Motivation

Walking briskly on the treadmill at the gym, I am trying hard to avoid looking at the bank of televisions above me. I hate them. After checking my email and  Twitter I consider listening to music. Ultimately I try to concentrate on the ball of my foot hitting the belt on the machine. exercise-log-sheet-exercise-log-sheet-track-pictures-947x947When I’m finished and on the way home I reflect on how much better I feel and marvel at how difficult it is to get myself to walk a minimum of 30 minutes five times a week. This is the “magic pill” my patients see on my whiteboards in the exam rooms. So if it is so difficult to motivate myself, why do I have the chutzpah to try to motivate other people?!

 

I don’t know the answer to that question. But like my patients, all I can do is get up the next morning and try to do it right today.

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A Caffeine-Containing Post

In follow up to an ER visit for a new onset migraine headache, my patient casually asks if caffeine could be playing a part in his headache and blood pressure issue. As we reflected on that possibility he admitted to drinking at least 64 ounces of diet, caffeine-containing sodas daily. WHAT?!?!? Not only can caffeine raise both blood pressure and pulse but if one already has hypertension, caffeine may elevate it even more than in a normal person.[1]  When he  presented to the ER with an excruciating headache and extremely high blood pressure he underwent a head CT scan that was normal and it was theorized that the blood pressure was due to the headache, perhaps a migraine. The problem I had with the diagnosis is that people do not typically present with their first migraine headache in their mid-40s. The ER started him back on blood pressure medication (he had been able to stop it about a year ago with diet and exercise) and sent him back to me for followup. So in my office we began to  explore the biggest question:  was the pressure causing the headache or the pain from the headache causing the blood pressure? In the time between the ER and our office visit he realized that he got a headache if he went a few hours without caffeine. We developed a plan for slowly stopping all caffeine products before ordering any more expensive tests. Since his pressure was still elevated,  his blood pressure medication was increased.

Over the course of a month he brought his exercise level back to 2012 levels (before he let work take over his schedule) . He reduced and came off the caffeine with the exception of one cup of green tea in the morning. He took the bigger medication dose just one day but it made him dizzy. Soon he found the 1/2 dose too much. By the time I saw him one month later his weight was down, his blood pressure was normal and he was completely off medication.

Moral of the story? First of all, caffeine can be beneficial[2] as can working hard. However–all things in moderation. Secondly, what you put in your mouth (or don’t) and how much you exercise you do can sometimes work as well as a pill. And there are no side effects!

1. Hypertension Risk Status and Effect of Caffeine on Blood Pressure. Hartley, Terry R., et al. Hypertension.2000; 36: 137-141. http://hyper.ahajournals.org/content/36/1/137.full

2. http://www.mayoclinic.com/health/coffee-and-health/AN01354

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The Magic Pill

When patients come in to one of my two exam rooms to wait for me, they see written on the white board THE MAGIC PILL “Walking five times weekly, 30 minutes (minimum)” Originally I had written the exercise recommendation for a specific patient but did not erase it. It generated so many conversations from patients coming in for other reasons that afternoon that now it resides permanently on the board (except when a helpful cleaning person erases it).

What has been surprising to me is that most patients WANT to talk about it. They frequently reference that they are walking, they want to walk or they hope to walk. It has been a great conversation generator. In addition to that it has given me the opportunity to talk about studies that illustrate how good walking is, or more generally, how important exercise is to well-being and longer living.

There are numerous studies linking improvement in depression with physical activity and a list of several of them can be found here. Thanks to direct-to-consumer ads, especially on TV, patients often have a magical idea of how anti-depressants work. When we talk about the number of side effects associated with these drugs, especially weight gain, medications become much less appealing.

Another important discussion often begins with how many patients have been told to stop moving because their back/knees/hips hurt. This is bad advice and it often comes from medical professionals. Of course it is USUALLY necessary to quit activity with an acute injury but if you stop too long muscle atrophy sets in and joint stiffness occur. More and more studies point to how important it is to keep moving. Denise Mann writes about this in a great article on WebMD entitled Dealing With Osteoarthritis? Try WebMD’s Joint-Friendly Walking Program”.

Brisk walking (defined as a 15-20 minute mile) can reduce heart disease (NEJM), improve function in osteoarthritis of the knee (Annals of Int Med), and prevent the development of diabetes (J of Epid), among other health benefits.

To sum up I want to introduce a video I first saw in Dr. Mandrola‘s blog because it is entertaining and educational:

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Menofuzzies in Perimenopause

Occasionally, the attempt to empathize with someone during a visit falls flat. She knows it, I know it, and the therapeutic encounter is anything but. Since I am around the same age as many of my female patients, when a woman comes in with perimenopausal symptoms I am quick to understand. It’s common for women to complain of sleep disorder, mood swings, weight gain, fatigue, irritability, muscle aches and memory issues on top of the daytime hot flashes and night sweats. A couple of years ago, at my husband’s 35th high school reunion, one of his former classmates was almost frantic because she thought she had early onset Alzheimer’s disease. As she spoke of her word-finding difficulty, walking into rooms and forgetting what she went there for and awakening every 45 minutes, all the women surrounding her were sagely nodding their heads. Nope, we told her, you aren’t crazy or paranoid, you are experiencing the “Menofuzzies”.

In order of magnitude what women most hate is:

  1. Weight gain.
  2. Mood swings.
  3. Weight gain.
  4. Insomnia
  5. Weight gain.
  6. Memory issues.
  7. Yep–Weight gain. It’s a big issue.
  8. Hot flashes and night sweats.

Even though I struggle with the fifteen pounds I have gained over the last 17 years, I am 5’10’ so the weight distributes well and I don’t look like I’m at the top of the acceptable BMI (Body Mass Index). Having never had any issues at all losing weight until I hit 40, I understand how frustrating it is to walk over fifteen miles a week (often more than that), eat far less than at any other period of my life and still have difficulty with the zipper. The mood swings I can deal with, the insomnia gets better with the exercise, the memory issues fluctuate but my older colleagues and friends (female) tell me that it will improve and the light at the end of the tunnel no longer appears to be a train. Except for the weight. Some of my patients have gained 20 to 50 pounds or more during this time of life and they are frustrated and angry. And they do not need me to empathize with them. Or tell them that other women are having the same problem. What they care about is THEIR weight gain and how to deal with it.

Unfortunately there are no easy answers to mid-life weight gain. It’s still a calories in/calories used kind of equation. I recommend Weight Watchers and these already time-stressed patients are frequently not interested in finding yet another meeting to attend. I suggest using the on-line and app versions of Weight Watchers and they promise to look into it. I encourage exercise and talk about the fact that it is the closest thing yet to a Magic Pill but they are already exhausted and look at me in disbelief when I tell them that one has to invest energy to make energy. I recommend apps like LoseIt to use self monitoring as a technique for weight loss. I advise them that there are no good pharmacologic solutions and rarely recommend lap-band surgeries or other similar procedures except in extreme cases.

I try to steer them away from hormones except when their insomnia from night sweats and persistent awakenings is intolerable. Generally patients don’t find much relief with over-the-counter preparations (OTC) but they seem generally safe to try. Many patients come in requesting anti-depressants but these often worsen their weight issues. Again, that Magic Pill of exercise can make a difference if an individual will stick with it. There’s no down side to exercise (unless you run in front of a truck) and a safe thing to try for many of the issues arriving in peri-menopause and beyond.

The bottom line is, like many health issues, there are no easy answers and certainly no ONE pill is going to make this transition and its difficult aspects all go away. Staying physically fit, maintaining or developing good dietary habits, having a fulfilling home life and a satisfying life outside of one’s home seems to be the best medicine for navigating this time of life. But not everyone has the supports in place to make the kind of lifestyle changes necessary to achieve these goals–their jobs exhaust them, their kids are in trouble, their husbands are unsupportive or absent, there is no flexibility in their schedules, their is no flexibility in their thinking and any number of other difficult circumstances. And when they are frustrated with little or no time to develop these kinds of lifestyle changes, they may find my advice lacking.

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Doctor I want…

My most vivid recollection of a patient requesting a medication he didn’t need was several years ago. He had esophagitis–inflammation of the esophagus, and was taking a medication called Aciphex and as far as I knew it was working splendidly with no ill effects. When I asked him why he wanted to change to Nexium he said to me, “Well, I saw it on TV. The ‘purple pill’ is MUCH better than what I’m on, right?” What?!? I spent a few minutes explaining that the medication that takes care of the problem IS the best medicine, not the one that some pharmaceutical company is pushing on television.

While the drug companies argue that their “direct to consumer” advertising contains important public service information about the condition that their drugs treat, I think most of us are pretty cognizant that “public service” is NOT what those ads are all about. Worse than that, the advertisements push treatments that are more expensive than other, often equally effective medications; create anxiety in patients that think they have a disease they’ve never even heard of before; and the worst, give consumers the idea that “everything” can be easily treated with a pill. Got depression? Here take this pill, it’ll help. Erectile dysfunction? You don’t have to exercise and lose those pounds, just take this pill. Diabetes? You don’t need to change your diet, just look at Paula Dean and take this pill. High cholesterol? Here’s your pill, no need to worry about those extra pounds and big helpings.

I get downright huffy about the direct-to-consumer route with pharmaceutical reps (who are feeding me lunch, so I suppose some would call me hypocritical) and consider it unethical for these companies to push complicated pharmaceuticals to patients with complicated medical problems in a 60 second time slot. We have a “pill culture” in this country that is aggravated by individuals who want a quick fix for all their problems. The only “magic pill“, if there is one, is exercise. Like all therapies, it will not cure everyone and people who do it still get sick. BUT exercise will make people feel better–look better–have more energy–lose weight (when coupled with dietary changes)–ache less–treat depression–increase “good” cholesterol–reduce your risk of Alzheimer’s–reduce risk of diabetes and heart disease and stroke–improve sleep–the list goes on and on. If exercise DID come in a pill, people would be clamoring for it and it would probably be illegal!

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