Everything Your Doc Wants You To Know

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Physicians Lindsey and Kirsten are back with a new topic. They discuss the concept of life space, the area in which one conducts life activities. Studies have demonstrated that larger life space positively affects health. Lindsey and Kirsten discuss the benefits of a larger life space and explore how to obtain these benefits even when life space is limited.

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In this episode we discuss shoulder pathology including impingement, adhesive capsulitis, arthritis of the shoulder, and rotator cuff injuries with physical therapist Lindsey Sandbeck. We review what to expect from a PT evaluation, as well as non-operative and post-operative physical therapy. Lindsey provides insight into strategies to optimize recovery from shoulder injuries and surgery.

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Dizziness

Dizziness can come in different forms: vertigo, lightheadedness, disequilibrium.

Vertigo: False movement, room spinning. Feels as if you are moving when you are not.

Benign Paroxysmal Positional Vertigo: acute, occurs with certain movements, lasts seconds to minutes

Dix-Hallpike to diagnose

Vestibular rehab/physical therapy to treat - Epley Maneuver

Meniere’s Disease: vertigo, with hearing loss and ringing in ears

Labyrinthitis

Central vertigo: can be more worrisome, exam looks for signs of stroke or other pathology. May need brain imaging.

Lightheadedness: feeling like one could pass out, pre-syncope

Cardiac causes: arrhythmias, valve disease

Orthostatic hypotension

Disequilibrium: sense of imbalance

Changes in nerve sensation can contribute: peripheral neuropathy, knee replacements

Vision and auditory impairment can also contribute

Diagnosis: monofilament testing, vibration sensory testing, gait speed, get up and go test, Romberg test all help evaluate

Treatable causes: B12 deficiency, thyroid disease, uncontrolled diabetes, medications that can be stopped (older anti-histamines)

Treatment: Adaptations (change in glasses, hearing aids), practice balance - physical therapy, strengthening

Persistent Postural Perceptual Dizziness (PPPD): persistent dizziness that worsens with motion or upright position, present > 3 months

Often follows BPPV or labyrinthitis

Anxiety, depression often present concomitantly

Treatment: Evaluate medications, consider medication to help with anxiety, depression

Health Pearl: For people who have been fully vaccinated for COVID-19, we discuss CDC guidelines and ways to safely expand activities.

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In this episode we discuss asthma. We review symptoms, diagnosis, and treatment. We also discuss triggers and how to minimize them. We talk about creating a home management plant, or asthma action plan, with your doctor. Finally, we talk about symptoms that indicate an asthma exacerbation and symptoms that might indicate a need for prompt evaluation.

Health pearl: try a low calorie Shrub for a refreshing alcohol free drink.

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Episode 37 - COVID-19 Vaccine Q & A

In this episode, we answer questions about the COVID-19 vaccine, including how it works, common side effects and who should get the vaccine.

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Episode 36 - Gut Health

In this episode we discuss a problem commonly encountered in our clinics, chronic diarrhea. We review various causes, and discuss how patients can help us determine the cause. We provide a basic overview of treatment of some types of chronic diarrhea.

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Common Aches and Pains

Tendonitis: Inflammation of the tendons (attachment of muscle to bone). Elbow, ankles, wrist, overuse.

Treatment: rest, ice, NSAIDS. Physical Therapy can be necessary and helpful

Bursitis: fluid filled sacs in areas of friction that can become inflamed.

Common: Trochanteric Bursitis (hip), Anserine bursitis (medial knee), Olecranon Bursitis (elbow)

Treatment: Physical therapy, Steroid injections, Ice, NSAIDS, stretching

Arthritis: Pain in the joints

Osteoarthritis: wear and tear or degenerative joint disease. Knees, hips, Spine, hands, shoulders

Risks: age, obesity, family history, prior injury, occupation

Pain worsens with use

Treatment: scheduled Tylenol, NSAIDS if able, injections ultimate joint replacement

Topicals always worth a try

Inflammatory Arthritis: most common Rheumatoid Arthritis (autoimmune- immune system fighting itself at the joints)

AM stiffness lasts hours, red, warm swollen joints, symmetric- hands wrists, feet, knees

Treatment: prescription medication to avoid destruction/deformity in the future

Future: Gut microbiome and diets role in joint inflammation and pain?

Health Pearl: Anti-inflammatory diet limit processed food, sugar, simple carbohydrates

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Episode 34: the 4M’s

4M’s to discuss with your physician: Medications, Mobility, Mentation, Matters Most (what Matters Most)

Help shape patient-centered care

Reduce hospitalizations, decrease the need for care

Mobility - evaluate yearly

Measures:

Gait speed is one measure (slower than 1 m/s increased risk of falling, increased risk of hospitalization)

Timed get up and go

Balance evaluation by physical therapy

Getting up from chair without using arms

Next step:

Home exercise program (NIH healthy aging)

Physical therapy

Multi-disciplinary falls and stability clinic

Driving

Multiple falls indicate increased risk for driving safety issues

Everyday movement is important to maintain mobility

Home exercises, Youtube exercises

Medications

Beer’s list - potentially inappropriate medications for older adults due to risk of side effects

Examples include benadryl, benzodiazepines, narcotic pain medications, some seizure medications

Need to look at benefits versus side effects

Evaluate for “prescribing cascades” - one medication is used to treat a side effect of another medication, and then another medication is used to treat side effects of that medication.

Polypharmacy - more than 6 medications is polypharmacy. More medications = more side effects and medication interactions. Deprescribing can help with this.

Goals of care can help determine which medications are adding value

Matters Most

It’s important to discuss what’s important and what makes life worth living, then delve deeper.

“What could you live without and still feel you have good quality of life?” Focuses on quality of life rather than just quantity

Patients can bring this topic up by bringing in an Advance Care Directive or Polst form, or mentioning this as a goal of the visit

Evolves depending on stage of life

Mentation

Assessment of memory and cognition, as well as mood

Generally we evaluate cognition when family brings up a concern or clinician notices a change

Can be done as part of Medicare Wellness Exam

Depression and anxiety can look like physical symptoms and cognitive changes in older population

Next steps if a concern is present:

Evaluate medications, which can impact cognition and mood

Obtain more information from screening tests, family members

Consider referral for further testing; this isn’t required to make a diagnosis

Neuropsych testing can distinguish between depression, anxiety, dementia

References

NIH National Institute on Aging

Deprescribing

Advance Care Planning

https://www.cdc.gov/aging/pdf/acp-resources-public.pdf

POLST: Portable Medical Orders

Health pearl: Get your influenza vaccines! They’re very important this year.

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Everything Doc Show Notes: Genetic Counseling

Special guest: Allison Hutchinson a certified genetic counselor. Has worked at Sanford Imaginetics for the last 2 years. Her focus is working with teams to offer genomic and pharmacogenomics education to providers, patients, and the public. She is part of a research collaborative investigating whether these education interventions have been successful and how to continuously improve. Prior to this Allison was a high school science teacher for over a decade. She enjoys listening to podcasts in her spare time!

Quote: “Teaching should always start the discussion and never end it.”

Genetic Counselor: Advanced healthcare providers with training in genetics and counseling.

Education includes semester in classroom, year in clinic, research throughout

Certified

Who should see a genetic counselor?

Those with rare genetic diseases in family

Family history of related cancers in 2 or more people on same side, often earlier onset

Help interpreting consumer driven testing

Cardiovascular diseases: arrhythmias with sudden cardiac death, familial hypercholesterolemia

Pretest counseling is important! Think about all possible outcomes of genetic testing and what you might do with range of results.

How to prepare?

Come with information about family members: cause of death, age of death, chronic diseases, so pedigree can be developed.

Help write letters to family

Most insurances cover but varies check with your insurance

For more information about Genetic Counseling visit:

https://imagenetics.sanfordhealth.org/

https://www.aboutgeneticcounselors.org/

https://www.augie.edu/academics/graduatepeducation/master-science-genetic-counseling

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The Dark Side of Isolation During COVID-19

In this episode, we discuss the unintended isolation that results from social distancing and quarantine measures, especially in the elderly. We review complications of isolation, including frailty, sarcopenia, depression, cognitive changes, and increased suicidality. We also review measures to help mitigate these adverse consequences, and discuss how everyone can help.

We explain which outings are safe and whether gathering during the summer can be safe. We review precautions that should be taken when out.

Health pearl: Find someone who could benefit from a safe, social distancing outing and do something fun together!

Resources:

Search “Adopt a Grandparent” to find a program near you.

Nacional Suicide Prevention Lifeline: (800) 273-8255, https://suicidepreventionlifeline.org

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Mental Health During the Pandemic

Child and Adolescent Psychiatrist Dr. Stefanie Hanisch joins us to discuss mental health, especially that of youth, during the current pandemic.

Dr. Hanisch was born and raised in South Africa. She attended medical school at the University of Pretoria, South Africa, before obtaining her fellowship in Child and Adolescent Psychiatry at Baylor College of Medicine in Houston, TX. She served as Chief Resident before moving to Fargo, ND. She has been in her current practice since 2007 and currently serves as her Department Chair in addition to having faculty appointment at the UND School of Medicine. Dr. Hanisch is married and has two sons. She enjoys traveling with her family and is an accomplished runner.

In this episode, we talk about mental health (with a focus on youth) during the pandemic. We discuss the following points:

How kids might respond differently based on their age and developmental level

How to talk with kids about their feelings and fears.

Validation of feelings

Spend time with the fear, and then transition to constructive thinking (what you can do about the situation)

The value of parental role modeling

How to maintain health for all during the pandemic

When to seek help: WHEN NEEDS OUTWEIGH RESOURCES

Available resources include:

Your primary care provider

First Link (211)

Emergency department

Health Pearl: take time to relax and destress. There are many great resources for this, including the following:

Headspace app

Ahway Island Podcast (for youth)

Calm app

Youtube Meditation

Peloton app - meditation, yoga, family work outs

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Episode 30 COVID-19: A Marathon, Not a Sprint

Recorded Sunday April 5, 2020

Today we are joined by Infectious Disease expert Dr. Dubert Guerrero to discuss COVID-19. Dr. Guerrero is a practicing Infectious Disease Physician at Sanford Health. He graduated from the University of the Philippines and completed his training in Internal Medicine at Akron General Medical Center. He went on to complete an Infectious Disease fellowship at Case Western Reserve University in Cleveland, Ohio. Dr. Guerrero is married and has three children.

In this episode, we discuss common questions related to the current coronavirus pandemic, including

What is social distancing?
Is social distancing effective?
Is it important to sanitize groceries and other items coming into one’s home?
What can we expect to see over the next several months regarding COVID-19 cases?
When can we expect to see vaccines and/or treatments for the virus?

Health pearl: take care of your mental health. You can do this by taking time for yourself every day, including exercise and mindfulness/meditation in your daily life.

Resources:

Center for Disease Control and Prevention

World Health Organization

Your state health department

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Your Questions Answered

This week we spend a few minutes summarizing key information about COVID 19.

The remainder of the episode is devoted to your questions, including topics ranging from which diet is best to how can you tell if your doctor is a good one.

Resources
COVID 19: https://www.cdc.gov/coronavirus/2019-nCoV/index.html

https://www.who.int/emergencies/diseases/novel-coronavirus-2019

Your state health department

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Episode 28 Pharmacogenomics with Dr. Natasha Petry, PharmD, BCACP

Natasha has a bachelor’s degree in Microbiology and graduated with a Doctor of Pharmacy in 2012 from North Dakota State University in Fargo, ND. She completed a post graduate Pharmacy Practice Residency at Trinity Health in Minot, ND and joined the faculty at NDSU as an Assistant Professor with a clinical appointment at Sanford Health. She is a board-certified Ambulatory Care Pharmacist and began working in the area of Pharmacogenomics in 2014. She is an affiliate member of the NIH funded Implementing GeNomics In practice (IGNITE) network. She currently works as a Pharmacogenetics Clinical Pharmacist for Sanford Imagenetics. In addition, she is pursuing a Master of Public Health degree. Natasha is a wife, mother to 2 beautiful girls, and enjoys attending sporting events.

Pharmacogenomics: The genetics of how people metabolize (break down) medications. Genetic information can help guide the use of medication dosing and medication choice. Genetics looks at the enzymes that break down medications. Can help determine efficacy or utility, safety and/or dosing

Still limited but growing rapidly- another “tool in the toolbox”

Genetics does not change in a lifetime

Cost can be limiting

Currently useful in prescribing antidepressants, some pain medications, cholesterol medications (statins), clopidogrel (Plavix), warfarin

Limitations:

No standardization in lab testing regarding which allele variants are tested

Cost

Limited actionable results that impact a finite number of medications

Genetic testing collected through blood, saliva, cells from the cheeks depending on lab used

Variable insurance coverage: preemptive testing not likely covered, reactive is being covered more often

Direct to consumer testing vs. laboratory (health system) derived testing

Need Medical Geneticists and Pharmacists to help interpret information

Health Pearl: Try out meal delivery kits for improved health

Resource list: https://imaginetics.sandordhealth.org

https://www.genome.gov/FAQ/Pharmacogenomics

https://ghr.nlm.nih.gov/primer/genomicresearch/pharmacogenomics

https://www.yourgenome.org/facts/what-is-pharmacogenomics

https://nigms.nih.gov/education/pages/factsheet-pharmacogenomics.aspx

https://www.cdc.gov/genomics/disease/pharma.htm

https://pharmgkb.org/page/pharmacogenomics

https://www.pharmkb/page/iAmACitizen

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Episode 27: Sugar and Metabolic Syndrome

In this episode we discuss the impact of sugar on metabolism and the adverse effects of sugar loads on various organ systems.

Metabolic syndrome: dysregulation of normal metabolism. It can lead to damage of many organs. Increases risk of diabetes, high blood pressure, excess body fat (especially central obesity), abnormal cholesterol. This increases risk for heart attack and stroke. Can also lead to fatty liver disease.

High fructose loads cause cellular inflammation. Fructose loads trigger a metabolic pathway that stimulates increased consumption of food and storage of energy. This is beneficial for animals that hibernate or don’t have access to as much food during winter, but not for humans. Fructose also depletes energy on a cellular level.

The more concentrated the sugar load, the more it stimulates increased food consumption and storage. Because of this, sugary beverages such as soda, sports drinks, and juice should be avoided.

Foods to limit/avoid to help improve metabolism:

Juice and soda, sports drinks, or other beverages with added sugar.

Potatoes

Bread

Chips

Rice

Dried fruit

Fruits (limit, don’t avoid) - some have more sugar than others (grapes are high in sugar, low in fiber)

Beer and wine

Foods/beverages that promote healthy metabolism:

Water

Vegetables

For fruit consumption, eating berries, kiwi, other low sugar fruits is better

Resources:

Peter Attia, MD episode 87: Rick Johnson, MD: Fructose - the common link in high blood pressure, insulin resistance, T2D, & obesity? https://peterattiamd.com/rickjohnson/

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www.everythingdoc.com

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Warning Signs of Heart Attack and Stroke

Heart Attack: Occurs with decreased blood supply to the heart muscle.

Symptoms:

Chest pressure, like elephant sitting on chest

Jaw Pain

Pain into left arm

Nausea/indigestion

Breaking into a sweat

Shortness of breath

Other warning signs: change or decrease in exercise tolerance

Stroke: Decreased blood supply to area of the brain

Symptoms:

Facial drooping/drooling

Arm or leg weakness/numbness

Speech difficulty

Acute imbalance or change in/lack of coordination

These symptoms are concerning enough to warrant evaluation in an EMERGENCY DEPARTMENT!

Health Pearl: Read book Being Mortal by Atul Gawande or watch PBS documentary of the same name https://www.pbs.org/video/frontline-being-mortal/

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A Pain in the Back

80% of the population will present to primary care with low back pain. Most of the time low back pain isn’t a signal of a worrisome underlying condition/ dangerous, though it can affect quality of life and become chronic.

Definitions:

Acute back pain: new back pain that has been present less than 4 weeks

Subacute back pain: back pain present for more than 4 and less than 12 weeks

Chronic back pain: back pain present for more than 12 weeks

Most of the time it will improve.

Symptoms:

Pain across the low back, may shoot down the leg or to other locations

Muscle spasm with stiffness

Difficulty urinating or moving bowels*

Weakness, foot drop*

Numbness, tingling

Tenderness over the spine

*More concerning symptoms

Causes:

Nonspecific - a definitive diagnosis is not obtained or needed

Injury/twisting/pulling

Osteoarthritis / degenerative disc disease

“Slipped disc” or disc herniation

Compression fractures

Radiculopathy (inflammation of the nerves)

Spinal stenosis (narrowing around the spinal cord)

Ankylosing spondylitis (auto-immune condition)

Scoliosis

Depression can increase pain sensations

Foot issues - flat feet, poor arch support can contribute

Kidney stones

Shingles

Intra-abdominal conditions (pancreatitis, gall bladder disease)

Less common, more worrisome causes: cauda equina syndrome, spinal infection, malignancy

Evaluation:

Office visit for history and exam, usually no X-rays or other imaging at the first appointment unless trauma occurred. Clinician can rule out worrisome symptoms

Management:

Physical therapy

Heat, ice

Acetaminophen, NSAIDs (ibuprofen, naproxen, etc) if approved by your clinician, muscle relaxants

Stretching, massage, rest

Exercise, strengthening supporting muscles - needs to be ongoing

Weight loss when indicated

Injections from pain clinic or spine clinic

Topical products (Biofreeze), lidocaine patches

Narcotic pain medications are not usually indicated. If they are, it would be for 3 days or less. Narcotics have no role in management of chronic pain.

Medications to help with nerve pain: duloxetine, gabapentin, pregabalin

Health pearl: book recommendation - Mayo Clinic Guide to Stress Free Living by Amit Sood.

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Episode 7: Living Well with Dementia

Dementia - changes in memory and thinking that are beyond what is normal for age. It is progressive (worsens over time).

Treatment can slow progression of dementia, but there is no cure. It is felt that regular exercise, following a healthy diet such as the Mediterranean diet, and staying socially and cognitively engaged can help prevent dementia. Controlling chronic diseases such as high blood pressure, high cholesterol, and diabetes can also help with prevention.

Today we are joined by Deb Kaul, the owner of geriatric consulting service “Dignity Care” and one of the Co-founders of “Memory Café of the Red River Valley.” Deb has a bachelors degree in Business Administration from UND and a BSN from the University of Mary. She also has a Master’s certificate in Geriatric Care Management from the University of Florida. Deb considers the lessons she learned while caring for her parents - both of whom lived with dementia, the most valuable education she has ever received.

Deb provides recommendations for living with and caring for people living with dementia:

Keeping the diagnosis of dementia a secret from the person with dementia robs the individual of their autonomy. It also perpetuates the stigma related to dementia.

It is possible to live well with dementia.

Our responses to the diagnosis impact how a person responds to the disease. If they are diminished and de-humanized, they lose hope.

How to engage with a person living with memory loss: Greet them with a compliment or information that reminds them about their life. Tell them their story (“That is a beautiful/handsome sweater.” or “You did such a great job raising your children.”) Avoid quizzing them (“Did ___ come to visit you this morning?”)

For caregivers: Communicate about what’s occurring. Allow the person with memory loss to set goals for themselves. Avoid arguments with people living with dementia. They lose the ability to rationalize and reason, and it’s our job as caregivers to think creatively to solve problems. Caregivers can apologize, redirect, distract to work around conflicts or disagreements “Live their truth.” People with dementia are living in the present moment, so living with them in their truth/reality can help them and reduce conflicts. Engage trustworthy friends to build a village of support around them. People living with dementia should continue to have opportunities to make friends and maintain some independence. Communicate goals with physicians and other medical providers. Continue to pursue joy in life (both caregiver and person living with dementia).

Available resources:

“What the Hell Happened to my Brain?” by Kate Swaffer. The author’s diagnosis resulted in “prescribed disengagement” by her physician. She was told to “get her affairs in order” when diagnosed at age 49. She challenged these ideas and has achieved incredible things while living with dementia.

The Dementia Alliance International (DAI) - https://www.dementiaallianceinternational.org/

Alzheimer’s Association - https://www.alz.org/

Memory Cafe- free socialization and support for people with mild to moderate memory loss and their caregivers

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Episode 23: Resolve to do your Advance Care Plan

We are joined by guest Gail Christopher to discuss Advance Care Planning. Gail is a nurse with over 40 years of experience in clinical nursing, surgery, utilization management, wellness coordination, and long term care among other things. In 2003 she obtained an MSN from UND with a focus on Nursing Administration. She works for Sanford Health in Fargo as the lead with the Advance Care Planning Team. In April 2019 she became a Certified Sacred Passage End of Life Doula through the Conscious Dying Institute in Boulder, CO. She has worked much of her career with the geriatric population and has a special interest in this area. She is a lifelong North Dakota native, and has 3 children and 5 grandchildren.

Advance care planning definition: formerly known as healthcare directive. Process of defining your goals and wishes for healthcare, especially if you’re unable to make those wishes known at some time in the future.

Barriers include

Good health (feeling it doesn’t apply)
Feeling their families already know wishes
Misconception that it’s only for elderly
Fear of facing mortality
Mistrust of others’ ability to follow directive

Steps of completing an advance care directive
- Who do you want as an agent to speak on your behalf?

Document your wishes
Communicate with your family about your wishes so they can advocate for you
Communicate with your PCP about your wishes. Your PCP can help maintain perspective and advocate for you

It’s important and can be helpful to think about how you want the end of your life to look.

Questions in advance care planning can include:

Where you want to die and how you would want that to look

What matters most to you? What makes life worth living?

Specific medical treatments that you would or would not want (including cost of certain treatments) - CPR, artificial nutrition, respiration, etc

Burial vs cremation vs donation

Organ donation

Autopsy

Once completed, advance care plans should be updated every 10 years or sooner if there are other major changes in health (new diagnoses, decline in health, death or change in the agent)

End of life can be a beautiful experience rather than something to fear.

Consults can be arranged with an advance care planning team. Local Sanford phone number: (701) 234-6980 to schedule an appointment or obtain advance care planning documents.

Resources:

https://www.cdc.gov/aging/pdf/acp-resources-public.pdf

https://polst.org/

Health Pearl: Butternut Squash Wild Rice Stew

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Winter Colds

Most of the time caused by viral infections (no benefit from antibiotics) as opposed to bacterial infections. Symptoms include nasal congestion, headache, sinus pressure, face pain.

Control symptoms with humidifier, nasal washes/rinses, steroid nasal sprays, guaifenesin for thinning of mucous, Tylenol, and time. Often more than 2 weeks to see resolution of symptoms and can be up to 4-6 weeks.

Health Pearl: Try to begin active traditions like a Turkey trot during the holidays. Okay to indulge for 1 day. Be sure to drink water as this helps keep you full. ***Additional information: Prevention is key! Remember to wash your hands often during cold and flu season. Cover your mouth with the bend of your elbow when coughing or sneezing. Stay home from work or school when sick.

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Exploring Menopause

Today Dr. Jean Marie McGowan joins us to talk about menopause. Jean Marie McGowan, MD NCMP FACP is an Internal Medicine physician with a special interest in Women’s Health. She attended the American University of the Caribbean for medical school and completed Internal Medicine residency, serving as chief resident, at the University of North Dakota in Fargo. Dr. McGowan started working for Sanford Health in the summer of 2016 and focused on improving women’s healthcare. She became a certified provider for menopause management by the North American Menopause Society and became Fellow of the American College of Physicians. She is director of the Pelvic Floor Clinic and co-director of the Preconception Clinic. In addition to seeing consults for menopause, polycystic ovarian syndrome and post-breast cancer treatment, she is a primary care physician. Dr. McGowan is associate faculty for the UND School of Medicine and clinical director for the Women’s Health rotation for medical students, residents, and fellows. She’s dedicated to educating the future generations of healthcare providers as well as the community to improve care for women. Dr. McGowan is also involved in research and won the inaugural Faculty Research Mentor of the Year in 2019 from UND Internal Medicine residents. Dr. McGowan grew up in Brooklyn, NY and currently lives in Fargo, North Dakota. Outside of work, she enjoys singing, running, and playing with her maltipoo, Minnie.

Definitions:

Menopause - occurs after the last menstrual period; a women has formally been through menopause when she has been free of periods for 12 months. Average age is 51.

Perimenopause - the time preceding menopause, lasting about 2-4 years.

Postmenopause - time following menopause.

Surgical menopause - menopause that occurs after surgical intervention (removal of both ovaries). May have more severe symptoms.

Premature ovarian insufficiency - when menopause occurs prior to age 40.

Symptoms - can vary among women, starting 2-4 years prior to last menstrual period and often lasting 2-4 years after menopause (can be up to 10 years or longer)

Perimenopausal: most common are vasomotor symptoms - hot flashes/flushes. Mood can also be impacted by progesterone and estrogen. This tends to be transient during the menopausal time frame.

Decreased estrogen can cause changes in sleep, memory, vision, hearing, skin; vaginal dryness, urinary tract issues.

Postmenopausal: vaginal dryness and urinary tract issues tend to continue. Avoid hot baths, certain wipes, irritating pads.

Decreased estrogen also affects bone health, cholesterol, heart disease risk. These effects tend to be seen 10-15 years after menopause. Exercise, diet, smoking cessation, limiting alcohol consumption can help mitigate these.

Diagnosis of menopause - hormone testing is not needed in most cases and is made based on cessation of periods, age. If considering premature ovarian insufficiency, hormone testing is indicated.

Patients often note decreased sexual desire in the perimenopausal period. This is not related to age or menopause itself.

Treatment:

Vaginal dryness

Vaginal moisturizers & lubricants can help with painful intercourse. Good Clean Love & UberLube are some well balanced options.

The only treatment is estrogen.

Pelvic floor therapy can be effective for pelvic weakness, painful intercourse, and urinary symptoms. Beyond Kegels is a helpful book for pelvic weakness.

Hormone replacement therapy (HRT) is indicated for severe hot flashes and genitourinary syndrome of menopause (vaginal dryness / urinary symptoms). Start within 5-10 years of last menstrual period. Can benefit cholesterol, heart health, ovarian cancer risk. Should be avoided in women who have had a stroke, blood clot, or pulmonary embolism. Evaluate carefully in women who already have heart disease.

Combination therapy: estrogen + progesterone, used for women who still have a uterus.

Estrogen only therapy - lower risk of breast cancer than combination therapy.

Come in pill, patch, vaginal ring, or combination of estrogen pill/patch and progesterone IUD. Estrogen dose is lower than what is found in oral contraceptives.

Vasomotor symptoms: black cohash helps 30% of women who have tried it; it can affect the liver so caution should be taken.

Bio-identical hormones: not regulated by the FDA, not proven to be effective. Not recommended and potentially dangerous.

“Menopause” supplements - not proven to be effective.

Paroxetine (Paxil) - FDA approved medication for hot flashes. Commonly prescribed for depression and anxiety. Side effect is weight gain. Desvenlafaxine (Pristiq) can also help with hot flashes, as can venlafaxine (Effexor). Gabapentin, clonidine are other options.

Weight gain, changes in body shape occur around menopause. Exercise (especially strengthening) and healthy diet will help. Many other menopause symptoms improve with exercise, healthy diet, and good sleep.

The good news: not all women have all symptoms associated with menopause. The positives include no more periods to worry about, migraines may improve, autoimmune diseases may improve.

References & Products:

Good Clean Love Moisturizer

UberLube Lubricant

Beyond Kegels by Janet Hulme

North American Menopause Society website: www.menopause.org

Correction: premenstrual dysphoric disorder is the syndrome of low mood or irritability prior to menstrual periods

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The THYROID episode

Thyroid gland sits low in the neck. Secretes two forms of thyroid hormone - T3 and T4

Symptoms: affects the heart rate, weight, hair, mood, reflexes, bowels, energy

TSH (thyroid stimulating hormone) is measured in the blood to monitor thyroid levels

High TSH means low thyroid

Low TSH means high thyroid

Goiter is enlargement of thyroid tissue. Can be active and secrete thyroid hormone or inactive.

Thyroid cancer: most common is papillary thyroid cancer - highly treatable. Medullary thyroid cancer is rare.

Graves disease: autoimmune disease that causes hyperthyroidism, goiters, and eye disease

Hyperthyroidism is TOO MUCH thyroid hormone. Treated with radioactive iodine ablation or thyroid resection. Often end up needing thyroid replacement.

Hashimoto’s thyroiditis: most common cause of hypothyroidism or LOW thyroid

Levothyroxine is used for thyroid replacement. Dose is weight-based and then monitored with TSH.

Replacement levothyroxine must be taken first thing in the morning at least 30 minutes apart from other medications and foods to absorb.

Health Pearl: Toenail fungus (thick, yellow nails) is a common problem. It can be treated with applying Vicks VapoRub to the nails at night.

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Medications and Deprescribing

Today we discuss medications, polypharmacy, and deprescribing.

We are joined by clinical pharmacist Dr. Douglas Gugel-Bryant, PharmD, BCPS for this week’s conversation. Doug received his bachelor’s degree in chemistry and biochemistry from Capital University in Bexley, OH. He received his Doctorate of Pharmacy in 2017 from the Northeast Ohio Medical University. He went on to do a post-graduate residency program with the Cleveland Clinic Akron General in Pharmacotherapy. Doug moved to Fargo after finishing residency and has been a part of our clinic for over one year. His current role is Medical Home Pharmacist for the Sanford Internal Medicine Clinic. A majority of his work is on diabetes patient management and transitions of care. He is also a pharmacy resource for the clinic. Outside of work, Doug plays tennis and solo-acoustic fingerstyle guitar.

We discuss the following:

What is polypharmacy and why does it need to be evaluated?

What is deprescribing? Why is it important?

How do clinicians balance the benefits of medication versus potential interactions and side effects?

How do age and health impact the benefits of medications?

Which medications should be evaluated for deprescribing? What potential side effects do these medications have as individuals age?

What is the process of deprescribing? Can medications be stopped abruptly?

What are barriers to stopping medication?

Resources:

www.deprescribing.org

https://www.healthinaging.org/medications-older-adults

Health pearl:

Schedule an appointment with your clinician to discuss your medications, goals, and deprescribing.

Doug Gugel-Bryant - Guitar (YouTube)

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Understanding Your Lab Results

In this episode, Drs. Lindsey and Kirsten provide an overview of the routine labs. We answer the following questions:

When are routine labs being ordered?
What does the lab result mean?
What are some causes of high or low results?
Which labs, when mildly abnormal, are not worrisome?

Lab tests included are the chemistry panel, the complete blood count, thyroid tests, hemoglobin A1c, and cholesterol.

Health Pearl: diastole is a phase in the heart cycle during which the heart relaxes and fills up. People need to spend time in diastole, too, in order to refresh and renew! It’s important to take your vacation time, or find ways to incorporate rest and relaxation into your life.

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Bone Health

Osteoporosis diagnosis: DEXA scan T score of <-2.5 or diagnosed clinically - a fall from standing height resulting in fracture or evidence of spinal compression fractures

Risk factors: age, female sex, previous fracture, family history of osteoporosis, medication like prednisone, smoking, excess alcohol intake, small frame...

There are no symptoms of osteoporosis- can see loss of height or forward hunched posture “kyphosis”

People with osteoporosis break their hip and that is what generally causes the fall- not the fall that causes the fracture

Prevention: weight bearing exercise, getting adequate calcium and vitamin D

Treatment: Bisphosphonates, RANKL inhibitors or parathyroid hormone analogs

Health Pearl:

Alton Brown’s Chocolate Chia Breakfast Pudding

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Episode 16: Depression & Prevention of Suicide

Emily Gard, LICSW, joins us to talk about depression and suicide. Emily is a Licensed Individual Clinical Social Worker and nationally certified mental health first aid trainer with over ten years of experience in the field of social work. Emily earned her undergraduate degree from Concordia College and a master’s degree in Social Work from the University of North Dakota. She initially worked as a chemical dependency social worker before pursuing graduate education. Currently Emily is employed by Sanford Health as an Integrated Health Therapist. She was named Sanford Health Employee of the Year in 2017. When Emily is not working, she enjoys spending time at the lake with her husband and five children.

Depression - feeling down, depressed, hopeless, helpless. May come out of nowhere or be triggered by stressors. Symptoms include tearfulness, loss of interest, appetite and sleep changes, irritability, stomach aches, headaches. Symptoms can be physical - fatigue, diarrhea, upset stomach. Isolation, irritability, frustration, and slowed thinking can be seen in the older population. Sadness and bereavement generally do not last for more than a few months. Depression tends to be persistent and pervasive.

Suicide is a side effect of depression. Warning signs include thoughts of being better off dead or not wanting to wake up. Talking to people who are depressed about suicide does not make them more likely to commit suicide. Many people experience ambivalence about suicide and want to be asked about how they are doing.

Warning signs of suicide:

talking about death
statements like “people would be better off without me”
feeling like they’re a burden
feeling isolated
feeling disconnected
preparatory behaviors - giving away things, purchasing firearms, making sure will and/or insurance are in order

The next step for friends/family/clinicians:

Ask how the affected person is doing
Make observations to the person
Using the word “suicide” is ok

People with depression need support just like people struggling with physical illness.

Local support groups

National Suicide Prevention Lifeline

American Foundation for Suicide Prevention

Columbia suicide severity rating scale - helps assess risk

Protective factors

Valued relationships (pets, children, parents, close friends)
Futuristic thinking
Employment

As a friend, you can highlight protective factors and help them focus on these things. Do this without creating guilt by asking “what’s one thing that you’re living for?”

Terminology - language is changing. In the past we would say “committed suicide” but just as people die of cancer, they die of/by suicide. This is more accurate and helps decrease stigma.

The Columbia scale helps identify level of concern when someone is alluding to suicide. Preparatory behavior, plan for suicide, and suicidal intent predict suicide attempts.

People can recover! Every emotion is temporary. Recovery is possible. If someone has had suicidal thoughts in their life, they don’t typically experience them again. People generally get better and are able to experience joy and quality of life again. People should know that they aren’t alone. Depression and anxiety are common and treatable.

Treatment of depression:

Non-medical includes therapy, behavioral activation: exercise, healthy eating, connecting with others.

Medications include SSRI’s, SNRI’s, other antidepressants, sometimes antipsychotics

These increase hormones in our brain that create positive feelings and emotion.
Sometimes they have to be tried to find the right one. It can take a 4-6 weeks for these to reach their full effect.
Medications don’t necessarily have to be life-long.
Side effects: feeling emotionally “flat,” fatigue, nausea, weight changes, appetite changes, sexual side effects.
Avoid heavy alcohol consumption while taking antidepressants.

Inpatient stays and partial hospitalization (PHP) can help individuals with suicidal intent. They help stabilize and facilitate mediation adjustments in addition to learning coping skills.

Exercise can be equivalent to taking a medication to help elevate mood. This shouldn’t be done in isolation but can be a helpful part of a treatment program. Being outside, being mindful of different sensations can elevate mood as well.

Cognitive behavioral therapy is a frontline approach for depression. Thoughts and behaviors are interconnected. Mindfulness, or the intention to pay attention, can be helpful in managing depression. Deep breathing can help regulate emotions.

Headspace, Calm, and Breathe are good apps. Or search “Guided meditation” on Youtube.

Health pearl of the week: Unplug! Technology can be enriching and helpful, but can also intrude into our lives. Think about having an hour of “unplugged” time per day (or even a day per week!).

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Congestive Heart Failure

2 types:

Systolic heart failure: pump weakens, ejection fraction (EF) less than 55%

Causes: heart attack, valvular heart disease, obstructive sleep apnea, viral, high blood pressure, excessive alcohol use

Symptoms: shortness of breath with activity, difficulty breathing when lying flat at night, swelling in the legs and fluid retention

Evaluation: clinical exam, stress test, echocardiogram, blood tests, chest xray

Treatment: medications include ACEi/ARB’s, beta-blockers, diuretics

Lifestyle changes: exercise, low salt diet, daily weights

Heart failure with preserved ejection fraction or diastolic dysfunction (poor relaxation):

Causes: age, hypertension, obstructive sleep apnea

Symptoms: swelling in legs, shortness of breath

Treatment: similar to above with focus on diuretics

Health Pearl: Colorful Stir Fry, adapted from Run Fast, Cook Fast, Eat Slow

Ingredients:

Two 8 or 12 oz packs of Extra Firm Tofu

2 Tbs Soy Sauce

1 Tbs Lime Juice

1 Tbs Honey

1 Tbs Minced Garlic

2 Tbs Sesame Oil

3 Cups chopped carrots, celery, broccoli

2 Cups sliced bell pepper, mushrooms, snow peas

Marinate sliced, dried tofu with soy sauce, lime juice, honey, and garlic in ziploc bag.
Saute carrots, celery, broccoli in sesame oil on high heat, stirring frequently, for about 5 minutes
Reduce heat to medium-high. Add pepper, mushrooms, snow peas. Saute 2 minutes
Add tofu with marinade. Saute, stirring occasionally. About 5 minutes
Serve over brown rice or quinoa.

Serves 4-6.

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What to expect when you’re… aging!

Consider yourself warned! We talk about normal aging and how to minimize the impact of age on the body.

From head to toe:

Hair thinning - occurs in women as well as men. Additionally, patterns of hair growth change with age.

Vision changes - decreased visual acuity, cataracts, and reading glasses are common

Dental - false teeth, dentures. Oral hygiene becomes more difficult due to decreased dexterity of the hands.

Hearing - hearing loss. Treatment is important due to potential for decreased cognition, changes in relationships due to hearing loss.

General physical appearance - change in distribution and appearance of fat distribution, decreased muscle mass. Metabolism slows, making it more difficult to lose weight. More protein is required to maintain and build muscle.

Cognition - some changes in thinking are normal, such as forgetting why you entered a room, forgetting names of people you haven’t seen in a long time.

Bowels - constipation can be a problem for many, looser stools occurs occasionally. Activity level, diet, and water intake can contribute to this.

Menopause and hormonal changes in men - both genders experience this. Can affect mood, libido, sexuality. Vaginal atrophy and dryness are common in women. Erectile dysfunction is common in men. Intimacy may need to change to accommodate both partners.

Urinary symptoms - lower urinary tract symptoms are common in men; urgency, frequency, incontinence can occur in both genders. Bladder becomes less elastic with age. Spasm can also occur related to triggers such as caffeine, citrus, and other irritants. Symptoms can be reduced with physical therapy, medical treatment.

Arthritis - osteoarthritis occurs in routine aging. Affects many joints depending on use, injuries, etc. A trainer or physical therapist can help remain active.

Balance - affected by vision, nerves, medications.

“Use it or lose it” for most components of normal aging. Healthy diet, physical activity, and adequate sleep help slow the impact of aging. Find out from your friends what has worked for them! Sharing your experiences and successes can help others.

Health pearl - Healthy Oatmeal, Chocolate Chip, Pecan and Orange Cookies
Adapted by Addie from SmittenKitchen.com

Makes about 3 dozen cookies

8 tablespoons unsalted butter, at room temperature
3/4 cup sugar
3/4 cup light brown sugar, firmly packed
1 teaspoon salt
1 teaspoon vanilla extract
2 large eggs
1 1/2 cups flour
1 teaspoon baking soda
1/2 teaspoon ground cinnamon
1/4 teaspoon ground nutmeg
1/8 teaspoon ground clove
1 ½ cup quick-cooking oats
2 cups chopped pecans
2 teaspoons freshly grated orange zest
12 ounces bittersweet chocolate chips (NOT semisweet)

Preheat oven to 350°F. Line a large cookie sheet with paper. Using an electric mixer, beat the butter in a bowl until light and fluffy. Add both sugars, salt, and vanilla, and beat until well mixed, about three minutes. Stir in eggs, one at a time. Sift together the flour, baking soda, cinnamon, nutmeg, and clove in a separate bowl. Add half of the flour mixture to the butter with the mixer on low speed. Once the flour has been incorporated, add the second half. Stir in the oats, pecans, orange zest, and chocolate chips. Drop approximately one tablespoon of dough onto the cookie sheet and bake for 10 to 12 minutes or until golden. Remove from the oven and cool the cookies on a rack.

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Episode 13 - Aging Well

Aging - the sum of all changes that occur with the passage of time that lead to functional impairment and eventually death

Factors affecting age: genetics, environment (stressors, habits such as smoking, alcohol consumption, diet)

It’s important to thing about death in order to help decide what living and aging well means for you. Take time to have conversations with your loved ones about what matters to you (quality of life versus quantity of life, what activities are important to you).

Answer the following: “How long do you think you’ll live?” and “How long would you like to live if given a fountain of youth?”

“What three things do you do to promote longevity?” “How well do you do at each of those (rate 1-5)?”

We all want to function as well as possible until death. Most of us will require help with at least one activity of daily living (dressing, bathing, toileting, food preparation) for the last 4 years of our lives.

Only 25% of longevity is due to genetics. The other 75% comes from environmental factors.

Life expectancy: 78.7 years for all comers, 81 for females, 76 for males

Blue Zones: National Geographic studied places in the world where people live the longest. People in these areas do the following: move naturally (walk, farm), have a sense of purpose, practice relaxation, in Okinawa - stop eating when 80% full; follow a plant-based diet; consume moderate alcohol; attend faith-based services 4 times per month; focus on loved ones coming first; surround themselves with the “right tribe” (family/friends with healthy habits).

Exercise can add years of independence to the end of life.

Diet: Mediterranean diet with plant-based protein, vegetables, olive oil, nuts and legumes adds health benefits to the heart, brain, and may contribute to longevity.

Control health conditions. Taking medication when needed will help prevent complications in the long-term.

Do supplements help with aging? Studies show more benefit from getting nutrients through a well balanced diet. If deficient in vitamin B12, vitamin D, supplements may be beneficial. Other supplements such as calcium, omega 3/fish oil haven’t proven to be as helpful. Ginko biloba hasn’t proven to be beneficial. Supplements are not well regulated.

Adequate sleep can contribute to longevity. Sleep related conditions such as sleep apnea should be treated.

Attitude appears to have an impact on longevity. Lindsey’s 104 year old grandmother choses to be happy, laughs daily, stays socially engaged (is on Facebook, church circle), has a sense of purpose, and has a sense of adventure.

Share your stories and life experience! The next generations need them.

Health pearl: Get outside! “Nature deficit disorder” is a loose term for symptoms related to inadequate time outside. Spending time in nature has a lot of positive health value, including reduced stress, better mood, better sleep, and lower blood pressure, among other things.

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The Waterworks for Men

Guest: Dr. Darin Lang, Internist and Geriatrician at Sanford Health. Trained at Virginia Mason in Seattle and Emory University for Geriatrics in Atlanta. Darin was born and raised in North Dakota. He’s been in his current practice at Sanford Health for 15 years working in outpatient Internal Medicine, nursing home care, and as a hospitalist. He is also the Internal Medicine Department Chair and an associate professor of medicine at the University of North Dakota School of Medicine and Geriatrics program. Dr. Lang is married and has 3 sons.

BPH = Benign Prostatic Hyperplasia. Affects older males and is an increase in the number of cells of the prostate, resulting in an enlarged prostate

Symptoms are urinary frequency, urgency, nocturia (waking at night to urinate), hesitancy, straining, slowed stream force, dribbling or obstruction

Alcohol, caffeine, and some over the counter medications can worsen symptoms (especially cold medicines)

Treatment:

Lifestyle changes include avoiding alcohol, caffeine and limiting fluids after evening meal

Medications: alpha blockers such as doxazosin and tamsulosin work quickly. Add on therapy - 5alpha reductase inhibitors (take months to work by shrinking the prostate)

Specialty physicians called Urologists are involved for procedures and more invasive evaluation

Health Pearl: Value of play

Follow us on Facebook and Twitter. If you’re enjoying the podcast, please write a review - this helps other listeners find us!

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Navigating Life Changes

Life transitions can be exciting at times but can also contribute to isolation, depression, and anxiety. Some major life changes include the birth of a child, menopause, becoming an “empty nester,” retirement, loss of a loved one, and loss of independence in the elderly. We talk with Dr. Zielke, PhD, and Trishia Powell, LICSW, about identifying signs and symptoms of stress, depression, and anxiety; treatment options for these symptoms, and behavioral strategies to help reduce symptoms.

Dr. Desiree Zielke, PhD, LP - owner, President of Becoming Balanced. Clinical Psychologist. Obtained her Bachelor’s of Science degree and Master’s of Science in Clinical Psychology from North Dakota State University. Graduated with her Doctor of Philosophy degree in Clinical Psychology from Indiana University Purdue University-Indianapolis upon completing a one-year internship in Salem, Virginia at the VA Hospital. Received postdoctoral training at Sanford Health and worked as a Licensed Psychologist at Sanford Health for five years. Dr. Zielke is licensed in both North Dakota and Minnesota. She is an advocate for self care in women and is excited to open a clinic focused solely on women’s health and wellness. Dr. Zielke is married and is mom to two yellow labs and 30 chickens. She lives on a hobby farm with her husband and is an aspiring yogi.

Trishia Powell, MSW/LICSW - Co-founder of Becoming Balanced and Licensed Independent Clinical Social Worker. Obtained her Bachelor’s Degree in Social Work from Minnesota State University Moorhead and her Master’s Degree in Social Work from the University of North Dakota. Trishia has over 15 years of experience working in the mental health field in the Fargo-Moorhead area, including in the hospital, outpatient/clinic, and community settings. She has completed a certificate training in Peri-natal Mood and Anxiety Disorders through Postpartum Support International. Her clinical work over the past several years has focused primarily on Women’s Health, particularly working with peri-natal and postpartum mental health, infertility and pregnancy/infant loss. Trishia was diagnosed with multiple sclerosis in 2018 and can identify on a personal and professional level with individuals dealing with chronic conditions. Trishia is a wife and mom to three children and a dog. She enjoys time with family and friends, exercising, napping, and attending her children’s activities.

Resources:

Online meet up sites where you can find others with similar interests. www.meetup.com

Facebook events and activities

Becoming Balanced - therapy services to help women in the FM community find their balance. They offer some extended hours, treadmill/walking appointments, classes.

Facebook - Becoming Balanced PC

(701) 551-1840

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A Salty Note on Sodium Chloride

Salt or Sodium Chloride recommended daily intake 2300mg daily or 1 teaspoon

High salt diet can contribute to high blood pressure or hypertension as well as worsen congestive heart failure or worsen swelling in lower extremities from venous insufficiency or leaky veins

READ FOOD LABELS!

Salty six = deli meat, pizza, canned soups, breads, tacos, cheese

Also watch out for pickled items!

Health Pearl: Try a foam roller to roll out aches and pains!

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Eating for health

This week we discuss nutrition and eating for health.

Nutrition: healthful food to fuel your body.

Positive nutrition can provide energy, boost immunity, improve overall health

Harmful eating patterns can lead to diabetes, heart disease, strokes, other health conditions

What matters? Calories, fat, carbs, protein? Is there a magic bullet? Whole foods - veggies, whole grains, fruits, legumes, seeds, nuts

Try to target the 80-20 rule. Eat healthful foods 80% of the time and occasionally (20% or less) allow yourself to eat things that are less healthy.

We discuss how to find healthy food and what to look for on labels, ingredients to avoid (high fructose corn syrup, artificial sweetener, etc)

Eating out can pose a challenge to healthy eating. Even a salad can have hidden ingredients that may add calories or reduce the health value.

Food we eat affects the microbiome of the gut. Plant based diets can promote growth of healthy bacteria in the digestive system.

We can help restaurants change the food they offer by increasing the demand for healthy options

How to shift your diet - aim for the 80-20 rule

Consider joining a CSA or vegetable coop

Think of it as an adventure in eating

Prepare food yourself

Meal prepping for the week works well for some, meal planning is another option, or consider joining a meal delivery service

Avoid purchasing or baking foods that may get you off track. The once-in-a-while foods can be bought once per month or on an intermittent basis. Try to have similar healthier substitutes instead.

Even if you can change one meal a week, you’re making progress

Many of us continue to face challenges with healthy eating at work or school. Less healthy snacks are often readily available. We can work as a community to improve these over time.

“Eat food. Mostly vegetables. Not too much.” - Michael Pollan

Menu for a week

Day 1

Breakfast: 2 boiled eggs with a slice of whole grain toast

Mid morning snack: trail mix with nuts, seeds, dried fruit

Lunch: Mixed greens with quinoa, protein (chickpeas, grilled chicken, or tofu), peppers, cucumbers, chopped carrots with vinaigrette

Afternoon snack: apple slices dipped in peanut butter or sunbutter

Supper: Chickpea & broccoli burritos, side of berries

Dessert: Avocado dark chocolate mousse parfaits with strawberries

Day 2

Breakfast: Green smoothie (1/4-1/2 cup spinach, 1/4 or 1/5 banana, 1-2 tablespoon peanut butter or sunbutter, 1 tsp ground flax seed, soy or almond milk)

Mid morning snack: cheese slices

Lunch: Left over amazing chickpea & broccoli burritos

Afternoon snack: Cottage cheese with 1/3 fruit

Supper: Roasted asparagus with garlic and olive oil, baked salmon with parmesan herb crust, side of quinoa seasoned with turmeric

Dessert: Berry and chia seed parfait (I use 1/2 the maple syrup and only berries for the topping)

Day 3

Breakfast: Whole grain toast with avocado slices

Mid morning snack: 1-2 protein bites

Lunch: Left over parmesan salmon and quinoa over mixed greens with balsamic vinaigrette

Afternoon snack: Berry and chia seed parfait

Supper: Lentil tacos from Thug Kitchen

Dessert: Smudgies (2 mashed bananas mixed with 2 tbsp peanut butter or sunbutter between two graham cracker squares, wrapped in foil and frozen)

Day 4

Breakfast: Steel cut oatmeal with seeds, almond slivers, or cottage cheese stirred in. Add cinnamon +/- nutmeg if needed for a dash of flavor

Mid morning snack: Veggies with hummus

Lunch: Reheated lentil tacos

Afternoon snack: Avocado slices with whole grain crackers

Supper: Kirsten’s salad (inspired by a favorite at Market on Front in Missoula, MT): Green leaf or romaine lettuce, grilled or baked lightly seasoned chicken, chickpeas, roasted sweet potatoes, chopped dried figs or dates, quinoa, crumbled goat or feta cheese, balsamic vinaigrette

Dessert: Yogurt with berries

Day 5

Breakfast: Protein muffin

Mid morning snack: Apple slices with peanut butter or sunbutter

Lunch: Left over salad, add toppings from the week (remaining salmon or chicken, roasted sweet potatoes, chickpeas, quinoa)

Afternoon snack: Trail mix with nuts, dried fruit, seeds

Supper: Whole roasted cauliflower (this is amazing - first had it in NYC and had to make our own), Evolved lentil wrap, apple slices

Dessert: 2-3 pieces dark chocolate (70% dark or darker - this will prevent over-eating)

Day 6

Breakfast: Muslii with greek yogurt (be on the lookout for excess sugar in yogurt)

Mid morning snack: 1/2 protein muffin

Lunch: Left over lentil wrap, reheated roasted cauliflower

Afternoon snack: Honey peanut butter protein energy balls

Supper: Greek turkey sliders

Dessert: Apple nachos (apple slices drizzled with sunbutter or PB and sprinkled with dried unsweetened coconut flakes)

Day 7

Breakfast: Baked eggs in avocado from popsugar.com

Mid morning snack: celery sticks dipped in PB or sunbutter

Lunch: Left over greek turkey sliders (so good!)

Afternoon snack: cottage cheese with 1/3 fruit

Supper: Garlic butter baked halibut on bed of roasted asparagus or green beans

Dessert: Peanut butter and banana yogurt pops - good for dogs too!

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Episode 8 - Sleep

Insomnia = Sleep difficulties

Multiple causes of sleep disruption: Obstructive sleep apnea, the need to urinate, medication side effects, restless leg syndrome, heart burn, worry, mood disorders (anxiety, depression), uncontrolled asthma

Caffeine can disrupt sleep. If having difficulties would limit intake to before noon.

Alcohol- poor sleep quality even if you feel helps you get to sleep

Medications that can disrupt sleep: decongestants, antihistamines (allergy and cold meds), nicotine replacement, inhalers, stimulants, some antidepressants

Obstructive Sleep Apnea: pause in breathing, snoring, morning headaches, awaken feeling unrefreshed, fall asleep easily if driving, reading, watching tv. Underdiagnosed so bring attention to symptoms of concern. Untreated leads to uncontrolled hypertension, heart failure, weight gain, atrial fibrillation, etc

Restless leg syndrome can lead to poor sleep - discuss symptoms with your PCP

Lack of sleep leads to poor decision making, poor concentration, increased accidents, poor ability to deal with life stressors

7.5-9 hours sleep is considered adequate

Sleep Hygiene:

Exercise daily but not within 2 hours of scheduled bedtime

Consistency in bedtime and wake time.

Prebedtime routine: quite time away from lights (screens included)

Limit total time in bed to 9 hours no matter if you have slept or not

Reserve bed for sleeping only – read, tv should be done elsewhere

If not asleep in 30 minutes or not feeling sleepy leave bed and do something quiet. Return when tired

Limit daytime naps to 30 minutes or less

Cooler temperature

Dark room

Quiet environment or white noise

Cognitive Behavior Techniques

Squeeze muscle groups from head to toe 30 sec and relax

Imagery

Meditation- new apps like Calm or CBT-i coach

Set aside worry time or worry journal

Work with cognitive behavioral therapist

Other things to try

Sleepy time tea

Melatonin 3-6mg

Blue lights during day time

Usually recommend avoidance of over the counter PM meds that contain Benadryl or diphenhydramine because of side effect profile- if use do so for short term/limited basis

Prescription options: never intended for chronic daily use

Mirtazapine: especially in older adult with low appetite, and low mood

Ramelteon: works on melatonin receptors, cost has been prohibitive

Trazodone low dose often helpful

We are often avoiding medications like Ambien and Lunesta because of side effects- reasonable if using short term for certain conditions. Can be habit forming. Also avoiding benzodiazepines like clonazepam and lorazepam except for short term/intermittent use in certain conditions. Would avoid long term nightly use as linked to dementia etc.

www.deprescribing.org

Health Pearl: check out The Blue Zones www.bluezones.com

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Episode 7: Living Well with Dementia

Dementia - changes in memory and thinking that are beyond what is normal for age. It is progressive (worsens over time).

Deb provides recommendations for living with and caring for people living with dementia:

Keeping the diagnosis of dementia a secret from the person with dementia robs the individual of their autonomy. It also perpetuates the stigma related to dementia.

It is possible to live well with dementia.

Our responses to the diagnosis impact how a person responds to the disease. If they are diminished and de-humanized, they lose hope.

Available resources:

The Dementia Alliance International (DAI) - https://www.dementiaallianceinternational.org/

Alzheimer’s Association - https://www.alz.org/

Memory Cafe - free socialization and support for people with mild to moderate memory loss and their caregivers

Upcoming conference: Redefining Memory Loss, Living Well Throughout This Journey. June 6, 2019 at Hilton Garden Inn, Fargo ND

Update on measles vaccination (MMR)

If you received the vaccine prior to 1967, it was less effective. It is recommended that this group gets revaccinated.

If you were born in the 1950s or early 1960s, you may not have been vaccinated.

Individuals born before 1957 are presumed to have immunity (likely had measles infection and so are immune to further infections) and do not need the vaccine (there are exceptions to this).

It’s safe to revaccinate if you’re uncertain of your vaccine history.

Healthcare workers who received the vaccine before 1967 or didn’t receive it should be vaccinated.

Health pearl: do something out of your comfort zone. “Go out on a limb, that’s where the fruit is!”

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Millions in US have diabetes or prediabetes but it is often PREVENTABLE

Diabetes Type 2: High blood sugar levels because of insulin resistance. Occurs when insulin released from the pancreas is less effective at moving sugar (glucose) from the blood stream into the cells.

Danger of high blood sugar levels over time- can cause blindness, numbness/pain in feet (neuropathy), kidney failure, heart attack/strokes, PAD (peripheral arterial disease), lead to amputations

Risk factors: diets high in sugars, refined carbohydrates (juice, soda, bread, pasta, sweets), sedentary lifestyle, obesity, genetics

Symptoms of high blood sugars: often no symptoms until very high blood sugars then can experience blurred vision, urinary frequency, excessive thirst

Diagnosed with blood test hemoglobin A1c level >6.5 (prediabetes 5.7-6.5, normal <5.7), or fasting blood glucose > 125

Treatment

Lifestyle modifications: diet, exercise, weight loss

Dietary changes: limit concentrated sweets, sodas, white breads and pastas. Change to whole grain/wheat breads and pastas or other pasta alternatives (edamame, lentil, chickpea etc). Limit white potatoes, choose sweet potato instead

1 carbohydrate serving is 15g: 9 grapes, half apple, 1/3 banana, 1/4 cup brown rice

Limit breakfast to 2-3 carb servings, lunch 2-3 carb servings, supper 3-4 carb servings

It matters what you eat with the carbohydrate. Absorbed more slowly (which is better) when eaten with protein or high fiber. So instead of drinking the glass of OJ eat the orange. Beans/lentils contain carbs but are a better carb choice because of high fiber/protein content.

Fill plate with ½ veggies, ¼ protein, ¼ fruit/healthy fat/grain

Medications: metformin, sulfonylureas (glipizide), GLP-1 agonist injectables (liraglutide) good for weight loss and heart disease, SGLT2 inhibitors heart and kidney benefit, DPP-4 inhibitors (sitagliptin), insulins

Health Pearl: Cucumber Quinoa Salad refreshing summer salad. Remember to rinse your Quinoa before cooking.

Additional resources:

Diabetes Food Hub

American Diabetes Association

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Episode 5: A Shot of Health

Today we focus on four adult immunizations: tetanus, pneumonia, shingles, and influenza.

Tetanus - a tetanus (Td) booster is needed every 10 years or less. Every adult should get Tdap once to protect against pertussis (whooping cough). Tetanus can be acquired from a skin puncture by rusty metal, and is also present throughout the environment, especially in soil.

Pneumonia - pneumonia is a lower respiratory tract infection / infection of the lungs. It can be caused by Pneumococcus bacteria, which has a thick outer shell that makes it more difficult for our immune system to fight. Generally pneumonia vaccines are started at age 65. They are given earlier for patients with a decreased immune system, compromised respiratory system (such as in asthma or COPD), and some other conditions. PCV 13 is the vaccine generally given first at age 65, and PPSV23 is given 1 year later. If given before age 65, they are given 8 weeks apart.

Shingles - shingles is caused by the chicken pox virus. After clearing chicken pox, the virus is dormant near the spine in nerve roots. Later in life, especially in situations of immune compromise, the virus can reactivate and cause shingles. The rash will affect one dermatome of the skin, which is the area of the skin supplied by nerves from a single nerve root. The older vaccine for shingles, known as Zostavax, was a live vaccine. Because it was live, certain populations couldn’t receive it. It also had lower efficacy, especially in older adults. The newer vaccine, Shingrix, is not live and has better efficacy.

Influenza - influenza is a viral infection that largely affects the airways and is worrisome when it causes viral pneumonia. Symptoms include fever, cough, body aches, runny nose, and headaches; this can progress to shortness of breath and difficulty breathing. We recommend the influenza vaccine yearly for everyone. Influenza can be life threatening even to healthy individuals. Yearly flu vaccines reduce mortality and severity of influenza infections.

Health Pearl: Tasty Lentil Tacos

If you like what you hear, please rate, review, and subscribe to our podcast. Please help us spread the word!

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Episode 4: Urinary Tract Infections

We discuss the anatomy of the urinary tract: bladder, ureters, and kidneys

We discuss infection being a pathogen (bacteria) causing an illness. This is different than bacteria that live with us that do NOT cause infection (colonized or part of our microbiome)

We discuss symptoms of possible bacterial UTI: burning with urination, frequency, urgency, incontinence, pelvic pain/pressure, fever, chills, flank pain (pain over the kidneys)

Other possible causes of similar symptoms: urethral irritation, bladder irritation (over active bladder), postmenopausal atrophic vaginitis

We discuss the risk of antibiotics when true infection is absent

We discuss that urine odor is NOT indicative of infection

Change in cognitive status is not necessarily indicative of UTI (yes, infection can contribute to confusion but also dehydration, constipation, fatigue can - more likely causes UNLESS symptoms described above are also present)

We discuss new data that suggests even with true infection antibiotics in healthy individuals may not be necessary

Ways to prevent UTI: drink plenty of water, do not hold your urine too long, avoid irritants (douching, soaking in bubble bath, tight clothing, perfumed soaps), moisturize with Vagifem or Replens type products. Other bladder irritants include caffeine, alcohol, sugar substitutes, carbonated beverages, citrus which can contribute to over active bladder symptoms

Practicing what we preach recipe: The Girl on Bloor Sweet Potato, Squash and Kale Buddha Bowl

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Episode 3: Prevention of Cardiovascular Disease

We explain the “leaky faucet” analogy for reducing risk of heart attacks and strokes.

We discuss the population that benefits from aspirin to prevent heart attacks and strokes and the population for whom aspirin is no longer recommended.

We discuss the benefits and role of statin medications in preventing heart attacks and strokes.

Supplements - we talk about fish oil, Coq10, and red rice yeast extract.

We explain which foods are best to avoid in order to lower the risk of cardiovascular disease, including red meat and processed foods.

We review foods that have proven value. These include unprocessed whole grains, nuts, seeds, healthy fats, vegetables, fruit, and legumes.

We talk about green, yellow, and red food classification.

The American Heart Association recommends 150 minutes of exercise per week. We discuss what counts as exercise and how to work towards this goal.

Links:

Blue Zones

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Episode 2: Getting the most out of your clinic visit.

Although you’ve probably been attending doctor appointments for years, you may not know everything that happens around your visit. Lindsey and Kirsten discuss what to expect at an office visit and how to maximize the time you have with your clinician.

Setting an agenda can be a useful tool to ensure that concerns are addressed.

The difference between annual exams and rechecks is discussed.

New research and changing health status of our population has led to changes in the annual exam. The utility of a head-to-toe exam in patients with no symptoms is surprisingly low. Similarly, screening urine and some other routine labs when patients are asymptomatic is not helpful. Most parts of the physical exam that screen for cancer have not been proven to result in better outcomes and sometimes result in harm through further testing and procedures.

Depending on health status, an “annual exam” may not be needed every year. We discuss how frequent an “annual exam” or other appointment is needed for certain age groups and health conditions.

We discuss how we review your chart before seeing you in the clinic.

Follow up question: we explain the role of a primary care physician for a patient who sees multiple sub-specialists.

Health Pearl: Kirsten enjoys running. She has found the Nike Run Club app not only makes her runs more enjoyable, but assists her in becoming a better runner through in-app coaching. Check out Nike Run Club at the App store.

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Episode 1: Purpose of Podcast, Getting to Know Us and Medical Training

Purpose/Mission To educate and inform about health matters affecting adults, from latest research updates to tips to navigate the health system and everything in between.

Lindsey Dahl Bio

Kirsten Juhl Bio

Education Required to become MD

-Four year undergraduate degree: can major in anything as long as the required premed classes are taken

-Medical Degree: 4 Years of Medical School (MD) or DO school (doctor of osteopathy)

Residency Programs: Internal Medicine =3 years, Pediatrics=3, Family Medicine=3, OB/GYN=3, Radiology=5, Surgery=5

Specialty Training: IM residency graduates can choose to do primary care or further specialize Cardiology, Pulmonology, Rheumatology, Endocrinology, geriatrics etc through fellowship training of varying lengths

Internal Medicine is a primary care specialty that focuses on treating adults with multiple chronic diseases like diabetes, hypertension, coronary artery disease, congestive heart failure, COPD, atrial fibrillation

Because there is a shortage of primary care physicians/MDs our health system utilizes team care with Advanced Care Providers which include Nurse Practitioners (RN 4 year training plus 2 additional years for NP degree) and Physician Assistant (4 year undergraduate degree with an additional 2 years clinical and classsroom experience)

Health Pearl: Spiced Chickpea Stew https://cooking.nytimes.com/recipes/1019

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Everything Your Doc Wants You To Know: Recent Episodes

Lindsey Dahl & Kirsten Juhl