowel habits are a bit different (some people normally pass stool every day and others may go 5 days at a time before they have a bowel movement), and the food we eat (and the fluids we drink) can vary our stool color and consistency quite a bit.

Bloody stool or severe diarrhea are important to discuss with your doctor because delaying treatment could cause you harm. Otherwise, you'll have to rely on more than the look and smell of your poop to determine if you have a disease or medical condition of concern. And don't forget to wash your hands thoroughly with soap and water if you choose to examine it Jurassic Park-style!
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Tuesday, March 20, 2018

Health Tip: Opioid Addiction - Why you should be concerned

You may have heard that there is an opioid crisis in the United States with people becoming addicted to pain killers, overdosing, and dying. Even though the Trump administration has identified the opioid epidemic as a "public health emergency," a recent public opinion poll suggested that Americans aren't as concerned as they should be. The public sees opioid addiction as a second tier national problem, and few people (7%) worry that they themselves could become addicted to prescribed pain medication. That being said, opioid overdose is the number one cause of accidental deaths in the United States, outpacing gun-related deaths by more than four times.

What is an "opioid" drug?
Opioids are a class of drugs that interact with the same receptors on nerve cells in the body and brain. They influence pain perception and can produce feelings of both nausea and euphoria. Drugs in this class vary in strength and potency, from the illegally-produced heroin and opium, to synthetic (and semi-synthetic) prescription drugs including Fentanyl, Demerol, Dilaudid, methadone, oxycodone, hydrocodone, codeine, tramadol, and morphine.

Why are they addictive?
Because they can be effective pain relievers and also have the potential to produce euphoria, they may become addictive. It is estimated that 54 million Americans (more than 20 percent of those aged 12 and older) have used prescription opioids for nonmedical reasons at least once in their lifetime. An estimated 25 million Americans are living with chronic pain conditions (defined as pain every day for at least 3 months).

So we have a perfect storm: millions of Americans in pain, and pain medicines that have euphoric side effects.

The other challenge with opioid medications is that the body habituates to them fairly rapidly, requiring higher doses to produce the same effect (known as drug "tolerance"), and causing unpleasant withdrawal symptoms (such as sweating, agitation, anxiety, muscle aches, insomnia, diarrhea, and vomiting) if they are discontinued too rapidly.

When ceasing an opioid medication produces withdrawal symptoms, the body is considered to be "dependent" on the drug to maintain its homeostasis (i.e. feeling "normal"). Dependency is not addiction, but it can occur as quickly as a day or two after starting a pain medication. So if you take opioid pain medicine, you may well encounter withdrawal symptoms when you taper down to discontinue it. It's important to recognize this, and resist the urge to treat the symptoms with more opioid. Studies show that the longer you take pain medicine, the more likely you are to become addicted to it.

Among people given enough pain pills for eight days or more, 13.5 percent are still using them a year later. Among those given a month-long prescription, that rate climbs to 30 percent.

What can you do to avoid opioid dependence or abuse?
If you are having surgery or are in severe, acute pain from an accident, opioid medicines may be the most effective way to control the pain. In these cases, it may be difficult to avoid using these medicines to get you through the acute phase of your recovery. Ask your doctor to prescribe these medicines "as needed" instead of scheduled (where the nurse brings you the meds without asking for them), and try to opt out of taking them as much as you can. Use alternative non-opioid medicines if appropriate, including acetaminophen, ibuprofen, and naproxen. Sometimes an ice pack, topical numbing agents, or nerve pain medications can take the edge off your pain without resorting to opioids. Remember that it is unrealistic to expect your pain to be reduced to zero after trauma. Work towards a tolerable pain level instead.

If you have chronic pain, it's important to do everything you can to avoid reliance on opioids for your pain. Seek out a physiatrist or pain management specialist and review alternative pain management strategies, including physical therapy, massage, meditation, hot and cold treatments, non-steroidal anti-inflammatory drugs, nerve pain medicines, anti-anxiety medications, anti-depressants, and topical numbing agents. If you have been on opioid medications for a long time, it may take time to taper off them to avoid severe withdrawal symptoms. Be patient, but be committed to discontinuing them. There are medicines that can help to treat withdrawal symptoms if they occur, and medications are also available to assist with long taper plans (such as methadone, buprenorphine, and naltrexone).
What makes opioids lethal?
No one dies of withdrawal symptoms, no matter how unpleasant they may be. People die of opioid overdose because at high levels, these drugs have a sedating effect, which suppresses the brain activity that controls breathing rate. It also dampens signals to the diaphragm, which moves to expand or contract the lungs. Opioids also suppress the brain's ability to monitor and respond to carbon dioxide when it builds up to dangerous levels in the bloodstream. Usually, people pass out and suffocate to death during an opioid overdose.

The most potent opioids are the riskiest for overdose. This is why extremely strong opioids such as Fentanyl are highly regulated, but also abused on the illegal market. Tiny amounts of this opioid can kill.

Opioid medications have a role in acute pain management, but they must be handled with extreme care. Most of us will become tolerant to opioid medications after a few days of use, and many of us will experience withdrawal symptoms when we taper off the medications. Knowing what to expect may be empowering for patients - so that they can avoid the cycle of withdrawal and increasing doses that can spin into dependency, lead to addiction, and put people at risk for overdose and death. When it comes to opioid pain meds, my advice is to use the lowest effective dose, don't chase withdrawal symptoms with more pain medication, and get off them as quickly as you can. When possible, plan your taper strategy with your doctor before your first dose of opioid.


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Friday, March 9, 2018

Health Tip: What is the best way to work out?

I was recently asked this question - what is the best way to work out? I find that people mean many different things when they ask this. Some mean, "What is the minimal amount of exercise that I can do and be healthy?" while others mean: "What is the best exercise for fat loss?" and still others mean: "What is the simplest way to fit exercise into my busy schedule?"

As you may have guessed, the answer to this question varies based on its true intent. First of all, let me tell you what research suggests about the minimum amount of exercise for "optimal" health.

The first official physical activity guideline for Americans was developed by the American College of Sports Medicine in 1975. And you may be surprised to discover that all of their updates since then have focused on "toning down" their initial heart rate goals! In 1975 they recommended 3-5 days per week of 20-45 minutes per day, exercising such that the heart was kept at 70-90% of its maximum rate for all those consecutive minutes.

By 2000, the recommendations had dropped that goal to 7 days per week, at least 20 minutes per day where the heart is at 40-85% of its maximum rate. (By the way, your maximum heart rate is approximately 220 minus your age. So if you're 46, then your maximum heart rate is 220-46=174 beats per minute). Over time, research seemed to suggest that accumulating minutes of intense activity over the course of the day was acceptable - all those minutes didn't have to be continuous.

The Institute of Medicine, IOM, (one of the most prestigious, invitation-only, expert panels in the United States, founded in 1970 to advise the federal government on health issues) has researched the topic of optimal exercise for health benefits and has distilled it down to this (in 2005):

Adults should get 60 minutes of moderate intensity exercise 7 days a week to prevent chronic disease and maintain a healthy weight.

How they came to that conclusion is quite complicated and you can read about it here.*

Just to add to the confusion, the newest guidelines (which are now 10 years old actually) from the Centers for Disease Control and Prevention (CDC) allow you to accumulate activity on a weekly basis, and they make an additional clarification: aerobic activity that increases the heart rate is not enough. Exercise should consist of aerobic activity and strength training.

The latest minimum healthy exercise recommendation is:

150 minutes of moderate intensity activity (such as brisk walking) per week AND muscle strengthening activities that challenge all major muscle groups, at least twice a week.

In case you're feeling badly about your current exercise level, it is estimated that only 20% of American adults are meeting the minimum recommended physical activity requirements by the CDC.

So in this health tip we've actually only answered the "what is the minimal amount of exercise adults should do to be healthy?" That leaves us with the question of specific exercises that can help with fat loss goals, sports-specific performance, diabetes management, or physical appearance. Nevermind the recommendations for different age groups, or people with injuries or disabilities. I'll save those topics for another time.

Please feel free to ask your questions for Health Tips by emailing them to this address:


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Friday, March 2, 2018

Health Tip: Flu Update

This has been a particularly bad flu season, though it seems we may be at the peak and about to see a decrease in infections. The Centers for Disease Control and Prevention (CDC) reports that flu season usually peaks between December and February, and having this season's peak at the end of February means that it is still going strong. In fact, more than half of the country is still reporting high levels of activity. Experts predict that there are many more weeks of flu season to go, and it could last until mid-April.

Why are children especially vulnerable to the flu?
So far, 97 children have died of the flu this season, most of them unvaccinated. Children are more vulnerable to flu viruses because they have inexperienced immune systems that have not been exposed to many infections. Once the body has fought off a viral infection, it can recognize the virus more quickly when it is exposed the next time. Early, robust immune responses are the body's best form of defense against disease. Vaccines are critical in helping to teach our immune systems to recognize foreign invaders. Even though vaccines may not confer 100% immunity, even partial recognition (or matching) may shorten the time it takes to mount an immune response, preventing the invaders from multiplying and spreading more broadly across body tissues.

When the viral load is extremely high, it can trigger massive, microscopic chemical releases that swell the lungs and make air exchange difficult. In some cases, bacteria in the respiratory tract overgrow and penetrate deeper into the lung tissue that is damaged by the virus, creating a second source of infection. In severe cases, air cannot get through the inflamed lungs and into the bloodstream, resulting in decreased oxygen levels and possible death.

What can you do to prevent the flu?
First of all, it is worthwhile to get the flu vaccine, even at this later date. Although experts estimate that it is about 34% effective at preventing the flu this year, it may also reduce the severity of the illness if you get it. Remember that it takes 10-14 days for the flu shot to become effective, so be extra careful about exposure to sick individuals while your body's immune system is ramping up to recognize the viral invaders. You can get the flu in those first two weeks just as easily as if you hadn't been vaccinated. (Some people who get the flu just after the vaccine incorrectly assume that they got it from the vaccine.)

Our main weapons (besides the vaccine) are, according to the CDC:
  6. Disinfecting contaminated surfaces. Clean and disinfect frequently touched surfaces at home, work or school, especially when someone is ill.
  7. Keep your immune system strong. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.
If you do get the flu, are there medicines to make it go away faster?
Yes, there are are three FDA-approved, anti-viral medications that can reduce the severity of the flu and reduce it's duration by a day or two.
  • oseltamivir (available as a generic version or under the trade name Tamiflu®),
  • zanamivir (trade name Relenza®), and
  • peramivir (trade name Rapivab®).
If you are in a "high risk group" for flu complications, you should see your doctor about anti-viral medications (they are only available by prescription). But hurry, these medications only help if you take them within 48 hours of symptom onset.
Who is at high risk for flu complications?
  • Children younger than 2 and adults over 65
  • Pregnant women
  • Nursing home residents
  • Native Americans
  • Those with medical conditions that put them at higher risk for flu complications (including heart disease, lung disease, asthma, and a long list of others.)

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