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Education

"Knowledge is Power"     "Know Your Enemy"                    "Resolve Brings Results”

Weight loss is much easier with a friend.

We are your friends, and wish to hear from you. For example below, we have set-up email interactive communications for you to provide "Budget Watchers" menus for lower calorie entrees, deserts, and beverages. We wish to post your effective ideas about smart stress management from common home confrontations, to critical money and work-related problems.

Just follow the drop box and we will post your group suggestions onto existing web pages or even develop new sections. Please also consider improving our current message. Be specific if possible.
 

We're all are seeking SUCCESS!!!

Slimmer Success Founder

Cary Fechter, M.D.

 

 * National Keynote speaker on Adult and Childhood Obesity since 2001

* Behavioral Modification Physician since 1983

*Founder of the National Student Body Challenge – A broad spectrum approach to the many factors that lead to childhood obesity

* American Diabetic Association advocate for a multi-factorial approach to reversing the obesity and diabetic epidemic


 

 

 

 

 

 

 

Disclaimer: An entire medical management section is presented below which discusses the need to reverse medical complications which may have already developed in the very obese.

It is intended to help the primary care provider to recognize the causes of obesity and the advantages of early intervention. It represents the opinion of Slimmer Success and must be discussed with your provider to confirm that such information applies with your condition.

By request, it is included in the education section and may, in part, be overly complex for the non-medical provider.

THE VERY OVERWEIGHT PATIENT (BMI> 33)
CLIFF NOTES REFERENCE MANUAL and SMART SHEET for COMPLIANCE

presented by


"RECROSSING THE LINE"

There are Weight-Related Conditions
So serious that your patient is too sick to exercise at all or sustain a diet.
This program recognizes morbid conditions that must be corrected
in order to successfully re-cross that unfortunate line.

Weary and frustrated, a bedridden patient in a nursing home in Millersville, Md. Pulmonary hypertension, sleep apnea, cardiac disease, hypoventilation syndrome, ALL spiraling toward an obvious fateful outcome.

 

 

 

 

                             Your patients may be frustrated and overweight, but still have a a                           chance to control their obesity, if effective measures are started before their spiral begins.

 

ALSO PRESENTED BY

A HEALTHY MEDICAL APPROACH TO SUSTAINED WEIGHT LOSS

for the pursuit of "Your ideal" figure

CONTENTS
ABOUT US: PAGE 2

CAUSES:
OBESITY-RELATED CONDITIONS BY FREQUENCY IN THE USA
PAGE 3

THE BASIC CAUSES OF WEIGHT GAIN PAGE 3

MAJOR MEDICATIONS- BY CLASSES AND ALPHABETICALLY PAGE 5

DIABETIC MEDICATIONS THAT WORSEN WEIGHT GAIN PAGE 6

 

MEDICATION MANAGEMENT:
SUMMARY OF THE ORAL DIABETIC MEDICATIONS
PAGE 6
SUMMARY OF THE INSULIN PREPARATIONS
PAGE 7
SUMMARY OF LIPID MEDICATIONS AND MANAGEMENT
PAGE 8-9
The S.M.A.R.T. COMPLIANCE © SHEET
PAGE 10
HEART SMART DIET
P. 12
GENERAL EDUCATION:
THE METABOLIC SYNDROME (Insulin Resistance Syndrome)
PAGE 14
OBESITY HYPOVENTILATION AND PULMONARY HYPERTENTION
PAGE 115
OUR FAVORITE FREE ON-LINE HEALTH CALCULATORS
PAGE 15


"RE-CROSSING THE LINE"
SUGGESTED TESTING INCLUDES:

CARDIO-PULMONARY STRESS TESTING

FOR EXERCISE CAPABILITY , EXERCISE AND DIET PRESCRIPTIONS-

SLEEP-RELATED DISORDERS/LAB- AASM certified sleep lab

PFT’S AND ECHOCARDIOGRAMS FOR PULMONARY HTN, OBESITY- INDUCED ASTHMA- if indicated

VASCULAR STUDIES- if indicated ( hypercholesterolemia, OR symptoms)

LIPID, DIABETIC, AND THYROID TESTING * on site, or your lab if requested

Stressing lifestyle changes, exercise, reduced intake, and motivation ( see www.slimmersuccess.com/programsteps )

Educational CD’s Web-site support Lifestyle contracts

On-site exercise equipment

Fractional cost meal replacements via direct-internet sales

Our favorite diet plans: South Beach, Adkins, Nutri-systems, and Healthy Choice

We even offer contracted discounts to local fitness centers

Page 2

 

 

Our founder is a cardio-pulmonary specialist AND national speaker who employs the safest-most effective management as defined by
American Heart Association & The American Diabetic Association.

SECTION ONE

CAUSES OF OBESITY- BY FREQUENCY

Medical Conditions that Cause Obesity that are Very Common

The following causes of Obesity are diseases or medical conditions that affect more than 10 million people in the USA:

Depression         Diabetes

Dysthymia              Metabolic Syndrome

Premenstrual Syndrome       Thyroid disorders

 

Medical Conditions that cause Obesity that are common

The following causes of Obesity are diseases or conditions that affect
 
more than 1 million people in the USA:

Autoimmune thyroid diseases           Binge eating disorder

Bipolar disorder          Cancer – edema, effusions, etc.

Congestive Heart Failure    Eating disorders   Polycystic ovarian syndrome

Causes of Obesity that are less common The following causes of Obesity are diseases or conditions that affect more than 200,000 people, but less than 1 million people in the USA:

Klinefelter’s syndrome - rounded body type

Postpartum depression - weight gain

 Causes of Weight Gain by Category

Eating more

o Overeating Pregnancy

o Recent childbirth - retaining weight after giving birth

o Aging – often due to changes in activity and metabolism.

o Appetite changes

o High-fat diet High-carbohydrate diet Excessive snacking

o

Page 3

o Sedentary lifestyle

o Reduced exercise or activity level

o Quitting smoking - or other type of tobacco withdrawal

o Rebound after prior dieting Comfort eating Stress eating

Depressive disorders - some people eat more (some eat less)

Several mental illnesses- such as bi-polar disease with excessive appetite,

when in the manic phase

o Compulsive eating

o Genetic tendency to obesity - Familial obesity

· Water retention - retaining fluid rather than true weight gain.

o Premenstrual bloating
Edema -

o Congestive heart failure Kidney failure Nephrosis

o Cirrhosis of the liver

Lymphatic obstruction

Hormonal conditions

o Hypothyroidism Growth hormone excess AND Growth hormone failure

· PCOS-Poly cystic ovarian syndrome

· Hypopituitarism Excessive Androgens

Postmenopause Orchidectomy Hypogonadotrophic hypogonadism

Non-pathological conditions

· Smoking cessation Pregnancy Athletes-Weightlifters in particular

 

Medications or Substances That Cause Weight Gain

 (by class-with examples)

PSYCHOLOGICAL

· Depression and Anti-Depresants-Wellbutrin appears to have the least weight gain

· Mania

· Sedatives such as Clonazepam

NEUROLOGICAL ANXIETY /DEPRESSION

Gabapentim Ambilify

Dilantin

ANTI-HYPERTENTIVES

Calcium blockers

DIABETIC MEDS
 In general, most oral diabetic medications , except Metformin and Januvia, cause weight gain.

  • Byetta, our favorite weight-related medication should be given AFTER oral diabetics have failed. Byetta is associated with WEIGHT LOSS-but is more expensive (managed care plans typically cover the cost)
     INSULINS are generally associated with weight gain
  • STEROIDS Cortisteroids Estrogens Androgens

    Page 4

     

    ALPHABETICALLY

    The Most Common Medications that Cause Obesity

    Compiled by Dr. Cary E. Fechter-Slimmer Success and Re-Crossing the Line of Charleston

    Ambilify                                                     Danazol                                         Medroxyprogesterone

    Actos                                                      Depakote                                       Megace

    Aldazine                                                 Depo Provera                                Megestrol

    Aldomet                                                 Desyrel                                           Melleril

    Aller-Chlor                                             Detrol LA                                       Methyldopa
    Alpha-Baclofen                                     Dexmethsone                                Minoxidil

    Amen                                                     Dilantin                                          Mircette

    Amodopa                                               Dimetapp                                       Mirena

    Anabolic Steroids                                   Doxazosin                                     Mirtazapine     Androgens                                                      

    Apri                                                         EFFEXOR-PROBABLY NOT!!           Neurontin

    Aripiprazole                                            Elavil                                               Neurotonin

    Aristocort                                                                                                      Norethisterone
    Astemina                                                Estrofem                                         NSAIDs
                                                                   Estrogen

    Atarax                                                     Etanercept                                       Oestradiol

    Atozine                                                   Ethinyloestradiol                             Olanzapine

    Avandia                                                  Ethyloestrenol                                 Oral contraceptive pills

    Avanza                                                   Etonogestrel                                    Orasone

    Baclo                                                      Flomax                                              Paxil

    Baclofen                                                Florinef                                              Perphenazine

    Baclohexal                                            Fluphenazine                                   Phenothiazines

    Biphasil                                                 Follicle Stimulating Hormone          Phenylbutazone

    Brevicon                                                                                                          Prednisone
    Bromaline Elixir                                                                                              Propranolol

    Bromatapp                                           Gabapentin                                         Provera

    Bromphen                                            Gapapentin                                         Prozac

    Brompheniramine                                Gleevec                                              Rectinol HC                     

    Cardura                                                Hydrocortisone                                  Redipred

    Catapres                                              Hydrocortone                                     Regaine

     Celestone                                            Hydroxyzine                                      Remeron

     Celexa                                                  Hysone                                             Risperdal 

     Cerebyx                                               Hytrin                                                 

     Chlorate                                                                                                        Seroquel

     Chlorpheniramine                                Insulin                                              Stelazine

     Clonazepam                                        Keppra                                             Terazosin

    Clonidine                                             Klonopin                                             Testomet

    Clorazepate Dipotassium                                                                               Thiethylperazine

    Clozapine                                            Levetiracetam                                     Thorazine

    Cortef                                                  Levodopa                                             Tibolone

    Cyclomen                                            Levonorgestrel                                   Tranxene

    Cyproheptadine                                  Lexapro                                               Tranylcypromine

    Cyproterone Acetate                          Lioresal                                               Trazodone

                                                               Liquorice                                             Tricyclic antidepressants

                                                               Lithium                                               Trileptal

                                                                                                                           Valproic Acid (Depacote)

                                                              Luvox                                                   Vistaril                Zyprexa                                                                                                         

     

     

    Page 5

     

     

    Oral Diabetic Medications

    Category Action Generic Name Brand Name WEIGHT EFFECTS/Comments
    Chlorpropamide Diabinese Generally taken one to two times daily, before meals; can have interactions with other drugs. First generation sulfonylurea (older drug) Weight NEUTRAL
    Glipizide Glucotrol
    Glyburide DiaBeta/ Micronase/Glynase
    Glimepiride Amaryl
    Meglitinide Works with similar action to sulfonylureas Repaglinide Prandin Novo Nordisk Taken before each of three meals
    WEIGHT GAIN
    Nateglinide Works with similar action to sulfonylureas Nateglinide Starlix Taken before each of three meals WEIGHT GAIN
    Metformin Glucophage
    Metformin (long lasting) Glucophage XR
    Metformin with glyburide Glucovance
    Rosiglitazone Avandia
    Pioglitazone Actos
    Acarbose Precose
    Miglitol Glyset

    Page 6

     

     

    Byetta, our favorite weight-related type II medication is not insulin. It should be given AFTER oral diabetics have failed, but before beginning insulin (according AACE quidelines). Byetta is associated with WEIGHT LOSS as opposed to weight gain (managed care plans typically cover the increased cost). It uses a much smaller injectable needle, but, again, is NOT an insulin.

    Insulin Preparations
    Which insulin to choose is based on an patient's lifestyle, your medical preferences and experience, and the patient's blood sugar levels. Among the criteria considered in choosing insulin are:

    · how soon it starts working (onset)

    · when it works the hardest (peak time)

    · how long it lasts in the body (duration)

    Since 1982, most of the newly approved insulin preparations have been produced by inserting portions of DNA ("recombinant DNA").. The following table lists some of the more common insulin preparations available today. Onset, peak, and duration of action are approximate for each insulin product, as there may be variability depending on each individual, the injection site, and the individual's exercise program.

    Type of Insulin Examples Onset of Action Peak of Action Duration of Action
    Humalog (lispro)
    Eli Lilly
    15 minutes 30-90 minutes 3-5 hours
    NovoLog (aspart)
    Novo Nordisk
    15 minutes 40-50 minutes 3-5 hours
    Short-acting (Regular)

     

    Humulin R
    Eli Lilly Novolin R
    Novo Nordisk
    30-60 minutes 50-120 minutes 5-8 hours
    Humulin N
    Eli Lilly Novolin N
    Novo Nordisk
    1-3 hours 8 hours 20 hours
    Humulin L
    Eli Lilly Novolin L
    Novo Nordisk
    1-2.5 hours 7-15 hours 18-24 hours
    Intermediate- and short-acting mixtures Humulin 50/50
    and 70/30 Humalog Mix 75/25 and 50/50
    Eli Lilly Novolin
    70/30
    Novolog Mix 70/30
    Novo Nordisk
    The onset, peak, and duration of action of these mixtures would reflect a composite of the intermediate and short- or rapid-acting components, with one peak of action.
    Ultralente
    Eli Lilly
    4-8 hours 8-12 hours 36 hours
    Lantus (glargine)
    Aventis
    1 hour none 24 hours
             

     A Synopsis of Lipid Management

    Treatment Options High Cholesterol *Further comparisons and study is suggested, however the following is a time-saving physician’s tool. It is taken from the ADA, AHA, and other creditable sources intended to be a quick, smart guide to a challenging science which is now America’s foremost clinical problem in morbidity and mortality.
    Why be aggressive?
    Decreasing total cholesterol by 10% can result in a 30% reduction in coronary heart disease incidence.
    For every 1% decrease in LDL (bad cholesterol levels), heart disease rates drop 2%. On the other hand, for every 1% decrease in HDL, there is a 2 to 3% increase in the risk of heart disease.
    Patients with established cardiac disease and multiple risk factors (metabolic syndrome, diabetes, or smoking and COMPLIANCE ISSUES) are sometimes given more intense lifestyle changes. Diet and exercise are basic interventions, Healthier Choices’ goal is to summarize medication choices

    The decision to start a patient with dietary therapy or drug therapy is usually based on a patient's LDL cholesterol levels, presence of heart disease, and risk factors. Your doctor should calculate your "10-year risk" (also known as a Framingham Risks) for developing heart disease and use that risk estimation to decide if and when to start cholesterol-lowering therapy either through dietary modifications or medications.
    First think LDL not total cholesterol, though relative risks for each are reviewed above. Goal LDL level will also depend on the below listed factors. The following table illustrates guidelines

     

    Patient Category

    LDL LEVEL

    LDL Goal

    Without heart disease and

    with less than 2 risk factors

    LDL greater than 160 mg/dL start diet therapy

    + exercise

    LDL greater than 190 mg/dL start drug therapy

    (160 to 189 mg/dL: LDL-lowering drug optional)

    less than 160 mg/dL

    Without heart disease and

    with 2 or more risk factors

    with a 10- year risk less

    than 10%*

    LDL greater than 130 mg/dL start diet therapy

    + exercise
    LDL greater than 160 mg/dL start drug therapy

    less than 130 mg/dL

    Without heart disease and with

    2 or more risk factors with a

    10- year risk 10 to 20%*

    LDL greater than 130 mg/dL start diet therapy

    + exercise

    LDL greater than 130 mg/dL start drug therapy

    (LDL 100 to 129 mg/dL: drug therapy optional)

    less than 130 mg/dL

    (optional goal: less than

    100 mg/dL)

    With heart disease

    LDL greater than 100 mg/dL start diet therapy

    + exercise
    LDL greater than 100 mg/dL start drug therapy

    (LDL less than 100 mg/dL: drug therapy optional)

    less than 100 mg/dL

    (optional goal: less than 70

    mg/dL**)

    With Type 2 Diabetes Mellitus

    LDL greater than 100 mg/dL start diet therapy

    + exercise
    LDL greater than 100 mg/dL start drug therapy

    (LDL less than 100 mg/dL: drug therapy optional)

    less than 100 mg/dL

    (optional goal: less than 70

    mg/dL**)

    *10-year risk calculators are available at on DrugDigest under the ?Interactive Tools? tab.
    **In patients that are ?very high risk? (those with established heart disease and multiple major risk factors including diabetes, metabolic syndrome, and current smokers), a more aggressive LDL goal of less than 70 mg/dL may be encouraged

    Page 8

     

     

     

     

     

     

    Discussion
    For the initial drug treatment of hypercholesterolemia, HMG-CoA reductase inhibitors, "statins", are often used because of their effectiveness and low incidence of side effects
    . Currently, six statin drug classes are available. The choice of which to use will depend on how much cholesterol reduction is needed, your preferences (read below for help), and prescription insurance benefits

    Cholesterol absorption inhibitors are a new class of cholesterol lowering agents and work together with statins to lower cholesterol. This class of drugs works to lower blood cholesterol levels by absorbing excess cholesterol (from foods) in the intestines and thus blocking cholesterol's entry into the bloodstream. In a study published by the Mayo Clinic in May 2005, it was found that the addition of Zetia (a cholesterol absorption inhibitor) to statin therapy may cause a further reduction in a patient’s cholesterol levels. It is thought that this reduction may be the result of the two drugs working together but at different areas of the cholesterol production pathway. In fact, one pharmacy manufacturer combined Zetia with a commonly used statin known as Zocor. This combination product is called Vytorin. However, as with any medications, there can be conflicting data. A study released this year (2008) said that objective control of plaque formation in the carotids was NOT seen with Zetia.
    Beyond the basics: Cholesterol Subclasses –taken from Berkeley Heart Labs
    We now know that cholesterol can be broken down beyond just LDL and HDL. Within both LDL and HDL, there exist particles that vary in their characteristics and therefore in their risk (in the case of LDL) and protective (in the case of HDL) factors for CAD. A much better assessment of CAD risk is achieved by enlarging the spectrum of testing to includeadditional disorders, such as a predominance of small particles within the LDL family (small LDL trait), and low levels of HDL2b, the most heart-protective type of HDL.

    This more comprehensive approach can point to treatment that differs from traditional therapy and is more effective in slowing, halting, or reversing the progression of CAD.
    LDL particles contribute to the harmful buildup of fat inside artery walls, a process called atherosclerosis. The LDL particles contribute to atherosclerosis partly by slipping through the spaces between the cells of the artery0-wall lining and unloading their cargoes of cholesterol inside the wall. LDL particles floating in the blood of the same person vary in size and small particles penetrate the artery wall with relative ease! Making matters worse, they are also more susceptible to oxidation, a chemical process that intensifies the atherosclerotic activity of LDL.
    People with a predominance of small LDL particles have an increased risk of developing CAD and suffering a heart attack. The small LDL trait is found in 50% of men and postmenopausal women, and in 30% of pre-menopausal women with CAD. The small LDL trait is also present in 50% of their first-degree relatives, who may or may not have CAD symptoms.
    HDL particles, on the other hand, inhibit atherosclerosis in part by carrying cholesterol out of the arterial wall and, the liver, via the circulation, which can dispose of it. The process is called reverse cholesterol transport. HDL2b is the most active of all the HDL particles in such transport. The more HDL2b you have the better

    HMG-CoA Reductase Inhibitors

    HMG-CoA Reductase is a chemical made in our bodies that helps the liver produce cholesterol. HMG CoA reductase inhibitors get in the way of that process, reducing the amount and frequency of cholesterol being produced. These medications cause the greatest reduction in cholesterol at the lowest doses and are used in many individuals at high risk of heart disease, or to help prevent those that have had a heart attack or stroke from having another one.
    Drugs in the class
    Atorvastatin (Lipitor) Lovastatin (Mevacor) Fluvastatin Extended-Release (Lescol XL) Fluvastatin (Lescol) Rosuvastatin (Crestor) Simvastatin (Zocor) Lovastatin Extended Release (Altocor, Altoprev) Pravastatin (Pravachol)
    Cerivastatin - Withdrawn From The Market (Baycol - Withdrawn From The Market) Cholesterol Absorption Inhibitors

    Drugs in this class work to lower blood cholesterol levels by absorbing excess cholesterol (from foods) in the intestines and thus blocking cholesterol entry into the bloodstream.
    Drugs in the class
    Ezetimibe (Zetia)- see carotid study results discussed above-this drug has a generally very low side-effect profile and continues to be prescribed by cardiologists and other physicians.
    Page 9


    Anti-lipidemic Agents How niacin lowers cholesterol levels is not well understood, but it seems to inhibit production of VLDL, and significantly lowers levels of triglycerides (primary indication) as well as LDLs. Niacin can also raise levels of HDL, the good cholesterol. Fibric acid derivatives affect the breakdown of body fats and reduce the amountof triglyceride manufactured by the liver. A very common side effect called ?flushing? (redness, burning,
    and tingling of the skin) causes may individuals to stop using this medication.
    Drugs in the class

    Niacin (Niacor, Nicolar, Nicotinic Acid)

    Bile Acid Resins Particles made up of bile and fat are reabsorbed by the small intestine, go into the blood, and travel directly to the liver where the bile is recycled. Bile acid resins absorb bile acid in the intestinal tract rather than let it be reabsorbed and reused by the body. This decrease in bile causes the liver to produce more bile. Since the liver uses cholesterol to produce bile, bile acid resins reduce cholesterol levels in the blood stream. Use of bile acid resins is a conservative approach to treating high cholesterol because the drug's action is limited to the intestinal tract. However, because they are known to be safe and have few side-effects, they are used to treat patients with moderately elevated LDL- cholesterol, in people who do not already have heart disease, and when drug therapy is necessary in young adult men and premenopausal women. They are also used in combination with other drugs (such as statins) to treat more severe forms of hypercholesterolemia.

    Drugs in the class

    Colesevelam (Welchol)
    Colestipol (Colestid)
    Cholestyramine Powder for Suspension (Prevalite, Questran, Questran Light)
    Combination HMG-CoA Reductase and Cholesterol Absorption Inhibitors
    This class combines the most potent cholesterol reducers (HMG-CoA reductase inhibitors statins) with another cholesterol lowering medication (Cholesterol Absorption Inhibitors) in one tablet to give those who take it that extra decrease in cholesterol they may not be able to achieve with one of the medications alone.
    HMG-CoA reductase is a chemical made in our bodies that helps the liver produce cholesterol. HMG-CoA reductase inhibitors get in the way of that process, reducing the amount and frequency of cholesterol being produced.Cholesterol Absorption Inhibitors block cholesterol found in food from being absorbed into the blood stream from the intestinesThe combination works by blocking cholesterol production by the body and well as blocking absorption of cholesterol from the food we eat.
    Drugs in the class
    Ezetimibe and Simvastatin (Vytorin)
    Treatment Options Elevated Triglyceride Levels
    Fibric acid derivative or niacin may be most effective. Both medications work by decreasing the liver's production of triglycerides.
    Additionally, fibric acid derivatives (or "fibrates") such as gemfibrozil also increase HDL-C production.
    Clofibrate (No Longer Available) (Atromid-S (No Longer Available))
    Fenofibrate (Micronized) Capsules (Antara, Lofibra)
    Gemfibrozil (Lopid)
    Fenofibrate Tablets (Tricor, Triglide)

     

     

     

    Page 10

     

    The S.M.A.R.T. Compliance Sheet

    Selecting Medications by Attitude Review Typing

    The SMART Sheet helps you choose medications consistent with your patient’s attitude. As you know, efficacy is the physician’s first choice, but realistically other factors too often ultimately dictate compliance… which ultimately dictates HEALTH!!!!

    Here’s a "rough" sequence of diabetic, lipid, and blood pressure medications in order of

    Cost and Significant Side Effects

    The following lists are from pharmacists, internists, and endocrinologists and do not favor any manufacturers and are NOT, in total, the opinions from the ADA, AMA ,AHA or official group-since they aren’t "allowed" to do it.

    Nonetheless, it is very informative, helpful, and we have made it as objective as possible (though a standard medical disclaimer makes final decisions the primary care provider’s responsibility).

    DUE TO THE SIZE OF THE SMART COMPLIANCE DRUG LIST, IT IS AN ATTACHMENT TO OUR CLIFF NOTES EDUCATIONAL BOOKLET.

    THE LISTS ARE ORGANIZED AS FOLLOWS AND CAN BE DOWNLOADED AT WWW.SLIMMERSUCCESS.COM/SMARTCOMPLIANCE

    Diabetic Rx

    Cost

    Average Wholesale Price US dollars from the FDA ( most efficacious meds per American Diabetic Association)

    Insulin Independent, Type II Diabetes

    Mild Diabetes

    Moderate Diabetes

    Severe Diabetes

    Insulin Dependent Diabetes (Insulins listed above)

    Side Effects

    Listed by the most common side effects that typically influences the choice of the more common diabetic medications (5% or greater incidence above placebo)

    Hypercholesterolemia Rx
    Cost

    Mildly Increased LDL
    Moderately Increased LDL

    Severely Increased LDL
    Side Effects

    Listed by the most common side effects that typically influences the choice of the more common cholesterol medications (5% or greater incidence above placebo)

     

     

     

    The S.M.A.R.T. Compliance Sheet (continued)

    Anti-Hypertensives-list from Joint National Commission 7 (JNC 7)

    Cost

    Mildly Increased
    Moderately Increased

    Severely Increased
    Side Effects

    Listed by the most common side effects that typically influences the choice of the more common anti-hypertensive medication (5% or greater incidence above placebo)

    The questionnaire first educates the patient as to the seriousness of uncontrolled diabetes , HTN, or hypercholesterolemia, before they begin answering their attitude results. It is a teaching tool for your patients to understand the benefit versus risk (side effects) that you, the caregiver consider with every prescription.

    The questionnaires are given to waiting room patients, and determine if they are low, moderate, or high cost conscious OR have a low, moderate, or high concern about side effects. A scoring average will help the physician match the attitude with an efficacious medication.

    An aspect of the educational value of the survey is an explanation that side effects may be transient or potentially permanent; or be "minor" such as muscle weakness, or life- threatening, therefore questions consider severity a primary consideration.

    Unfortunately, in our experience, money-which includes even travel distance and gas costs affect doctor visits and even purchasing crucial medications. We are discussing an "ad hoc" survey of lifestyles, and priorities to realistically recognize other true/personal obstacles to health care which we see daily.

    Note: Convenience is left to you, the provider. Review your patient’s current regimen-is he on BID meds, aversion to tastes, pill sizes, needles, etc. and

    Potential drug-drug interactions are numerous and will be reported as potentially dangerous by practically all of the American pharmacies-who will be asked to modify your prescription.

    The point-scale attitude questionnaire has been very helpful in initial development. It needs to be updated only when insurance plans change, or, for personal reasons, attitudes have changed-we suggest annual updates.

    We have begun the software-programming of the questionnaire and results. But the complexity of scanning the results and calculating scores, so far has been expensive, cumbersome, and requires special equipment. We believe this paper-based system is effective, for now.

    Heart-Healthy Diet for the High Cholesterol Patient-

    A great handout

    Learn how to eat a heart-healthy diet and reduce your risk of heart disease.

    By paying close attention to what you eat, you can reduce your chance of developing atherosclerosis, the blocked arteries that cause heart disease. If the artery-clogging process has already begun, you can slow the rate at which it progresses. With very careful lifestyle modifications, you can even stop or reverse the narrowing of arteries.

    While this is very important for everyone at risk for heart disease, it is even more important if you have had a heart attack and/or procedure to restore blood flow to your heart or other areas of your body, such as angioplasty, bypass surgery or carotid surgery. Following prevention advice can protect against restenosis, or the re-narrowing of your arteries.

    Page 12

     

     

    Feed Your Heart Well

    Feeding your heart well is a powerful way to reduce or even eliminate some risk factors. Adopting a heart-healthy diet can help reduce total and LDL cholesterol (the "bad" cholesterol), lower blood pressure, lower blood sugars, and reduce body weight. While most dietary plans just tell you what you CAN'T eat (usually your favorite foods!), the most powerful nutrition strategy helps you focus on what you CAN eat. In fact, heart disease research has shown that adding heart-saving foods is just as important as cutting back on others.

    Here are 5 nutrition strategies to lower your cholesterol and reduce your risk of heart disease:

    1. Eat more vegetables, fruits, whole grains and legumes. These wonders of nature may be one of the most powerful strategies in fighting heart disease.

    2. Choose fat calories wisely. Keep these goals in mind: Limit total fat grams; Eat a bare minimum of saturated fats and trans-fatty acids (for example, fats found in butter, salad dressing, sweets and desserts); When you use added fat, use fats high in monounsaturated fats (for example, fats found in olive and peanut oil).

    3. Eat a variety -- and just the right amount -- of protein foods. Commonly eaten protein foods (meat, dairy products) are among the main culprits in increasing heart disease risk. Reduce this nutritional risk factor by balancing animal, fish and vegetable sources of protein.

    4. Limit cholesterol consumption. Dietary cholesterol can raise blood cholesterol levels, especially in high-risk people. Limiting dietary cholesterol has an added bonus: You'll also cut out saturated fat, as cholesterol and saturated fat are usually found in the same foods. Get energy by eating complex carbohydrates (whole wheat pasta, brown or wild rice, whole-grain breads) and limit simple carbohydrates (regular soft drinks, sugar, sweets). If you have high cholesterol, these simple carbohydrates exacerbate the condition and may increase your risk for heart disease.

    5. Feed your body regularly. Skipping meals often leads to overeating. For some, eating five to six mini-meals may help keep cravings in check, help control blood sugars and regulate metabolism. This approach may not be as effective for those who are tempted to overeat every time they are exposed to food. For these individuals, three balanced meals a day may be a better approach.

    Other Heart-Healthy Strategies:
    Reduce salt intake. This will help control your blood pressure.
    Exercise. The human body was meant to be active. Exercise strengthens the heart muscle, improves blood flow, reduces high blood pressure, raises HDL cholesterol ("good" cholesterol), and helps control blood sugars and body weight.
    Hydrate. Water is vital to life. Staying hydrated makes you feel energetic and eat less. Drink 32 to 64 ounces (one to two liters) of water daily (unless you are fluid restricted).
    Enjoy every bite. Your motto should be dietary enhancement, not deprivation. When you enjoy what you eat, you feel more positive about life, which helps you feel better and less likely to overindulge.

     

    The Metabolic Syndrome
    (Insulin Resistance Syndrome)
    PAGE 13

    Characteristics according to The American Heart Association
    Central obesity (excessive fat tissue in and around the abdomen)- Elevated waist circumference: Men: Equal to or greater than 40 inches (102 cm) Women : Equal to or greater than 35 inches (88 cm)

    · Dyslipidemia (blood fat disorders — mainly high triglycerides (Equal to or greater than 150 mg/dL) and Reduced HDL ("good") cholesterol: Men — Less than 40 mg/dL Women — Less than 50 mg/dL Insulin resistance or glucose intolerance (the body can’t properly use insulin for blood sugar) Elevated fasting glucose: Equal to or greater than 100 mg/dL (5.6 mmol/L) or use of medication for hyperglycemia Hypertension (130/85 mm Hg or higher)
    Some studies include:
    Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor)Proinflammatory state (e.g., elevated C-reactive protein)
    CAUSES overweight/obesity physical inactivity genetic factors RESULTS coronary heart disease type 2 diabetes stroke and peripheral vascular disease
    Obesity is now more serious than smoking and is very treatable. Management should NOW be a major goal for every great physician.

    Obesity Hypoventilation Syndrome

    The obesity hypoventilation syndrome, also known as Pickwickian syndrome, is the combination of obesity , falling oxygen levels in blood (hypoxia) during sleep and increasing carbon dioxide levels (hypercapnia); this is the result of hypoventilation (excessively slow or shallow breathing) during sleep. Obstructive sleep apnea is often but not necessarily present. Pulmonary hypertension is common and later causes cardiac arrhythmias.
    SIGNS AND SYMPTOMS

    Most people with obesity hypoventilation syndrome have concurrent obstructive sleep apnea, a condition characterized by snoring, brief episodes of apnea (cessation of breathing) during the night, interrupted sleep and excessive daytime sleepiness. In OHS, sleepiness may be worsened by elevated blood levels of carbon dioxide, which causes drowsiness ("CO2 narcosis"). Other symptoms present in both conditions are depression, hypertension (high blood pressure) that is difficult to control with medication and headaches occurring in the morning. Blurring of vision and visual changes may result from papilledema (swelling of the optic disc) in response to the raised carbon dioxide levels.

    Diagnosis

    If OHS is suspected, various tests are required for its confirmation. Arterial blood gas levels are determined to measure oxygen and carbon dioxide levels; this requires a blood sample from an artery, usually the radial Page 14

    artery. To distinguish various subtypes, polysomnography is required. To distinguish between OHS and various other lung diseases that can cause similar symptoms, CT scan, PFT’s and echocardiography may be performed. Criteria

    Formal criteria for diagnosis of Obesity Hypoventilation Syndrome are:

    Body mass index over 30 kg/m2 , Arterial carbon dioxide level over 45 mmHg , No alternative explanation for hypoventilation-such as use of narcotics


    Treatment

    Reduction in weight, either through a regimen of diet and exercise, medication or sometimes through bariatric surgery, has been shown to improve the symptoms of OHS and resolution of the high carbon dioxide levels. Weight loss may take a long time and is not always successful.

    Overnight mask ventilation with positive airway pressure may lead to an improvement in most symptoms of OHS.

    Diagnosis and Treatment of Primary Pulmonary Hypertension

    Primary pulmonary hypertension is a rare disease of unknown etiology, whereas secondary pulmonary hypertension is a complication of many pulmonary, cardiac and extrathoracic conditions. Chronic obstructive pulmonary disease, left ventricular dysfunction and disorders associated with hypoxemia frequently result in pulmonary hypertension.Signs and symptoms of pulmonary hypertension are often subtle and nonspecific. The diagnosis should be suspected in patients with increasing dyspnea on exertion and a known cause of pulmonary hypertension.

    Diagnosis: In patients with unexplained dyspnea, reduced maximum oxygen consumption, and signs of elevated right heart pressures (such as jugular venous distension), an echocardiogram can determine pulmonary pressures and right heart hemodynamics. If pressures are over 50 cm H2o pressure, then medical intervention is indicated. If it is not diagnosed and treated then progressive cardiac arrhythmias and respiratory failure is expected within 2 years.
    Treatment with Oral Traclear and Calcium blockers are used in early Primary Pulmonary Hypertension. Treatment with a continuous intravenous infusion of prostacyclin improves exercise capacity, quality of life, hemodynamics and long-term survival in patients with primary pulmonary hypertension. Management of secondary pulmonary hypertension includes correction of the underlying cause and reversal of hypoxemia. Lung transplantation remains an option for selected patients with pulmonary hypertension that does not respond to medical management. (Am Fam Physician 2001;63:1789)

    · Our Favorite On-line FREE Weight Loss calculators:
    Measure Your Metabolism

    http://health.msn.com/weight-loss/measure-your-metabolism.aspx

    Calculate your daily caloric needs. You will find by comparing light activity to moderate activity…that increased activity will greatly reduce weight if done regularly!!!!

    This chart is taken from the web page: there is about 700 calories per day difference between a very light and moderate activity level (that’s one pound a week!!! Activity Level:

    Choose an activity level below to determine how many calories you burn a day.

      Very Light Seated and standing activities, painting, driving, laboratory work, typing, sewing, ironing, cooking, playing cards, playing a musical instrument
      Light Walking on a level surface at two-and-a-half to three mph, garage work, electrical trades, carpentry, restaurant trades, housecleaning, child care, golfing, sailing, table tennis
      Moderate Walking three-and-a-half to four mph, weeding and hoeing, carrying a load, cycling, skiing, tennis, dancing
    Page 15 Heavy Carrying a load uphill, felling a tree, heavy manual digging, basketball, climbing, football, soccer

     

     

    Typically a higher activity category will burn on average about 550 additional calories per day!

    Weight Loss Calculator

    http://health.msn.com/weight-loss/weight-loss-calculator.aspx

    Find out how long it will take to reach your healthy weight loss goal, and how many calories you should consume each day.

    We use this calculator to also show how many days it would take to lose to a target (or desired) weight—given that you burn or exercise different calories each day

    FOR MORE OF OUR FAVORITE GREAT CALCULATORS .......

    http://health.msn.com/tools-and-resources

     

     

     

     

     

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