I find it amusing when I’m watching the evening news on TV and a dozen ads appear for medications with smiling happy people and at the end an announcer rattles off the side effects, ranging from rashes to gastrointestinal issues and sometimes death.  Obviously everyone who takes these medication will hopefully not get all of these side effects.  This brings to mind a situation that I’m finding more common in my practice:  there needs to be shared decision making between doctor and patient when selecting therapeutic medications.

Here are some helpful points to help you and your medical provider to customize your medication regimen.

• There are often MANY medications in each drug class.  If one medication does not work or you experience unpleasant side effects, don’t be afraid to tell your provider you want to try another.  I call this the “Goldie Locks and the Three Bears” process.  As I mentioned earlier, not everyone will have the same side effects from the same medication.
• Find out what has worked for others in your family.  At a recent conference, a psychiatrist mentioned that she treats families where they “swear” by certain anti-depressants and shun others because they don’t work or have unpleasant side effects.  It may not be too far from the truth that people who share some of the same genes would respond better to some medications than others.  I frequently ask my patients with high blood pressure if they have a close relative who also has high blood pressure and what they are taking and whether their regimen is effective.  Over the years, we are learning that high blood pressure has many different causes with a root in genetics.  It makes perfect sense to consider treatments that have worked for blood relatives.
• Do you process medications quickly or slowly?  People who process medications quickly through their bodies usually have to take higher doses, and vice versa.  In general, people who have smaller body sizes and women would be more likely to be slow metabolizers.  To get a better understanding, I like to propose the analogy of people who drink alcohol.  Some people can have one glass of wine and get very tipsy (slow metabolizer), whereas others can have a bottle and remain sharp (fast metabolizer).  Ask yourself, when you take Tylenol or Motrin for pain, do you usually need to take a lot for the pain to go away or can you get by with just one pill?  If you are the latter, you are a slow metabolizer which means you may want to tell your medical provider that you should start on a low dose and increase slowly.
• Find out what the main side effects are and discuss them in the office with your healthcare provider.  Are these compatible with your life and your other health issues?  For example, one type of weight loss medication called Orlistat has a major side effect of diarrhea.  This may not be the best choice if you have hemorrhoids which get worse and can be quite painful with frequent bowel movements!  In the treatment of hypertension, one of the first line drugs is a diuretic (makes you urinate) called hydrochlorthiazide (HCTZ).  For many people who have a long commute in the morning, having to find a bathroom on a subway or bus can be yet another hassle in your day.  Fortunately, there are over 200 other medications to treat blood pressure now!  If the diuretic doesn’t fit into your life, why not try another medication which fits better into your lifestyle.
• Maybe there are side effects which you actually want!  No, I didn’t mistype that last sentence!  Interestingly enough, some side effects can be positive.  A few examples: Metformin taken by diabetics for lowering blood sugar has the side effect of weight loss, Finasteride taken for enlarged prostate can regrow men’s balding areas on their head, Topamax is an antiseizure medication that can also reduce migraines and causes weight loss, Spironolactone is a diuretic (water pill) used for treating high blood pressure that can also reduce body hair (requiring less shaving of the body) and induce breast growth.  Talk with your doctor and ask if there may be a medication which can “kill two birds with one stone”.
• Find a dosing regimen that works for you.  Some medications have “extended release” versions so instead of having to take a medications twice or three times a day, you only have to take it once.  This can also give you a cost savings since you would only need half the number of pills.
• Is there a similar drug with a generic version.  In general, generic versions are cheaper than their brand name counterparts and can be just as effective.  If you healthcare provider prescribes a medication and you realize at the pharmacy that the co-pay is way too expensive, don’t leave the pharmacy with the medication.  Once you do, you will not be able to bring it back for a refund!  I advised that you inform the pharmacist and your provider that the cost is too expensive.  The pharmacist can work with your provider to prescribe a less expensive and likely generic version.
• Healthcare providers often do not know what the cost of the medication will be for your particular insurance.  In the US, each insurance creates a formulary of preferred drugs.  If you are prescribed a non-formulary medication, it will likely cost you more.  I recommend that patients obtain this formulary from their insurance each year (since it can change yearly), and bring it to each provider visit and encourage him/her to prescribe medications on that list.  Some EMR (electronic medical records) can identify the formulary medications, but may not always update with your particular insurance.  As a rough guide, if you have seen a commercial on TV for the medication, it is not likely to be on the formulary as it is a newer medication.

Recently, in the news there have been several security breaches with large companies ranging from social media to finance and healthcare websites.  These incidences were mainly inappropriate release of names, addresses, dates of birth, and social security information.  Something you may not think about as being just as important is your health information but I would argue information about diseases you may have or even your personal habits (alcohol, tobacco use, etc.) are just as valuable and can be used against you if stolen.

Here are steps to secure your healthcare information.

• Do not email your healthcare providers.  Email is not considered a secure way of transmitting your protected health information (PHI).  Email should be assumed as “hackable” and anyone can gain access.
• Check if you medical office has a portal.  These are password protected channels of communication that provide a secure way of sending messages to your medical provider.  They also usually offer the ability to request refills on medications, check your lab results, and schedule appointments.
• Shred all medical office bills/lab results after you are done with them.  Do not place them in trash or recycling bins.  Better yet, throw them in with food waste such as coffee grounds.
• Oftentimes, insurance ID numbers are the same as social security numbers.  Be sure that you are not giving these out to medical offices too often.  Name and date of birth are usually sufficient as patient identifiers.
• Avoid posting your health information on social media websites. Given the recent issues with Facebook, we should all be more careful about posting on these sites.
• Be careful about apps which help you “track” your health.  When you use some of these, you may be allowing them access to more than just how many steps you’ve taken or what you’ve eaten.

In many parts of the country, trees are sprouting green leaves and flowers are appearing.  Pollen from plants is so fine and small that it be carried into your home with the slightest breeze.  Pollen is the main cause of spring allergies which can result in itchy, watery eyes, running nose, sore throat and even cough (from a post-nasal drip).  We are officially at the beginning of the Spring Allergy season!  Here are some tips to make your family’s allergy season more bearable.

• Trees typically pollinate (shed pollen into the air) during dawn and dusk periods.  Keep your windows closed during these times and try to plan outdoor events away from these times.
• Keep car windows closed and use the air conditioner instead.  Better yet, set the air conditioner to “recirculate” the air and not bring in air from outside.
• Wipe your shoes off to remove pollen which may have stuck onto your shoes after walking outdoors for long periods of time.
• Wear sunglasses with thick sides (the area that loops over your ears).  This can prevent the wind from blowing pollen into your eyes.
• Purchase “natural tears” eye drops.  These can be helpful to wash out any pollen.  I use a type that come in tiny individual plastic droppers which I carry with me at all times.  They are convenient and disposable.
• Avoid giving gifts of flowers to loved ones who have allergies.   Lilies, chrysanthemums, cherry blossoms, sunflowers, and daisies are notorious for causing allergies.  If you are an allergy sufferer and get a gift of these flowers, consider donating them to a community center or charity such as a homeless shelter.  Better options (less allergenic) flowers include tulips, roses, crocuses, geraniums, hydrangeas, carnations, orchids and daffodils.
• If you do have allergies that are worse in the spring, start taking your antihistamines (Claritin, Zyrtec, or Allegra) now. Most are over-the-counter, taken once a day and non-drowsy (except for Benadryl).  They need to be taken prior to exposure to pollens to have the best effect.  Nasal steroids (such as Flonase, Nasacort, or Rhinocort) are nasal sprays that can be used to lessen nasal symptoms.  If your allergies are particularly bad, you may even want to take both types of medications.
• I am a big fan of sinus rinses.  It makes perfect sense, pollen gets into your nose and sinuses, you wash the pollen out and you will feel better. I do sinus rinses every morning.  I find the experience just like flossing, you may not feel comfortable or want to do it at first, but once you get used to it you find the process quite routine. I recommend the NeilMed brand.
• Track the pollen count and plan your days accordingly.  You can visit the website Pollen.com for an up to date reading of the pollen count for the day and forecast for the next few days.  The pollen count can vary dramatically based on which plants are blooming, how many of those plants are in your area, and weather conditions.  Generally, the pollen count goes down significantly on rainy days since the water pulls the pollen out of the air.  Avoid being outdoors excessively on high pollen count days and you will feel less miserable.
• Purchase a HEPA rated air filter for your home and change the filter regularly.  The best air filters are very noisy, but you don’t need to run them 24/7.  I would recommend turning it on just as you leave for work and turn it off when you get home.  The eight or so hours you are away is enough for most filters to remove pollen in the air.
• Change the air filters in your air conditioner.  Be sure to buy HEPA filters as replacements.  These may cost slightly more, but they have a finer mesh that is designed to remove the small pollen particles.
• Upholstered furniture and rugs/carpets often trap tons of pollen tracked in on your clothes and shoes.  Consider getting them thoroughly cleaned, or remove the rugs completely.  Allergy sufferers should consider buying leather furniture, as they can be easily wiped clean and do not allow for pollen to collect easily.

Recently, the New York Post reported the NYC Department of Health findings that Asians are the ethnic group with the lowest rates of obesity in an article titled “Asians are the least obese demographic in NYC: survey”.  While this is likely true based on Body Mass Index (commonly a BMI>25 is considered overweight and a BMI >30 is obese), it does not mean Asians are not suffering from weight related problems including diabetes, hypertension (high blood pressure), and heart disease.  Currently, there is an epidemic of all of these diseases in the Asian and Asian-American community (including people from China, Korea, Philippines, India, Bangladesh, among others)  Why is there a discrepancy?  Essentially the BMI is not a good measure for obesity for the Asian population.  Many studies have shown that the Asian body type tends to accumulate fat inside the abdomen, which is a place where increased fat dramatically increases risks for many diseases.  The abdomen is where the major organs involved in metabolism (e.g. liver produces cholesterol and sugar, pancreas secretes insulin which helps to process sugar, kidney regulates blood pressure, etc.), and having excess fat in that area literally can “choke” off these organs and cause them to function improperly.  So while their weight may be the same as other races, the fat distribution is more localized rather than distributed evenly throughout the body.  Years ago, there were studies showing that people with body types that looked like apples (larger midsection) have higher rates of cardiovascular disease than people whose bodies looked like pears (larger hips and thighs).  Generally speaking, most Asians have apple shaped bodies.

I’m very concerned these recent study findings will limit resources allotted to health education for the Asian population in New York.  It gives the impression that this population does not need preventive health initiatives since they “are not fat”, but this is a dramatic misconception that they are not at risk for many serious diseases.

What is a better measure for obesity among Asians?  BMI can be used, with lower cutoffs (23-26.9 as being overweight and above 27 would be obese).  The abdominal waist circumference would be an even better tool with ethnic specific cutoffs for Asians with cut offs being 35 inches (90 cm) for men and 31 inches (80 cm) for women.  To properly measure a waist circumference, you should take a fabric tape measure and wrap it around at the level of your belly button.  Pant or belt sizes are normally not accurate as we normally wear our pants below the belly button and hence they would typically be lower than the clinical waist circumference measurement.  These standards for obesity already exist and should have been used in the NYC DOH study rather than BMI alone.  I’m quite surprised and disappointed that a health authority who should have been knowledgeable about health among the diverse population in New York would not have acknowledged the proper way to assess obesity among Asians.

Happy Healthy Heart Health Month!  To mark the occasion, we should all take some time to consider one of the most important organs, the heart.  Diseases affecting the cardiovascular system including myocardial ischemia (“heart attack”), strokes, and aortic aneurysms (ballooning of the large artery in the chest) account for the leading cause of death in the US.  Sadly, these deaths are largely avoidable through lifestyle changes and proper screening.  Are you at risk?  The American Heart Association has put together a wonderful self-assessment tool called Life’s Simple 7, that you can complete to find out.

In addition, here is my checklist of things you need to consider and discuss with your primary care provider:

• Know your numbers.  Blood pressure, cholesterol (including breakdown of LDL “bad” and HDL “good” types), blood sugar, heart rate, weight, height, and BMI are essential to an assessment of your fitness.  If you have any abnormalities in any of these, you should ask your primary care provider how you can improve them.
• If you have a blood pressure monitor at home (I believe everyone should have one of these, even if you don’t have high blood pressure.  They are inexpensive and can detect blood pressure issues early), check your blood pressure a few times a week and record these numbers.  Bring these readings with you when you see your provider.  Having multiple readings at different times can help your provider find out if you have a blood pressure issue.
• Do you have a family history of cardiovascular disease.  Ask your blood-relatives for their history.  It is important to find out about high cholesterol, diabetes and hypertension (high blood pressure) history since these are the main contributors to heart disease.  If you have any family members who have had a heart attack or stroke before the age of 50, this is a VERY significant piece of information as cardiovascular disease affecting younger people usually means there is a genetic component.
• What is your exercise capacity?  Has it changed recently?  The heart helps pump blood to muscles so that you can move around.  If you used to be able to climb three flights of stairs without getting short of breath, but now you climb just one and feel winded, something may be going wrong with your heart.
• Are you still smoking?  Smoking is the most significant risk factor for heart disease.  Quitting will reduce your heart disease risk significantly.
• Is your diet too high in saturated fats and sugars?  In general, most saturated fats are derived from meat.  However, there are also plant-based fats that are bad for you such as the “tropical oils” such as coconut oil or palm oil.  Reduce these in your diet as much as possible.  Sadly, many manufacturers of packaged goods will add these to make cookies and cakes taste better.  Be sure to read the labels of all the food you buy and if you see these oils, avoid buying those foods.  Sugar comes in many forms, some which are worse than others.  I would reduce intake of any corn-based sugars such as corn syrup as these have been shown to worsen blood sugar.  Honey or cane sugar, in moderation of course, would be better options.  Stevia, which is technically a spice that makes things taste sweet but doesn’t contain sugar and has no calories, would be the best option.
• What is your stress level?  More and more studies show that stress has a very negative impact on our health.  Stress induces our body to secrete hormones such as cortisol and epinephrine.  In small doses, these are great for helping us ‘weather the storm’ when we face challenges.  However, over time these can have deleterious effects on our body such as increasing blood sugar, weight gain, and raising blood pressure.  We all need to manage stress as much as possible.  Try meditation to help with stress, or start seeing a therapist to talk through your issues.

Be sure to get your annual physical exam, including bloodwork and possibly and EKG!