For Patients

Cholesterol Guidelines

Current recommendations:  You may recall that a total cholesterol of less than 200 is ideal.  We pay less attention now to the total and more to the breakdown of the cholesterol types.  Goals also change depending on other risk factors for heart disease (age, high blood pressure, diabetes, smoking, obesity, family history); the guidelines now suggest we use a cardiovascular risk calculator to determine who would benefit from a statin.  These medications have benefits beyond simply lowering the LDL.  http://www.cvriskcalculator.com/

Looking at LDL, the “bad” cholesterol that tends to clog blood vessels, ideal levels are <130 or with known coronary artery disease (i.e. after a heart attack) or diabetes:  <100.  We recommend starting a statin drug with a 10 year CV risk of 7.5% or higher.

Raising “good” cholesterol (HDL) is just as important as lowering bad cholesterol.   HDL should be >40 and a level >60 actually protects the heart.  Aside from medication there are only three ways to raise HDL.  Think of them as the three “E’s”:  exercise, estrogen, and ethanol (the chemical name for alcohol). 

Alcohol intake in moderation:  1-2 drinks per day will raise HDL and this is thought to convey heart benefits.  However, any more than 2 drinks per day will tend to raise blood pressure and cause other ill effects that will offset this benefit. 

Exercise: at least 30 minutes of brisk walking, running, biking, or swimming at a minimum of 3-5 times a week will also tend to raise HDL.

Estrogen:  females have higher HDL levels than males and this may also be seen with oral contraceptives or estrogen supplementation. 

Are there ways to reduce cholesterol other than medication? 

–About 1/3 of your cholesterol comes from the diet and 2/3 is produced by the liver.  Therefore, dietary changes alone are not always sufficient.

–In general, patients can try six months of dietary modification and exercise and reassess. 

–What should I eat if I have high cholesterol?  A balanced diet with no more than 30% of total calories from fat is recommended.  Limit the big offenders in terms of saturated fat and cholesterol (whole milk, eggs, butter, cheese, fatty meats); drink 1% or skim milk; eat more chicken, fish, and lean cuts of beef or pork; add more fruits, vegetables, legumes; buy reduced fat cheese and dairy products.  When cooking, use olive oil or canola oil (monounsaturated fats are best).  Also, a high fiber diet (especially soluble fiber—oat bran, apples) can lower cholesterol levels.

–A popular diet that would fit the above guidelines would be the Mediterranean Diet.

Weight Loss Recommendations

Calories count. Women need about 2000 calories per day and men, 2500 to maintain weight.  So to lose weight safely, about 1-2 lb per week, restrict to 1200–1500 calories per day (women) and 1800—2000 per day (men). 

Keep a food diary. Studies show that people who keep one lose more weight than those who do not.  Write down everything you eat, and when, and total the calories.  This helps to increase awareness of eating patterns and calorie intake.  There are free apps available to help track this such as MyFitnessPal.

Portion control. Many times this is the biggest flaw in the American diet.  Do everything you can to limit portion size!  When eating at a restaurant, split entrees, or order an appetizer as a meal.  At home, pay attention to serving sizes; measure or use a kitchen scale.  Or try the plate method: eat on smaller plates–a salad or luncheon plate.  Fill half that plate with fruits and/or vegetables, ¼ of the plate with a lean protein, and ¼ of the plate with whole grains.

Liquid calories count, too. Hidden sources of excess calories include flavored coffee drinks, regular sodas, fruit juices, sports drinks, and alcoholic beverages. 

Increase your physical activity. Exercise at least 30 minutes a day to enhance weight loss and cardiovascular health. 

What should I eat to lose weight?

High protein may help.  Evidence suggests that high protein diets enhance weight loss.  Try to increase intake of lean proteins, such as chicken, fish, reduced fat dairy. 

Eat a colorful diet.  In general the more “color” a food has (blueberries, tomatoes, spinach, squash, etc) the more nutrients and antioxidants it has, so eat a rainbow of colors for the most health benefits.

Eat more fiber.  Fiber helps you feel full longer, and has other health benefits as well. Read labels, as not everything labeled “whole grain” truly has more fiber.  Aim for 20-30 grams of fiber a day. 

 Add in “low calorie dense” foods.  For example, having a green salad or a broth-based soup at the start of a meal will tend to reduce total calories consumed.

Consider the meal replacement strategy.  Shakes, protein bars, frozen entrees such as Lean Cuisine, or even a bowl of cereal can also be used to replace meals—they provide balanced nutrients while eliminating the guesswork regarding calories.

What about a weight loss program? If tracking calories and exercise isn’t enough, many have had success with Weight Watchers and Noom; they emphasize counting calories, portion control, exercise, but also include supportive weekly meetings and other program features for accountability.

What about weight loss drugs?  Unfortunately, there are no good options.  Prescription drugs only result in a mild weight loss (10-15 lb), they have significant side effects, the weight is usually gained back after stopping.

How to Manage Insomnia

Practice good sleep habits.  Timing:  Go to bed at the same time every night and also get up at the same time each morning.  Also, avoid napping for more than 20 minutes during the day.  Environment:  the room should be as dark as possible (consider sun-blocking shades if this is a problem).  The bedroom should also be quiet and cooler than the rest of the house to promote sleep.  Stop using electronic devices 30 minutes prior to bedtime, as screen time interferes with sleep.

If you can’t fall asleep initially, get up and out of bed and move into another area of the house to read, write, or do some other activity until you feel tired; then return to bed.  If you wake up too soon or too frequently, pay attention to what awakens you; is it pain?  Feeling warm?  Restless legs or leg cramps?  Heavy snoring?  Need to urinate?  These may be contributing factors that need to be treated.  Also, the Alphabet List is an effective technique taught by cognitive behavioral therapists to help you fall back to sleep faster upon middle of the night awakening. https://jennyevans.com/2011/11/10/trouble-sleeping-alphabet-game/ https://bronhogan.com/insomniacs-alphabet-technique/

Natural foods that promote sleep include warm milk, hot cocoa, cheese, ice cream, yogurt, lean meats (any food which involves the breakdown of protein.)  Melatonin is an herbal supplement with similar effects.

Avoid caffeine for at least six hours before bedtime (including coffee, cola, tea and chocolate.)  Also, alcohol interferes with sleep and causes early morning awakening.  Limit intake to 1-2 drinks per day and avoid drinking alcohol 2 hours prior to bedtime.

Sleep aids, over the counter (such as Benadryl) can help reset a disturbed sleep cycle but in general should be used sporadically and not continuously for longer than a few weeks.  They tend to lose effectiveness over time and have been linked to memory problems, falls, urinary retention, and other complications, especially in older patients.

A formal sleep study may be indicated which involves sleeping overnight (usually now in your own bed!) while oxygen levels, respiratory patterns and other parameters are monitored remotely.  This can help diagnose narcolepsy, sleep apnea, restless leg syndrome, and other conditions that are potentially treatable. 

Breast Self-Exams

“Doctor, should I perform regular breast self-exams?”

As an MD who is also a woman, I tend to have a mostly female patient panel, so I get this question all the time.  Now: you must take my response with a grain of salt, because it is coming from a woman who chose to forgo mammography at age 40 in favor of my own monthly self exams, when at age 44, I found a lump at home and was then diagnosed with breast cancer.  So one could argue that I am the least objective person/physician when it comes to offering an opinion on this issue.

If you search the literature, you will find that there is “no evidence” to support breast self-exam as a supplement to, or in place of, screening mammography.  The same goes for the physician-led examination in the office during a yearly physical.  In fact, a Cochrane analysis in 2003 suggested it would do more harm than good, leading to an increased number of benign breast biopsies without any benefit to mortality.  In other words, putting a woman through an unnecessary procedure, with some slight risk involved in addition to the emotional stress that accompanies it.  In 2009, the U.S. Preventive Services Task Force also advised against it, citing similar data.  

On the other hand, this same Cochrane analysis states that women should “generally be aware of any breast changes.”  And in my opinion, the U.S. Preventive Services Task Force recommendations are always the most–how shall we say–nihilistic.  Or, at least extremely conservative, in that they often argue against routine screening that both clinicians and patients are very accustomed to ordering, or have found valuable in their own practice, even me.    

The Annals of Internal Medicine devoted the entire February of 2016 issue to:  “Solving the Breast Cancer Screening Controversies.”  I eagerly read this cover to cover before realizing, I am not really any further along than I was before.  The data is still equivocal or lacking in many areas.  Ironically, this was weeks prior to my own diagnosis. At the time I thought, clear as mud; now, one month later, here I am, wading through it.

There is also an alternative classification that we physicians use in our everyday practice, all the time: Can’t Hurt, Might Help.  When I polled my colleagues on this issue, we all tend to agree.  Women should examine their breasts, once a month, in the shower, with warm soapy water that facilitates the detection of any irregular contours.  Moving up and down in rows, like “corn rows”, starting at the breast bone and working your way out to the armpit, you should press down with three fingers using a circular motion.  Doing this routinely, the patient will get to know what “normal” is like, and is better equipped to detect a change this way.  I would argue, perhaps even better than the doctor who performs this exam once a year during an office visit, because they don’t have months to years of experience doing it at home for comparison.

While I try not to promote anecdotal based medicine, there are often clinical questions that evidence based medicine cannot provide a clear answer to, either.  When this occurs, I try to rely on my clinical judgment, years of experience, and also common sense, including the Can’t Hurt, Might Help approach.  To me, self-exam in the shower with warm soapy water is something women are probably doing, anyway; it might help if we promote this more specifically, rather than the vague suggestion to “generally be aware of breast changes.”   Empowering the patient is an important step in any sort of health care initiative, and this way, we have a means to equip and engage our patients–even while at home–to be proactive in their breast health management.  

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