Shared Decision Making
In an era where there are so many options in the medical field, having the opportunity for shared decision making is more important than ever. Shared decision making is when a doctor and patient decide together on what needs to be done next. This contrasts with the more traditional practice of medicine in the 19th and 20th centuries, where the health care providers had the knowledge and dictated to the patients and their families of what needed to be done. Shared decision making is important when more than one option is being presented and it’s not 100% clear on what needs to be done. In a more “clear cut” situation, the role of shared decision making is less pronounced. For example, a young person comes in with acute appendicitis. We know that if we don’t operate and remove the appendix quickly, it can burst, cause peritonitis and ultimately lead to death. We wouldn’t converse about it for an hour with the patient and his family; we would say that this is what needs to be done and this is what we are going to do. Another common case (that I have often experienced as a cardiologist) is when someone is having a heart attack. We know that it’s important to move quickly and take care of the situation, and giving a variety of options is not the best use of time.
In instances that have more than one option and are not as acute (or urgent), shared decision making is a very ethical option and practice with most physicians. Here’s an example of how this tends to play out: say we have a patient who comes in for an appointment. She feels fine, and has no symptoms of an impending heart attack or stroke, but is considered high risk. As a doctor, I offer the option of prescribing a statin (which lowers cholesterol). These medications have been widely used since the 1980s and have been credited for cutting the number of heart attacks in half. They have been very powerful and useful, but they need to be taken on a daily basis. While they are generally safe to use, it’s important to remember that there are no medications without side effects. Statins are not “muscle friendly”, and approximately 1 in 5 patients develops muscle aches while taking this medication. This is not life-threatening, but it can inhibit daily activities. It becomes a back and forth discussion that takes time and effort from both the patient and the doctor. Of course, it is much easier for a doctor to say “here is your prescription, take this daily and come back in two months so I can check your cholesterol levels”. But the approach where the physician invites the patient to make decisions together based on the patient’s comfort level can be extremely beneficial. On one hand, we want to educate the patient on what we think is best; but on the other hand, we want him to be able to follow through with that decision.
Shared decision making is a wonderful thing. It’s what patients deserve, but it takes time and a good attitude from both the patient and the physician. It takes the realization from the patient that there are no easy fixes in medicine and that prevention is the first line of defense. Does your doctor practice shared decision making? If you’re not sure, have a discussion with her and find what fits your needs the best.
To your health!
Dr. Anthony
Should we be taking aspirin daily to prevent heart attacks and strokes?
Aspirin is a medication we have been using for over one hundred years. At a low dose, which averages between 40-100 mg a day, aspirin has been used in the last two to three decades primarily for the prevention of heart attacks and strokes.
We know that heart attacks and strokes can occur when cholesterol plaque in one of our major heart or brain arteries first develops, then matures (which can take decades!), and -- without warning -- becomes unstable and cracks. When it reaches this point, the blood flow over the unstable plaque recognizes the situation as “bleeding” or a “hole” in the artery. It tries to repair the situation by flowing very quickly to where it believes the problem is happening, and in the process can form a clot over the unstable plaque in less than one minute. So here we have a situation where a cholesterol plaque may only obstruct 10-20% of the opening (lumen) of a heart or brain artery. When this plaque becomes unstable, the blood forms a clot over it and within a minute there is a 100% obstruction of the blood flow. Because there is no blood flow through the artery, the cells start dying in a matter of 3 minutes for the brain and 30 minutes for the heart. This is how most heart attacks and strokes can occur.
A low dose of aspirin works by inhibiting the sticky cells in the blood, called platelets, from sticking together and forming a clot. However, at a high dose, aspirin also inhibits various enzymes and good cells. While a low dose would protect the arteries from clotting, a higher dose would not. This is why we have been using a low dose for the prevention of heart attacks and strokes. If too much aspirin is taken, it can cause bleeding, which has the reverse effect and can encourage clotting of the arteries.
Those who have had a heart attack or stroke are instructed to continue taking a low dose of aspirin every day for the rest of their lives. However, we must remember that science has no “last word”: it’s all based on the function of time and the evaluation of the available evidence.
So let’s say that the evidence from twenty years ago overwhelmingly supported using aspirin for the prevention of heart attacks and strokes -- not only for secondary prevention (meaning you’ve already had a heart attack or stroke and you’re taking it as a way to prevent this from happening again), but for primary prevention, which means you never had a heart attack or stroke, but you were deemed to be at a higher risk for suffering from one. This includes people with diabetes, smokers, those with high LDL or high blood pressure, a family history of heart disease, etc. For all of these people, we thought it made sense to give a low dose every day for the rest of their lives to prevent heart attacks or strokes from ever occurring in the first place.
A few months ago, science came forward and said that this is not correct. We have reevaluated the evidence, and in the modern era of medicine-- with better use of “statins” (Lipitor, Crestor, etc), medications that lower the LDL (bad cholesterol), and improved treatment of high blood pressure-- we don’t think the benefits of taking aspirin for primary prevention outweigh the risks. This is big news for patients and doctors!
Randomized trials and observations from the American College of Cardiology and the American Heart Association, which included tens of thousands of patients for years, have concluded that the use of aspirin is no longer appropriate for primary prevention of heart attacks and strokes -- except for those at very high risk (meaning those who have at least a 10% risk of developing heart attacks or strokes over the next ten years). The studies indicated that patients who have already had a heart attack or stroke should absolutely continue taking aspirin for secondary prevention. But for using aspirin for primary prevention, we have to really dive into the risk factors of the patient (age, family history, lifestyle, blood pressure level, cholesterol level) and determine if this is appropriate. Only if we evaluate these factors as being high, and the risk of bleeding from aspirin is low, then it is ok to use aspirin for primary prevention.
As with any kind of medication or regimen, please speak with your doctor before determining whether you should start or stop taking aspirin.
To your health!
Dr. Anthony
Healthy + Homemade: Whole Wheat Bread
Ah, bread… we hear a lot of contradicting views on bread for our diets. Is it healthy? Is it not healthy? What kind of bread is better? What about the sugar content? All of these questions are valid!
My wonderful wife, Katerina, has a very simple and healthy whole wheat bread recipe that you can make at home. It’s MY favorite bread, and I had to share the recipe with you!
Why opt for a recipe like this rather than buy a loaf at the store?
When we make something from scratch, we feel connected to it. We’re excited about it. We control the process and the ingredients. Let’s look at the sugar content for bread: depending on the brand and the type, a slice of bread could be upwards of 8g per slice. Not just that, they are extremely processed and leave very little nutritional benefits.
This whole wheat bread recipe has everything you need, has about 1 gram of sugar per slice, keeps you full (fiber content), and tastes absolutely delicious!
The ingredients are not hard to find, and they are not expensive — give it a try!
Whole Wheat Bread
Ingredients:
1.5 cups of warm water
1 Tbsp Active Dry Yeast
1.5 tsp of salt
1 Tbsp of honey
3.5 cups of whole wheat flour
Directions:
Fill a bowl with 1.5 cups of warm water. Add in 1 Tbsp of Active Dry Yeast, 1.5 tsp of salt and 1 Tbsp of honey. Whisk together until it’s dissolved. Cover with a towel to keep warm and set aside for about 10-15 minutes.
In another bowl, sift 3.5 cups of whole wheat flour.
After your yeast mixture has had time to rest, pour it into a mixing bowl (preferably your stand mixer with a hook attachment). Add the flour 1 cup at a time, allowing the mixture to incorporate before adding more.
Once the mixture has formed a dough (you’ll know that it’s ready when it pulls away from the sides of the bowl), take it out and place it on a whole wheat flour-dusted surface — like a clean countertop.
Knead the dough a few times and shape it how you’d like. Place it on a piece of wax paper (dust with whole wheat flour) on a pan, cover with a kitchen towel, and let it rest for about 30 minutes.
Remove the towel and with a sharp knife, carefully cut slices across the top (I do three or four!). Dust with a little more whole wheat flour.
Place the pan into a 400-degree preheated oven and let it bake for 28-30 minutes.
Enjoy!
To your health,
Dr. Anthony (and Katerina!)
New Year, New Diet? - Mediterranean (Part 3 of 3)
In my years of practicing medicine and prevention of cardiometabolic diseases, our diets and the way we eat make a very profound difference on our health. In my previous two blogs about the Paleo and Keto diets, I shared my professional opinion on their structure. But there is one more diet that I explain in my book which is a very healthy way of eating — the Mediterranean Diet.
The Mediterranean Diet is rich in whole, natural foods, including fresh vegetables, lean proteins and fish, and olive oil.
The Mediterranean Diet gained popularity - as you can guess - near the Mediterranean Sea and has since expanded from its creation in the 1960s and 70s. It is a diet rich in fruits, vegetables, nuts (unsalted), fish, eggs, lean meat (mostly white meat), whole grains and olive oil — but red meat is rarely eaten. As with all healthy habits, processed foods, deep fried foods, and sugary beverages have no place in Mediterranean diet.
Key items to success with the Mediterranean diet (similar to Paleo) is that you consume healthy, whole foods made from scratch from fresh ingredients and that processed foods are thrown out of the window. It’s also important to note the lifestyle that goes along with this diet. The people who ate the Mediterranean diet would typically work out in the fields for 6-8 hours a day six days a week, which helped them keep up with their muscular physiques and flat bellies.
When comparing the Paleo and the Mediterranean diets, you can see many similarities with the biggest differences coming down to legumes, whole grains and dairy products (these are part of the Mediterranean Diet, but not the Paleo Diet) and the red meat and butter that are liberally allowed in the Paleo diet. The overall lifestyles that match these diets are similar to those who have daily physical work for several hours. There is good scientific evidence that people who eat the Mediterranean diet are prone to living longer, having less chance of contracting diabetes, and that the diet can protect against Alzheimer's and dementia.
Following a diet to live healthier should never be a “fad'“. Focusing on whole foods, while getting rid of sugars, processed and deep fried foods are probably the most important take home messages from both the Paleo and Mediterranean diets. Red meat (when eaten in moderate quantities, and provided that you check your cholesterol with your doctor) or “antinutrients” in legumes are not going to ruin your health. Always complement your diet with an active lifestyle and, of course, do not smoke.
To your health,
Dr. Anthony
New Year, New Diet? - Paleo (Part 2 of 3)
It’s hard to believe we’re almost through the month of January! Have you taken steps towards a healthier life?
In my last blog, I shared some information about the Keto Diet — and this time, I want to share one of the two diets that I have studied for many years and encourage my own patients to follow.
Let’s start with the Paleo Diet!
The Paleo Diet comes from the term “paleolithic”: meaning the era of early stone age and cavemen. Cavemen had no choice but to eat what they had access to, which for many, was heavy in protein — whereas, for others, it was predominantly plant-based. So, in the Paleo diet meat is in big time, including red meat.
What all is “ok’d” in the Paleo Diet? Grass-fed meat, poultry, fish, shellfish, eggs, vegetables, fruits, nuts, seeds and healthy oils are the favored foods.
Processed foods, sugars (including sugary beverages), dairy, legumes and grains are off the table.
Grass-fed meats and vegetables are always a win on the Paleo Diet.
A strong argument of the proponents of Paleo diet is that the human body was created for the challenges of the cavemen, so why shouldn’t we eat today what they ate then? A positive point of this diet is that, once you exclude sugars from your diet, you avoid insulin spikes and can lose weight without feeling hungry. I believe that cutting out legumes, whole grains and dairy is a rather weak point of Paleo diet as these foods contain fiber (legumes and whole grains), protein (legumes and milk), and antioxidants (all three). The concern that legumes contain anti-nutrients that block the absorption of other essential nutrients is more theoretical than real; one would have to eat extremely large quantities of the same legume to have a negative impact on their nutritional status.
Finally, a better way to approach Paleo diet is to consider it as a part of a “Paleo lifestyle”: cavemen used to walk for 2-4 hours a day and seven days a week, jump, lift weights and climb trees. This diet makes it ideal for those who are extremely active.
Overall, eating whole foods, cutting out the sugars and eliminating processed foods are strong, positive points of the Paleo diet — while cutting off legumes, dairy and whole grains is controversial.
Do you eat Paleo? Would this be a way of eating that you would consider trying?
To your health,
Dr. Anthony