Thursday, March 28, 2013

End the Yo-Yo Dieting & Embrace a Healthy Life Style

By: Robert A. Shaffer M.D., Gastroenterology Associates N.A.P.C. Medical Director of Shaffer Weight Loss Center and Denise Biro, Weight Loss Coordinator

      Summer is just around the corner and it will soon be swimsuit season. Here are a few tips on how to begin your weight loss journey without adding an additional expense to the pocket book. Reaching and maintaining long term weight loss goals can be as simple as this: clean out unhealthy food items from your pantry, create nutritional menu and grocery list, plan and begin physical activity daily. 

     Unhealthy food items or pre-packaged foods are found in a cardboard box, preserved in a can, or wrapped in plastic, and contain no real nutritional value. Not only are these convenience foods high in sodium they are empty calories that may cause hunger pangs in thirty minutes. Foods high in nutritional value help reduce the risk of certain disease in addition to aiding in weight loss efforts. Start cleaning the refrigerator and pantry, place all unneeded food in a box, and donate to the shelter of choice.

     The U.S. Department of Agriculture Food Guide of America suggests to make half of your plate fruits and vegetables, then add grains, add protein last and include a small amount of dairy (or some other calcium source). Select foods with reduced or zero added fats, sodium, and/or sugars. Buy fresh or frozen fruits and vegetable when possible over canned or boxed. Choose the leanest cut of meat, and whole grains that contain fiber. Create a weekly menu consisting of breakfast, lunch, dinner, two snacks, and a grocery list based on the suggestions above. Being prepared in the kitchen with meal planning will keep the focus on long term health goals.

    Adding exercise to a weight loss plan not only burns calories but will also help prevent weight regain. The best way to be accountable for exercise is to plan ahead and allowing time in personal schedule to do it. Set a goal and work up to at least 3 to 5 days a week for 30-45 minutes. Physical activity can include parking further than usual from work, walking up stairs instead of taking elevators, gardening and walking the dog.

     Long term weight loss goals can be achieved by careful planning of consuming a variety of fresh vegetables, fruits, whole grains, lean protein and increasing moderate activity to most days of the week.  Be sure to consult with your doctor before starting a new physical activity regimen. Some people will require special dietary strategies for weight loss and should consult with a physician or certified nutritionist offering such services.



Monday, March 25, 2013

Cognitive Enhancement for the 21st Century

By: H. Randall Griffith, Ph.D., ABPP

Ackerson and Associates, Birmingham Alabama
Most of the questions I tend to get in my clinical practice regarding cognitive enhancement have to do with memory functioning. However, memory is but the tip of the iceberg for cognitive enhancement. In order to understand how we can change our cognitive functioning, it is useful first to think about how the brain processes information in general. The brain is a vast storage and communication network comprised of around 100 billion neurons, which are the basic cells that make up the brain, as well as some 100 trillion connections among these neurons. Think of the internet, but on a vaster scale. Each neuron could represent a networked device on the internet: it receives information from thousands and thousands of other devices and can send out information to thousands and thousands of others. The connections between neurons are called synapses, and it is at these synapses where the dynamic processes of brain functioning primarily occur.
             Unlike in the world of the internet, where everything comes through one cable or wireless connection, in the brain the number of synapses are critically important for the functioning of an efficient network. The brain is flexible in the way it makes these connections, astonishingly so. Microscopic images of synapses that are presented in a time sequence show these connections among neurons literally blooming before the viewer's eye. Well-connected neurons can be widely influential, and are able to become more efficient in their response to receiving messages: they actually learn to respond more robustly to certain signals from other “familiar” neurons. The bottom line is that the health of neurons, their connections, and the biochemical processes that govern the actions of these connections is critically important to how our brains function (or do not function!) as we age.
             So what do we know about the aging brain? Neurons die. Actually, they die throughout the lifespan, at certain points in our lives die at an astonishing rate. A newborn child has more neurons in their developing brain than they will ever need – too many, in fact. Part of early development is the loss of neurons that really have no use, called pruning. By and large, this process is over early into our lives, and development takes on a new job, that of creating new connections and strengthening important connections. This is essentially learning, which mostly occupies the first two decades of life. Our brains literally soak up information during this time of life, for most of us working in a highly efficient manner to store new information so that it is easily accessible. As well, the brain becomes more efficient. Neurons that are near each other do not necessarily need to have long connecting fibers, or axons, to communicate. However, neurons sometimes have a long haul to get neurochemical signals to their destinations. The longest axons in the human body literally are stretching from head to foot (the sciatic nerve). In order to be more efficient, such long nerves need to have a lipid-protein covering, or myelin, to make the signal transmission go faster (in the brain the neurons do not work wholly on electrical impulses but on electro-chemical impulses). The process of myelination helps explain why balanced nutrition for children and teenagers is so important for cognitive functioning. Myelination of the frontal lobes, where emotions, behaviors, and critical thought processes are regulated, is not fully complete until the 20s or 30s. So for parents of teenagers, it is somewhat comforting to know that the teenage brain is not finished developing!
             Starting in the late 30s to early 40s, our brains actually start to shrink, subtly at first but after the 6th decade at a more accelerated rate. Unfortunately, neurons do not live forever. And even if some new neuronal regeneration occurs (and we are discovering more and more that this may be the case), remember this is only one part of the equation, because it is the synapses, the connections among all those neurons, that really represent what we have learned. The loss of neurons means that synapses are becoming less robust, less efficient.
             As well, aging (and the health issues that inevitably emerge from aging) affects the efficiency of the nerve bundles deep within the brain. This relates to blood supply to the brain. Oxygen is the most critical need that the blood supply provides to the brain. Neurons begin to die within one minute of oxygen deprivation, and within 3 minutes of total interruption of oxygen serious brain damage has occurred. Most of our brains will not suffer the effects of full anoxia. However, chronic starvation of the brain can cause cumulative damage to the neurons and their axons. The medical term for this process is microvascular ischemia: micro (as in small) vascular (as in blood vessels) and ischemia, or restriction of blood flow to tissue. Unfortunately, in the brain there are susceptible areas related to the type of blood vessel that supplies that area of the brain. The blood vessels that supply the myelinated nerve bundles in the brain are more prone to changes in blood pressure and also to the effects of inflammation. The result is that damage can occur to these nerves without a noticeable clinical stroke; accumulate enough of such damage over time and this will start to affect the efficiency of the brain.
             When damage to the nerves interconnecting the neurons occurs, there will be a loss of synapses, just like telecommunication wires being damaged by falling trees in a storm. Fewer connections mean that the ability of the brain to access its vastly distributed information network becomes inefficient, slower, and unreliable. In the severest of circumstances, the neurons themselves can die from damage to their nerves, or from the loss of connectivity. When one considers the accumulation of such “silent” damage over time, it is not surprising that brains begin a slow, steady decline in size somewhere around middle age.
             So, how could we slow or even possibly stop this process of cumulative damage to the brain? The answer lies in promoting cardiovascular health. We are fairly well educated about how to decrease risk of heart disease nowadays; most all of us have had tests to measure qualities of heart health such as measuring blood pressure, cholesterol levels, blood sugar, triglycerides, and such. Good heart health prevention not only focuses on keeping track of these tests, but also taking the medical, behavioral, and lifestyle steps to ensure heart health to the fullest extent.
             In the medical realm, it is critical to treat those diseases that affect the heart to protect the brain. So for instance, high blood pressure should be monitored closely,  medications used to help control blood pressure (if needed), and regular medical checkups. The same thing goes for high cholesterol, diabetes, cardiac arrhythmia, and the like. There is no better step to take than to keep such conditions medically under control.
          There are habits that are very bad for the heart and brain. Tobacco use is a risk factor for heart disease. Chronic obstructive pulmonary disease (COPD) can lead to serious implications for the brain, as difficulty getting oxygen to the bloodstream due to poor lung function will have an effect on the regular, steady supply of oxygen that the brain needs. Not getting good sleep can be detrimental to the brain’s ability to store information. Sleep and its cycles are intimately related to how the brain processes and stores information, as well as repair and regenerative processes. Good sleep habits are conducive to good sleep: schedules, routines, regularity. Also, avoiding any type of
behavior or activity that may make it harder to get to sleep, such as consuming caffeine in the evenings, watching television in the bedroom or actually while in the bed, etc. Treating sleep problems medically is also important. Sleep disturbances are often a sign of diseases that can impact the brain.
             For the brain, you are what you eat. Having poor eating habits, such as eating most calories late at night and eating irregularly, contributes to obesity, disturbs the sleep cycle, and leads to daytime variations in glucose levels. Fatigue can often be related to poor diet and dietary behaviors. In contrast, there are good dietary additives and supplements that have been shown to promote brain functioning. We know that fish oil, specifically its component docosahexaenoic acid (DHA), is an excellent protector of heart and brain health. Turmeric, a component of curry-based foods, is also increasingly recognized as protective for heart functioning. Blueberries are also the latest “super food” of the brain, as are avocados. Such food components and ingredients likely play a role as antioxidants, which help reduce oxidative stress and inflammation. Avocados may also help lower blood pressure.
             While eating right is important, another essential lifestyle change is the role of cardiovascular exercise. While this is one of the lifestyle changes that may have the most impact with the littlest cost, it is probably one of the hardest lifestyle changes to make and maintain. It may be best to start with the small changes that are easiest to maintain. For instance, if you are capable of it, park further away in the parking lot. Take the stairs instead of the elevator if only going up or down a few flights. And consider a modest and easily maintainable exercise routine. For instance, recent research has indicated that as little as 30 minutes of brisk walking 3 times a week can be beneficial for your health.
             A last lifestyle consideration is being more mentally active. Much like physical strength, mental strength and endurance is a “use it or lose it” phenomenon.  Mental activity that stimulates processing speed, in particular visual attention and processing, can actually improve speed of thinking as we age and can result in benefits in our everyday functioning. Enter computer-assisted cognitive training applications. While there are many such programs out there, here are two to consider. I do not endorse these products, but they are examples of what you might want to look for in a brain training software. One is Lumosity:, a website where members can use brain training activities and keep track of their progress. Another is Brain Age:, which is marketed by Nintendo for their hand-held Nintendo DS game system. The desirable features of a brain training software would be games that focus on concentration and reaction time, as well as keep track of your scores over time so that you can see if your score is improving, so you have feedback on potential improvements in your skills. Equally important to the process is periodic “tune up” sessions, once you have achieved your goal, to maintain your progress.
          While not all cognitive aging effects can be prevented, comprehensive lifestyle changes may help to delay the more serious cognitive complications of aging. Consider a recent book, The Alzheimer's Prevention Program by Dr. Gary Small and Gigi Vorgan. Dr. Small, who is an eminent researcher in memory and memory disorders from UCLA, presents the argument that, even if a person has family risk factors of Alzheimer's disease, preventive measures can delay the onset of this disease. An ambitious goal, but not impossible. Many researchers studying neurological diseases share this same goal, and many of the drugs that will be developed in the next decades will considerably slow onset of Alzheimer's. Until then, armed with knowledge regarding prevention, we can put the best foot forward to improve cognitive functioning well into older adulthood

Friday, March 22, 2013

“ Silent Reflux – Do You Hear the Throat Clears?”


By: Carleen F. Ozley, MS, CCC-SLP
ExcelENT of Alabama
Ever been in a crowd of people, shopping at the mall, standing in line at a fast food restaurant and heard someone constantly clearing their throat? Ever listen to a friend talk and suddenlynotice that between every few words or sentences that they are clearing their throat? Ever had anyone ask YOU the question, “What’s wrong – you keep clearing your throat?”

            Chronic throat clears is a major symptom of laryngopharyngeal reflux or LPR. It is a most misunderstood and disturbing symptom for the sufferer. Laryngopharyngeal reflux is a condition in which stomach acid leaks out of the stomach and into the esophagus and throat. The acid irritates the throat and the vocal cord area. It may result in voicing/swallowing difficulties and sinus infections. Some people with LPR may experience quite a bit of heartburn, but most people with LPR report little or no heartburn and therefore, it is often referred to a “silent reflux.” The laryngeal area, compared to the esophagus, is much more sensitive to irritation and injury from stomach acid. LPR is present in up to 50% of patients with voice disorders.

            Reflux more often occurs at night when we are sleeping. When we sleep, the stomach muscles and the esophagus relax and open slightly. Gravity is no longer working to our advantage to keep the acid inside the stomach. This supine position can allow acid in the stomach to travel up through the esophagus and irritate the back of the throat where the vocal cords are located.

            It may take up to 8-12 weeks of daily usage of medication along with diet and lifestyle modifications before reduction/resolution of symptoms occurs.

The most common symptoms of LPR are listed below:

1. Chronic throat clearing (increases after eating)

2. Sensation of “lump or something stuck in the throat” that does not clear with repeat swallows.

3. Dry cough

4. Hoarseness of voice loss

5. Swallowing difficulties and feeling that “solids won’t go down”

6. Sore throat

7. Aspiration – choking while eating because food enters the airway

8. Excessive mucus production

9. Reddening/swelling of and around the vocal chords observed during a LaryngealVideoEndoStrobscopy

10. Postnasal drip
In addition to a proton pump inhibitor or other reflux meds your ENT physician may prescribe, the following strategies for diet and lifestyle are recommended to assist in reducing the symptoms of LPR and especially the “nagging throat clears:”
1.      Avoid spicy, acidic, tomato based, fatty foods, chocolate, citrus fruits and citrus fruit juices and peppermints.
2.     Reduce weight around mid section that increases abdominal pressure that can aggravate reflux.
3.     Eat small, frequent meals/ no large meals.
4.     Wait at least 1-2 hours after eating before exercising.
5.     Do not wear tight, restrictive clothing around your waist. Be careful about assuming body positions that exert pressure against your waist. For example: gardening, lifting weights, bending over at waist.
6.     Limit your intake of coffee, tea, colas (caffeine) and alcohol.
7.     Stop smoking.
8.     Wait at least 2 -3 hours after eating before lying down.
9.     Elevate the head of your bed with a foam wedge or use bricks under head of bed for 2-4 inch elevation.  Be sure your chest and neck is higher than your stomach. A 45 degree angle is best.
10.            Take your reflux medicine exactly as prescribed. Be sure it is at least 30 minutes prior to eating.
**Be sure to drink the required number of oz. of water daily. Body weight divided by 2.2 = oz. needed.
Take this simple test to determine if you may be experiencing LPR.
Within the last MONTH, how did the following problems affect you?
Circle the number that best represents the severity of the symptom
0 = No Problem 5 = Severe Problem
1. Hoarseness or a problem with your voice                         0 1 2 3 4 5
2. Clearing your throat                                                                 0 1 2 3 4 5
3. Excess throat mucous or postnasal drip                             0 1 2 3 4 5
4. Difficulty swallowing food, liquids or pills                          0 1 2 3 4 5
5. Coughing after you ate or after lying down                      0 1 2 3 4 5
6. Breathing difficulties or choking episodes                          0 1 2 3 4 5
7. Troublesome or annoying cough                                          0 1 2 3 4 5
8. Sensations of something sticking in your                           0 1 2 3 4 5
throat or a lump in your throat
9. Heartburn, chest pain, indigestion, or                                0 1 2 3 4 5
stomach acid coming up

If you require an antacid or taking an OTC PPI more that 2x week on a weekly basis and scored 13 points or higher, perhaps you need to have a LaryngealVideoEndoStrobscopy to further visualize the damage that may be caused by untreated LPR. Remember, those throat clears may be sign of something more serious that just a “nagging throat clear.” 
1 Belafsky PC, Postma GN, and Koufman JA. Validity and reliability of the reflux symptom index (RSI). Journal of Voice. 2002. 16(2): 274-277.

Submitted by Carleen F. Ozley, MS, CCC-SLP
Voice and Swallowing Therapist
ExcelENT of Alabama

Monday, March 18, 2013

Time for a Change

By: Warner Huh, M.D.

Since the end of World War II, Pap smear screening has markedly reduced the incidence and mortality of invasive cervical cancer in the United States, Canada, UK, Australia, and Western Europe. Interestingly, it’s one of the few widespread screening tests that have never been evaluated in a randomized clinical trial,yet it has undoubtedly forever changed women’s healthcare.

However, we may have reached the maximum benefit of Pap-based cervical cancer screening and have learned quite a bit about this diagnostic test in the last 20 years. Unfortunately, a single Pap smear has a false negative rate of 50% (yes, 50%!). That might be even higher in areas where prevalence of disease is low (i.e., an over-screened population or one with high HPV vaccination rates).

Counter to common belief, more Pap testing is not necessarily better for women. We have learned that over-screening, including annual screening, puts most low-risk women at considerable risk for unnecessary tests, procedures, and treatment. Some of this treatment may in fact jeopardize an individual woman’s future fertility and ability to carry a pregnancy to term. Thus, all professional societies, including the American Cancer Society, the American Society of Colposcopy and Cervical Pathology (ASCCP), the American Society of Clinical Pathology (ASCP), the American Congress of Obstetricians and Gynecologists (ACOG) as well as the United States Preventive Services Task Force (USPSTF), no longer recommend annual screening. Instead, women should start their screening at age 21, then be screened at three-year intervals with Pap testing alone from 21-29 years of age , and then at five-year intervals with Pap and HPV (provided that both results are normal). This is a marked departure from the age-old adage that women have learned, “Get your yearly Pap smear,” but it’s based on a high level of scientific evidence and correctly balances the benefits and risks of cervical cancer screening.

Testing for the human papillomavirus (HPV) has become an integral part of cervical cancer screening – we presently use it to figure out equivocal Pap smears and in conjunction with Pap smears in women less than 30 years of age. Persistent infection with HPV is a major risk factor for cervical cancer, and essentially all cervical cancers have identifiable DNA sequences of HPV – in other words, the development of cervical cancer without a preceding persistent HPV infection is exceedingly rare.

HPV testing has been shown to have a much higher sensitivity than Pap-based testing. More specifically, numerous trials have demonstrated a sensitivity in the mid to high 90% range (false negative rates of less than 5%). In fact, there have been eight randomized controlled trials (which included more than 270,000 women) that clearly demonstrate that HPV testing outperforms Pap testing for the detection of cervical pre-cancer and cancer.

At the recent 2013 Society of Gynecologic Oncology Annual Meeting on Women’s Cancer in Los Angeles, end-of-study results were presented on the recently completed ATHENA trial (Addressing the Need for Advanced HPV Diagnostics) by Dr. Thomas C. Wright from Columbia University. (As disclosure, I served as senior author on this abstract and this study was funded by Roche Diagnostics.) This is the largest prospective registration study in the area of HPV diagnostics in the United States with more than 42,000 women enrolled.  At the end of the three-year follow-up period, here is what we learned: 1) The incidence of cervical pre-cancer and cancer in women who were HPV negative was a little more than half that of women who were Pap negative- these results indicate that HPV testing is superior to Pap testing for cervical cancer screening in a well-screened population, and 2) Testing with both Pap and HPV (as currently recommended) provides minimal benefit over HPV testing alone.

The bottom line is that these results are consistent with the other eight randomized controlled trials, all of which have been done outside of the U.S. So, these results were much needed to understand the value of this type of testing in a U.S. population.  Parts of Europe have started to embrace this concept of primary HPV screening, but unfortunately, we are well behind them. 

Although I do personally understand that it’s hard to imagine transitioning from a women’s healthcare standard like Pap testing (we may not like to admit it, but much of women’s healthcare revolves around the Pap test), it’s hard to ignore the facts. Why would we want to use a test that is less sensitive, particularly in the cancer screening setting, in lieu of one that picks up more disease and clearly outperforms the other?

It’s time for a change. The real question is whether we are ready for it.

Warner Huh, M.D., is a professor in the UAB Division of Gynecologic Oncology and a senior scientist in the UAB Comprehensive Cancer Center. He is a nationally recognized expert in the research and treatment of gynecologic cancers, with a particular emphasis on cervical cancer and the effects of the human papillomavirus.

Thursday, March 14, 2013


by Saritha Uppala, MD

Obesity has reached epidemic proportions in the United States.  In Alabama, among residents age 18 and older, 69 percent are overweight with a Body Mass Index (BMI) of 25 or greater ; 32.2 percent are obese, with a BMI of 30 or greater.  This puts Alabama in fourth place for the state with the highest obesity rates. By 2030, 62.6 percent of adult Alabamians will be obese, nearly double the 32 percent in 2011.

Many of us think obesity and overweight are simply due to an energy imbalance; therefore it seems logical to advise “just push yourself away from the table and join a gym.” However, many other factors should be considered– food, environment, socioeconomic status, family structure variation, community dynamics, health care, genetic influence and metabolic problems. Fast foods have been a large contributor and supersizing makes the situation worse. For example, drinking one soda a day for a year (150 calories) will add 15 extra pounds. Just to burn the calories in a single, plain pack of M&M candy, one has to walk the entire length of a football field (100 yards).

Obesity related disease starts early – BMI 24(women), 28 (men). It has been estimated that over 300,000 deaths per year in America are attributable to obesity, making it the second most frequent preventable cause of death (after tobacco smoking).

Obesity is linked to cardiovascular disease (coronary heart disease, hypertension, myocardial infarction, congestive heart failure, and stroke), diabetes, and various types of cancer, as well as many other health problems. An increase in BMI from <25 to >30kg/m2 is associated with an increased prevalence of hypertension from 15 percent to 40 percent. For one unit increase in BMI increases the prevalence of congestive heart failure by 5 percent, gallstones by 5-11 percent, hemorrhagic stroke by 6 percent. Weight loss in obese patients associated with decrease in 4 mm Hg systolic and 2 mm Hg diastolic per Kg of weight reduction, similar benefits noted in osteoarthritis, obstructive sleep apnea, diabetes, and may improve depression in many individuals.

Obesity is a medical condition with numerous co-morbidities and deserves to be approached as a serious health threat. Overweight patients deserve competent, nonjudgmental, ompassionate, and comprehensive treatment by medical personnel willing to take the time and have the patience to see them through a long –term treatment regimen, particularly in those whose weight is creating major social or emotional challenges.

There are many diet options that work but the right one to use will depend on the individual patient. Each obese patient is different and Heterogeneity exists among those who are overweight and obese. A traditional, low-fat diet may be particularly ineffective for weight loss for those with insulin resistance, which explains the substantial variability in weight loss success among different individuals trying to follow the same diet. We strongly believe that treatment plan should be individualized.

With that in mind, the physicians of Medicine Montclair are now offering a weight loss program entitled “Aim for Healthy Weight.”  This program is completely focused on an individualized treatment plan that assesses the readiness of the patient to lose weight, evaluates the patient to better understand their current lifestyle, analyzes the cause of excess weight, and investigates specific abnormalities in lab tests that can identify co-morbidities associated with obesity.

“Aim for Healthy Weight” allows the physician to work closely with the patient to set realistic goals for weight loss, maintenance of weight loss and prevention of weight gain. 

While we can’t promise miracles, we can strive to better understand the problem and issues facing the patient and establish a sensible approach that will have a better than even chance at success.


Dr. Saritha Uppala

Medicine Montclair – Trinity Medical Center

Fellow, American Society of Bariatric Physicians,

Board certified in American Board of Obesity Medicine

Board certified in Internal Medicine

Monday, March 11, 2013

Prevention and Treatment of Heart Disease

By: Dr. William Fonbah
Medical West Hospital

Most of us walk around every day without giving much thought to what keeps us going. Heart disease just doesn't happen to "other people" - it is something that all of us need to give attention to. I'm sure you've heard about it before, but heart disease remains as the number one killer in the United States. Think about that. It plays a major role in the way our world operates - be it on personal relationships or professional life. People get sick, miss work, have to leave certain positions because of stress… on and on.

If you've never had one, you may find it hard to believe that there are times when a person doesn't realize that they've had a heart attack. They just think that it's something else, and if they just sit down or wait a minute, the pain/discomfort will go away. It's important to note that not all heart attacks are the same - and multiple symptoms make it more likely that you are having a heart attack.

Signs & Symptoms of a Heart Attack

1) Chest pain or discomfort (most common) - this is where some people can get confused, thinking it's just a bad case of heartburn or indigestion. But if it doesn't go away, it can be a sign of a heart attack.

2) Discomfort in one or both arms, the back, upper part of stomach, neck, or jaw.

3) Nausea, vomiting, sudden dizziness, cold sweats, light-headedness

4) Shortness of breath

5) Fatigue

Risk Factors

Of course, it's best just to not have a heart attack. Here's what can put you at risk for heart disease:

1) Smoking

2) Overweight/Obese

3) Unhealthy diets with excessive trans fats, cholesterol, saturated fat, and sodium

4) Lack of exercise

5) Diabetic

6) High blood pressure

7) HIgh blood cholesterol

All of the above are things that you can take action on. Unfortunately, there are also a few things that you can't do anything about:

1) Age. Risk rises for men after 45, and women after 55 or after menopause

2) Family history of heart disease


As stated before, many risk factors are actionable. Stop smoking, for instance. Put down the second twinkie. But that's stuff you know. Some other tips on how to better side step heart disease:

1) Eat variety of fruits, vegetables, and whole grains. Lean meats are good, too. Poultry, beans, low-fat milk, and fish. Stay away from those added sugars, sodium, cholesterol, etc.

2) Be physically active. Walk up the stairs instead of the elevator. Go on walks, runs, bike rides - whatever is best for you. Talk to your personal physician about an exercise program that will work for you. (And try to make it fun or challenging - keep your mind preoccupied from the work involved.)

3) Maintain a healthy weight. This is a combination of the two above - but it's important to know that the extra weight you carry around puts additional stress on your body, and if you've got high cholesterol, the risk of clogged arteries increases. So extra stress + clogged arteries = bad news.


In the instances when a person has had a heart attack, we are fortunate in that technology and research are giving us more and more tools to help people get back to regular life after the attack.

1) Clot Busters - they have a fancier name, but that is what they are. They dissolve blood clots that block coronary arteries. Best used within several hours after the beginning of heart attack symptoms. The sooner, the better.

2) Angioplasty - the balloon in your arteries. We use this to press built-up plaque in the arteries and restore blood flow.

3) Beta blockers. These decrease workload on the heart and help to prevent repeat heart attacks.

4) Anticlotting medicines are used to prevent platelets from combining to form blood clots.

5) Anticoagulants - blood thinners.

6) ACE inhibitors to work on lowering blood pressure and reducing heart strain.

7) Bypasses. Take a healthy artery in the body and use it where it is needed.

In treatment, it is extremely important that the patient follows the doctors orders. Too many anticoagulants or beta blockers can cause problems as well. Because everyone is different, medical staffs take great care in preparing the treatment combination for you as an individual. What works for one person may not for another. In short - follow your doctor's orders.

Know that heart disease is a major part of our society. But we can work to make ourselves healthier and be better prepared to avoid and/or treat heart disease. Do what you can to make yourself healthier.

- Dr. William Fonbah

Monday, March 4, 2013

Change and Opportunities

By: Bill Cockrell
Cockrell and Associates, LLC

When I got into healthcare management 32 years ago (yeah, I’ve been around), Medicare paid based on your usual, customary and reasonable (UCR) fee schedule, not a system based on relative value units and a “sustainable growth rate (SGR)”.  Indeed, that was a time when you charges meant something beside what you base your contractual write off’s on.  Malpractice claims were around but were relatively rare.  We weren’t dealing with EMR’s, HIPAA, Stark Law, HMO’s, PPO’s, ACO’s or many of the other issues that face us today.  I thought, at the time, this is the easiest job in the world, the doctor sees the patient, the patient appreciates it and follows the doctor’s direction, we bill the patient who, usually, paid the bill and then collected from the insurance company themselves.


Today, we have The Accountable Care Act or ACA, multiple payer models, a world where we can charge what we want (and nobody cares, they pay based on their fee schedule), the Hitech Act, OIG scrutiny, RAC audits and all those other acronyms listed above.  We have the annual battle over what to do about an increasing SGR cut (despite hopes to see a true fix in 2013).  We work in an environment where everything is questioned by an increasing army of watchdogs.  We’re forced to document and share more information than ever before and there are people actually watching what we say, We have The Commonwealth Fund reporting through their web site and CMS rolling out their Physician Compare website and other grading systems.  Added up there are plenty of things to deal with, but is it all bad? 


The facts are we cannot maintain the spending pace we see, even though overall spending in healthcare is growing at a slower rate.  If we are honest with ourselves, we can all see situations where the current delivery system of medicine is ineffective.  Providers are rewarded on a transaction basis – the more they do, the more they get paid.  Specialties compete with each other for higher payments because, if we can’t increase the funds available, the only place for money to come from is from someone else. 


The result of all of this is that providers have to find better ways to coordinate care for the long term.  I still run into providers who are unwilling to “bite the bullet” and install an EMR (they are going to get left behind because they will be at a “competitive” disadvantage compared to their colleagues).  That competitive disadvantage comes in the form of overall quality limitations and higher costs.  This may not be on an individual physician basis but on the level of comprehensive care for an individual patient where we really can reduce costs by eliminating duplicate testing.   It’s also not good enough to claim “my patients are sicker” so I should be paid more.  The question is, can you prove it.  When a provider files an insurance claim, how many diagnoses do they enter?  Is it all, or many of, the diagnoses related to that patient or are they just the ones required for payment for that visit.  Yes, it’s more paperwork (or less if you really use an EMR) but it gives a better picture of what is going on with that patient.


New payment models designed to take care of patients over a longer period of time are being developed every day.  The growth of Accountable Care Organizations (ACOs), which I originally questioned, shows the focus on quality and cost over an initial three year period.  Patient Centered Medical Homes (PCMH) focus care on the patient over extended periods of time.  Reduced readmissions reduce costs and save lives because, hopefully, those readmissions are reduced because we did a better job up front.The problem is we live in a time where we want to feel gratified (paid) now.  Whether it is quarterly or annual bonuses or other rewards few deal with results from long term success.  MGMA’s Connexion Magazine summarizes ACO shared savings as “Share rate x (expected expenditures – actual expenditures) x quality multiplier = realized shared savings” (November / December 2012 edition).   The article goes on to point out that the problem is the quality measures have a long term focus.  Of the 33 measures only six (readmission rates, ambulatory-sensitive condition admission rates, medicine reconciliation, screening for falls and vaccinations) can be expected to generate short term savings.  And, once again, that frustrating documentation issue is part of the equation.


So, all that said, when you look at where things are, we can oppose all change or we can pick the best parts, work to implement them, and fight those parts which might not really be in the best interest of the patient but might look good politically.  Providers need to work together to make sure the best care is delivered and not as individual groups who are protecting their own turf.  If the providers don’t do it, someone else will, and they might not be the best ones to decide these things and we don’t need bureaucrats making healthcare decisions.Unless a provider is planning on retiring in the next couple of years, it’s time to add long term thinking to our existing short term processes.


So, in the final analysis, we can focus on fighting all change or we can adopt the opportunities that exist for improvements in the healthcare delivery system.  And, if providers really take the lead, some good things might really happen.