Stepping into the New Year with a Walking Program

Article By: Clark Stream, PA-C

January 2011

Millions of Americans make New Year’s resolutions to become fit and lose weight.  With good intentions, most of us do not reach our goals.  No matter what your age or level of fitness, starting a walking program is one of the easiest and most affordable forms of exercise.  A regular fitness program with walking will not only keep your body fit, but it can also reduce your risk of diabetes, high blood pressure, arthritis, heart disease, cancer, dementia and Alzheimer’s disease.  According to the American Heart Association, exercise therapy with walking is the best treatment for claudication, (leg pain and cramping with walking).  Walking has become one of the most popular ways to say fit.

Before starting any new exercise program it is always recommended that you first consult with your primary care provider.

Beginning your Walking Program

The best way to start is slow and easy.  The best time to start walking is today.  Just walk out the door and walk around your neighborhood for 10 minutes.  That’s it.  Do this every day for a week and you are on your way to better health.  Add five minutes to your walks with a goal of 30 minute walks 3-5 days per week.  Be sure to drink water before, during and after your walking.  Warm up by walking slow for the first few minutes.  Try adding some flexibility movements while warming up, like ankle and arm circles or hip and shoulder twists.  Now that you are warmed up you should walk at a normal pace.  Your breathing should not be labored.  A good rule of thumb is…If you can’t talk you are walking too fast, if you can carry a tune you are walking too slowly.  At the end of the walk you need a slower pace to cool down.  Your heart rate and breathing will slow down as you prepare for the final stage of your walking program…stretching.  Taking time to stretch after every workout will help prevent injury and allow you to increase your walking distance with time.  Basic calf, hamstring and lower back stretching should be done after each walk.  Don’t forget your shoulders and neck with gentle range of motion stretches.

Keep track of your time, distance and occasionally record you weight loss, heart rate and blood pressure readings.  Walking with a friend makes the physical activity a social activity that will help you stick with it.  Physical activity will add more energy to your life, by increasing your metabolism and helping you sleep better.  Walking can help you lose weight, reduce mental stress and improve memory. 

Go on, step up and begin a walking program…It’s the best way to improve your quality of life, for the life of your legs.

High Cholesterol? Know and Control Your Numbers

Article By: Clark Stream PA-C

April 2011

Why is high cholesterol bad?

Cholesterol is a waxy, fat-like substance made by the liver and found in our diet.  It travels in your blood through the blood vessels.  Over decades, high blood cholesterol levels may result in damage and narrowing of arteries called atherosclerosis.  The American Heart Association has estimated that over 50 million Americans have high cholesterol.  People with high cholesterol have a greater risk of stroke, heart attack and peripheral arterial disease.

What are the good and bad cholesterols?

Lipids are fats.  Blood is mostly water.  Fat and water don’t mix.  Our bodies get help carrying the lipids (fats) through the bloodstream by using a protein shell called a lipoprotein.  There are two main kinds of lipoproteins:

          LDL (low-density lipoprotein) is know as “bad cholesterol.”  It mainly carries cholesterol.  It delivers the cholesterol to body cells with excess building up in artery walls.  This increases your risk for heart disease and stroke.

          HDL (high-density lipoprotein) is known as “good cholesterol.”  It is mostly a protein shell.  The shell collects excess cholesterol that LDL’s leave behind on blood vessel walls.  That’s why high levels of HDL cholesterol can decrease your risk of heart disease and stroke.

An easy way to remember the good from the bad is:  L in the LDL is lousy and H in HDL is healthy.

Who should be screened?

Because symptoms of high cholesterol are uncommon, many are not aware that their levels are too high.  Experts agree that screening for the levels of cholesterol, including LDL and HDL is very important for men over 35 and women over 45 years of age.  Many doctors support screening all men and women 20 years and older, and children from families with a high risk of heart disease.  People with healthy levels (total cholesterol less than 200 or LDL less than 100) should have his or her cholesterol rechecked every five years.

 What should my cholesterol be?

Know your numbers!  Cholesterol is checked with a simple blood test.  A fasting lipid profile, including total cholesterol, HDL, LDL and triglycerides will give you an overall look at your cholesterol risk.  Optimal target numbers commonly used include:

                             Total cholesterol:  Under 200

                                    HDL:  40 or higher for men, 50 or higher for women

                                    LDL:  Under 100

                                    Triglycerides:  Under 150

Controlling cholesterol levels.

If your total cholesterol, LDL or triglycerides are high, or your HDL is low, follow these steps to help control your levels:

            Eat less unhealthy fat:  Cut back on saturated fats and trans fats in foods like chicken skin, red meat, egg yolks, deep fried foods and high-fat cheeses.

            Be Active:  Choose an activity you enjoy like walking, swimming or riding a bike.  Work up to 30 minutes of activity most days.  Remember, some activity is better than none.  Always check with your health care provider before starting an exercise program.

            Quit Smoking:  Quitting smoking can improve your lipid levels.  It also lowers your risk for heart disease and stroke.

            Take medications as directed:  Many people need medication to get their LDL to a safe level.  Medication, however, is not a substitute for exercise or watching your diet!

Things to Remember:

Ÿ  A simple blood test can check your cholesterol level.

Ÿ  High cholesterol places you at risk for arterial disease including heart attack and stroke.  LDL cholesterol increases these risks while HDL cholesterol decreases risk.

Ÿ  Stop smoking, eat healthy and exercise.

TIA Prevention

Article by: Jennifer Clark, PA-C, MPAS

May 2011

50,000 Americans suffer from TIAs (Transient Ischemic Attack) every year; and of those 50,000 people, approximately one third will unfortunately progress to have a stroke, also known as a Cerebral Vascular Accident (CVA).  Most of us are aware of the detrimental effects of a stroke, but we are not as familiar with the signs and symptoms of a TIA or what we can do to prevent one from occurring. By understanding what exactly a TIA is, as well as the risk factors for developing one, we can enable ourselves to take proactive measures in preventing it from happening all together!

A transient ischemic attack is defined as a sudden focal loss of neurological function that completely resolves within 24 hours. This is caused by a brief period of inadequate blood flow from either the carotid or vertebral arteries to the brain. The symptoms of a TIA happen suddenly and can include vision loss often described as a curtain closing over the eye, difficulty with speech, weakness or inability to move one side of the body, or facial drooping. . A stroke (CVA) differs from a TIA in that it is a neurological deficit that is often permanent and occurs as a result of tissue death due to lack of blood flow to a region of the brain due to either a hemorrhage or a blockage of an artery.

Certain risk factors predispose us to developing TIAs. Uncontrolled hypertension or high blood pressure is certainly the most important. This can be a silent risk factor since hypertension is often asymptomatic. It is important to check your blood pressure regularly, whether with your family physician or when you are at the store or the gym and a blood pressure monitor is available. Any blood pressure reading greater than 140/90 is considered high blood pressure and needs to be evaluated and treated. If you have a diagnosis of hypertension, make sure you are taking your medications as directed and are following up frequently with your doctor to ensure it is controlled appropriately.  High blood pressure can also be affected by our diet; therefore it may be recommended that you start a low sodium diet.

Elevated cholesterol, also known as hyperlipidemia, can lead to atherosclerosis, or development of plaque in the arteries.   We should be screened for hyperlipidemia every five years, and if diagnosed should be on medications to help lower cholesterol, which in turn will help stop the progression of atherosclerosis. If diagnosed with hyperlipidemia, it is imperative to follow up frequently to monitor effects of treatment with medication and lifestyle modification.

Carotid artery disease is also linked to TIAs. This is often discovered by physical exam, if your practioner hears any abnormal sound in the neck then an ultrasound can be obtained for further evaluation. A screening ultrasound may also be ordered based on age and risk factors. Taking a daily baby aspirin and maintaining control of cholesterol helps prevent progression of carotid artery disease.

Cigarette smoking not only increases the risk for TIAs, but it increases the risk for having a stroke by 2.5 times! By stopping smoking not only do you decrease chances for stroke and TIAs, but you help reduce risk of disease throughout the entire body. Smoking is linked to numerous types of cancer and disease, therefore quitting is one of the most important things you can do for your health.

Atrial fibrillation is another risk factor for TIAs. This is a diagnosis of an irregular heartbeat. If you check your pulse and notice that it is irregular, make sure you make an appointment for further evaluation.

 Diabetes Mellitus that is uncontrolled is also a condition that can predispose you to TIAs as well as heart disease. Maintaining an ideal body weight and following the American Diabetic Association recommendations for diet as well as frequent visits to your family medicine clinic or endocrinologist and ophthalmologist is essential for management of this disease.

Obesity and sedentary lifestyle are both risk factors that we can reverse. Eating a sensible diet and cardiovascular exercise are very important lifestyle changes we all need to incorporate! The American Heart Association recommends 150 minutes of cardiovascular exercise a week, or five 30 minute sessions. If you are completely inactive this may seem like a lot, but if you gradually change your lifestyle to incorporate physical activity, this is a highly attainable goal.  Limit the use of alcohol consumption to more than two drinks a day for men and one drink a day for women.

Prevention consists of understanding risk factors and making necessary lifestyle changes helps decrease the chances of developing a transient ischemic attack in the future. While we can’t change our genetics, we do have the ability to change how we live our lives and our health, and making simple changes to the way we do things can help improve our quality of life for many years to come.

My Father-in-Law and Stroke

Article by: Bud Shuler, MD, FACS

May 2011

My father-in-law is a great man, and not just because he is the father of my awesomely talented wife.  He is however a stubborn “old fart.”  Raised in central Colombia, he is the epitome of an ungracefully aging Hispanic senior.  He doesn’t, like many of us, want to give in to Father Time and the limitations each additional day bring.  He also is “rather” set in his ways.  Until six years ago, he was active, enjoying the newly found freedom of retirement, and doting on his three grandchildren.  He had planned well for retirement, sacrificing as Dave Ramsey says, “living like no one else, so that he could live like no one else” during retirement.  He did have a darker side.  He refused to stop smoking, despite the pleas of his children to do so.  His rather macabre opinion that he planned to “just die of a massive heart attack and be gone,” epitomizes the misunderstanding of many smokers.  That is until 23 March 2005, when he arose from bed, only to collapse in a heap on the floor.  He had had a stroke.

He couldn’t move his right side, couldn’t speak, and lost control of his bladder function.  Oh, he knew what he wanted to say, but he could only grunt.  His leg and shoulder he fell on hurt badly, but he couldn’t tell anyone.  If it wasn’t for the dull thud as he crumpled onto the floor, my mother-in-law would have found him the next morning.  To a stoic, self sufficient, confident gentleman, he had entered hell on earth, completely coherent, feeling pain, and unable to move or communicate to those in this world.  But he could pray, and he got to know his Maker well over the next few hours.  Fortunately the blood flow was restored to his brain and his symptoms resolved, but not before he realized the error of a lifetime.  There was nothing he could go back in his life and change, but there was something he could do from that day forward.  Stop smoking.  He didn’t do it for his family per say.  He didn’t think about his wife, children, and grandchildren visiting him in a nursing home, or the extensive care that would be needed to sustain his life.  He didn’t think about the sacrifice of time and energy, or the mounring his family would endure.  No, at that moment, lying in a hospital bed staring at the ceiling, he was coming to terms with his future.  The immediate driving force to stop smoking was selfishly motivated.  He didn’t want to “live” the rest of his life on earth, in the “hell” he had just experienced.

So imagine yourself, smoking your cigarette one moment, the next, helpless but aware of all that it around you.  My father-in-law described the event as the most vulnerable he had ever felt in his life… pain, fear, humiliation, uncontrollable helplessness with nowhere to flee.  There was no escape, but by God’s mercy. 

You have a choice.  You alone can change your future, and your family’s.  Stop smoking today and avoid a stroke tomorrow.

Laughter Really is the Best Medicine

Article by: Jennifer Clark, PA-C, MPAS

April 2011

In the 2001 children's Pixar Film Monster Inc. the main character, Sulley, discovers that the energy derived from a child's laughter was significantly more powerful than the energy acquired from their fear. While the story is fictional, its message certainly has some significant truth. How many times have we all heard the cliche: "Laughter is the best medicine"? With April being National Stress Awareness Month, it is the perfect time to address the truth in this timeless statement.

Research derived from multiple studies has indicated that there is a significant relationship between emotion and the cardiovascular system. Negative emotions such as fear, anger, depression, and stress cause the vessels to constrict with increased blood flow while laughter has been shown to promote the release of nitric oxide (NO) which helps the vessels expand and contract appropriately in response to changes in blood flow. This also decreases inflammation within the blood vessel. This is demonstrated in a study conducted by the University of Maryland Medical Center. Two random groups of individuals were evaluated before and after watching comical and dramatic movies. One group watched various clips of Saturday Night Live (SNL) while the other watched segments of the 1998 DreamWorks movie Saving Private Ryan. The examiners evaluated the participates with Brachial Artery Reactivity Testing (BART) which consisted of an ultrasound evaluation of the blood flow through the brachial artery. Interestingly, the BART evaluation of the group that watched Saving Private Ryan revealed a 35% decrease in the blood flow while the SNL group demonstrated a 22% increase in blood flow. Another study conducted by the American Academy of Cardiology revealed similar findings with a 20% improvement of blood flow with laughter.

          Not only does a hearty laugh help the vascular system, but it also helps our bodies in multiple ways. In addition to improved blood flow, laughter has been shown to help relax the muscles in the body for up to 45 minutes afterwards which can also help lower stress levels and physical tension! Laughing increases the release of endorphins (our body's "feel good" chemicals) which help with pain relief and overall well -being. A good joke can also boost the immune system which in turn helps improve healing from illness and infection, and lowers stress hormones that can have a negative effect on multiple organ systems throughout the body. Lowering stress hormones also helps focus and relaxation. As we all know but often don't realize, laughing also helps nurture our social relationships. By improving our connection with friends, family and coworkers we find fulfillment and self actualization.

          Dolly Parton may have said it best in the movie Steel Magnolias when she said "Laughter through tears is the best emotion." So the next time you are feeling sad or stressed, take a moment to have a big laugh, and feel good about knowing you are helping your entire body, mind and soul.

DVT is Preventable and Treatable

March 2011

Deep Vein Thrombosis, or DVT, is a life threatening condition that occurs in approximately two million Americans each year.  DVT is when a blood clot forms in one of the large veins of the deep venous system, most commonly in the lower limbs. The primary and most dangerous complication of DVT is a pulmonary embolism or PE.  A pulmonary embolism (PE) occurs when a segment of clotted blood (most commonly from the lower extremities) breaks loose, and travels toward the heart through the circulatory system.  This clot can then become lodged in the artery that carries blood from the heart to the lungs (pulmonary artery), causing a severe dysfunction in respiratory function.  More people die in the United States from a PE than from breast cancer and AIDS combined.

Some of the biggest risk factors for DVT include sitting for long periods of time such as when driving or flying; inheriting a blood-clotting disorder, cancer,  Injury or surgery, pregnancy, oral contraceptives or hormone therapy, obesity and smoking. Symptoms for DVT may include, but are not limited to; swelling, pain, redness, skin discoloration or skin that is warm to the touch. Most healthy, active individuals are at low risk of developing DVT, but it can happen. Be aware of the risk factors and also aware that over time, your risk factors can change. Assess your risk on a regular basis, and if you observe anything suspicious, speak with your healthcare provider right away.

In the diagnosis of DVT your healthcare provider will take into account your specific symptoms and risk factors, and frequently will order some type of diagnostic or objective testing such as an ultrasound and/or blood work.  An ultrasound is a non invasive and painless way to image veins for DVT. A wand-like device (transducer) is placed over the part of your body that is in question.  As sound waves travel through your tissue with the help of gel, they will reflect back a moving image on a video screen. An ultrasound technologist can then image the venous system where clot may be visible if the patient is positive for a DVT. Sometimes a series of ultrasounds are done over several days to determine whether a blood clot is extending, and also to be sure a new one hasn’t developed. 

The good news is that DVT is preventable and treatable.  DVT treatment options include blood thinners, clot busters, filters and compression stockings.   With March being DVT awareness month, we encourage you to stay active and have a conversation with your healthcare professional about reducing your risk for developing a DVT.

March Ushers in DVT Awareness

Article by: Bud Shuler, MD, FACS

March 2011

March ushers in DVT awareness month, a chance to learn more about a devastating, sleepy killer.  A DVT, or deep vein thrombosis, is a blood clot that typically forms in the veins of the legs or pelvis blocking the return of blood flow to the heart.  This often leads to painful swelling of the affected leg.  Occasionally, they will break lose and end up in your lungs.  This is known as a pulmonary embolism, or PE.  When this occurs, you could die.

According to “The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism 2008”, DVT’s occur in about 500,000 Americans per year with at least 100,000 people dying either directly or indirectly from the event.  Yes, as many as 1 in 3 people with a blood clot in their leg or clot in their lungs die each year.  Unfortunately, it is more common in our rapidly growing and aging population.

A useful concept of the etiology of the disease is attributed to Rudolf Virchow, a German physician, who in 1856 described factors that lead to clotting of blood in a vessel.  Defined as Virchow’s Triad in the 1950’s it includes:

·         Hypercoagulopathy (blood that is more likely to clot)

·         Stasis (blood that is not moving through a vessel like it should)

·         Damaged lining of the wall of the blood vessel

Understanding this helps outline the risk factors that can lead to DVT and PE, and aid in its prevention.  Although hypercoagulopathy can be an inherited disorder, it is commonly found in people with active cancer, on birth control pills, and in smokers. Stasis is the cause of the often described “economy-class syndrome” in which travelers develop blood clots from sitting in confined airline (or automobile) seats, unable to move their legs. The heart pumps the blood to the legs but the body relies on the calf muscles to help pump the blood back to the heart.  If you don’t use your calf muscles, your blood pools in your calves, causing swelling, and potentially a clot.  Often stasis is attributed to medical conditions such as post partum, hip and knee surgery, and stroke or bedridden patients; but stasis is also found in people who sit at a desk or computer or in front of the TV all day.   In addition, severe congestive heart failure is a common factor contributing to DVT while in the hospital. Lastly, the damage to the walls of the veins occurs as a result of trauma, prior DVT’s, varicose veins, and smoking.

Even though this is not a common occurrence for your every day person, there are steps that you can take to further minimize the risk.  First, if you have a family history of blood clots, talk to your medical provider.  If you have inherited a clotting problem or have cancer, your provider may recommend medication to help lower your risk of clots.   An aspirin a day has not been shown to significantly alter the development of blood clots in veins, but may be reasonable if your provider feels you have other risk factors.  Another great way to keep your blood thin is to stay hydrated.  Drink plenty of water and avoid caffeine and alcohol when you travel.  Your calf muscle pump is really the key to avoiding blood clots, so use it.  This includes walking frequently during the day, wiggling your feet at the ankles when seated for more than 20-30 minutes, and elevating your legs.  Graduated compression socks also augment the function of your calf muscles.  Damaged veins with recurrent phlebitis, skin changes, or ulcers should be evaluated by a specialist, but all people with varicose veins do not need treatment.  And lastly, stop smoking!

I never thought of 23 as middle age

 Article by: Bud Shuler, MD., FACS

February 2011

Take a moment and count to eight. Eight seconds...barely enough time to tie your shoes. Strange to think that in that short passage of time, someone in the world died from tobacco use.   Although I first learned it from my parents and grandparents, as a medical provider, I recommit my life daily to making a difference in the lives of others.  As a vascular surgeon, I spend much of that time trying to improve the body’s ability to carry life-giving oxygen and nutrients through our patients’ diseased arteries, so that their quality of life is worth living.  And much like the commercial alluded to in the title above that has Rick Stoddard, a motivational speaker, talking about his wife of 24 years dying at age 46 from lung cancer, I am rather blunt in my discussions with patients about their attempts to thwart our efforts. 

My staff is often humored by my leading statement, “I can tell that you smoke.”  Leading in with that comment, I always get the response, “Really, how did you know?”  What follows rouses anger, shock, disbelief, but more often than not, a spark of personal accountability.  “I can tell you smoke because you smell bad” seems to work for the men.  The women usually bristle when I respond, ”because your face looks old!”  Now that I have their attention, I offer help in any form to aid in their cessation.   I explain the importance of tobacco on the degradation of a person’s health but more importantly on that of their family.  An individual has the freedom to choose whether to smoke or to stop smoking, but the family must often accept the emotional pain and financial burden that comes with their failing to stop.   Smokers often ignore the personal accountability that should come with their decision to smoke.  I try to alter their perspective a bit.

Many of our grandparents and even our parents have passed away, but they continue to frequent our memories because of the amazing influence they had in our lives.  Have you ever thought about what you would give, or give up to have them around another day, or week, or month?  What is the value you place on their love and supportive smile, their depth of wisdom concerning the challenges of life we are facing now, their warm embrace?  I remember how wonderful mine were and miss them daily.  They were my heroes.

Unfortunately, I lost 3 of my grandparents to the destructive power of tobacco.  I know that had they stopped sooner, they would have likely been around a little longer and gotten to meet my wonderful wife and our precious children.  They chose not to accept their addiction to cigarettes as something more than a personal problem because they didn’t realize until too late that their decision affected their own children, their friends, and more selfishly, me and my children.  We are much wiser now.  We better know the effects of tobacco on our bodies and the poor quality of life that usually follows.  We also have many aids to assist us in changing this habit, from medications and electric cigarettes to help lines, support groups and classes at both local hospitals and the Department of Health.  Assistance is available.

This Valentine’s Day, seek help.  Commit yourself to making a difference in the lives of others.  Show your love to your grandchildren and children and begin to practice personal accountability in your life and theirs.  What is the value of my parents and grandparents?  Priceless.  Be priceless to yours.

New Year Resolutions for 2011 and Tips to Follow Through

Article by: Bud Shuler, MD, FACS
January 2011


New Year’s resolutions abound and often are rooted in deep-seeded yearnings that bother us to the core of our being, but are so ingrained that we have trouble completing the task we set out to conquer.  We give up or give in often just shy of the goal, thereby allowing our list to remain unchanged year to year.  But that does us no good in the end.


Smoking is the number one cause of death in the United States.  If smoking cessation is your goal for the New Year, you are in the overwhelming majority as more than four out of five smokers say they want to quit.  With support from those who love you, encouragement and affirmation, and often some medical supplementation from your doctor, up to 40 percent of participants are able to quit smoking and stay off cigarettes for at least one year.  The benefits are overwhelming, not to mention you begin to look younger and smell better.  Benefits include,

·         Nicotine-free in 72 hours

·         Withdrawal symptoms resolved within 2-3 weeks

·         Improved breathing within six months

·         Easier to walk by and chronic cough often resolves in 3 months

·         Heart attack risk cut in half within 1 year

·         Calculate the money you will save at http://www.ucanquit2.org/calculator/Default.aspx

The second greatest underlying cause of death in the United States, according to WebMD, is the combination of a lack of physical activity and not eating the right foods, taken together.  Now that Thanksgiving and Christmas seasons are behind us, better attention to what we consume is also important.  Processed food of limited nutritional quality creates a less than optimal future quality of life. When you exercise, you…..

·         Improve mobility and flexibility

·         Improve the “pain of old-age”

·         Lower the risks of falls and the associated disability that follows

·         (when accomplished with others), enrich your relationships and persistence 

·         Enhance weight discipline

·         Reduce the risks of multiple medical-related conditions, including heart disease, some cancers, and back and joint complaints

There are many ideas and beliefs on how to go about sticking to your New Year Resolutions, but I would like to suggest a few:

·         Seek medical advice before you begin.  Everyone should have a checkup every year and established care with a local medical provider.  There are many great providers who are committed to your well-being from which to choose.  Medications and support groups they can recommend will also aid in smoking cessation. 

·         Recruit your support group to enable you to succeed and persuade them to join you.  This encouragement improves success and accountability and builds lasting relationships.  It also empowers others to take charge of their future.

·         Begin with a realistic end in mind.  For example, with weight loss,  a 3 pound loss each month is reasonable.  30 pounds every 30 days is not sustainable, nor often healthy, but 30-35 pounds a year is.  Therefore, 100 pounds will likely take at least 3 years.  Be patient, it will last.

Have a Happy New Year!