Those at higher risk for vitamin D deficiency include: breastfed infants, older adults, people with limited sun exposure, dark skinned individuals, people with fat malabsorption (diseases such as cystic fibrosis, Crohn’s disease), people who have undergone gastric bypass surgery, and the obese.

Your body creates vitamin D after you are exposed to sunlight. Sunlight stimulates the conversion of a naturally occurring compound in the skin to an active (usable) form of the vitamin. 10 minutes of sunshine 3- 4 times per week may be enough to help your body create the vitamin D it needs.

Children from birth to 18 years of age need 400 IU of vitamin D daily. Breastfed babies may need a prescription vitamin supplement with vitamin D (from your physician) because human milk only has a small amount of vitamin D. Once the child is weaned, he/she should consume > 1 liter/day of vitamin D fortified formula or whole milk. Always ask your physician before giving your child any vitamin supplements.

Adults need at least the following amounts of vitamin D:

• <50 years of age: 200 – 400 IU daily
• 50 – 70 years of age: 400 – 600 IUdaily
• >70 years of age: 600 – 800 IU daily

Children and adults who do not get any sunshine may need 800 – 1000 IU daily.

Foods such as fish, fish oil, eggs, and cheese naturally contain vitamin D. You can purchase vitamin D fortified milk, orange juice, yogurt, margarine, and cereal. Vitamin D supplements are available over the counter or by prescription.

Be active. Get 30 minutes of exercise 4 – 5 times per week. Try and do something active every day. Take a walk. Take the stairs. Clean the house. Do some gardening. Take surfing lessons. Take an exercise class. Take dance lessons. Get the kids away from the television and video games and enroll them in organized sports. Take the kids to the YMCA.

Watch what you drink. Avoid soft drinks, cream coffees, alcohol, fruit juices/drinks, energy drinks, sweetened iced tea, and flavored milk. Water is a great way to keep your stomach full without taking in extra calories.

Do not skip meals. Regular meals increase your metabolism. Skipping meals causes your body to go into protective/hibernation mode, making weight loss harder. Eat a healthy breakfast. People who skip breakfast tend to weigh more.

Avoid fast food. Fast food such as hamburgers, chicken nuggets, french fries, pizza is high in calories and can cause weight gain. Pack a healthy lunch instead of eating out. This way you can control what and how much you eat.

Don’t grocery shop when you are hungry.

Chew sugar-free gum between meals to cut down on snacking.

Eat a lot of fruits and vegetables. Aim for 3 cups of vegetables and 2 cups of fruit daily.

Do not eat in a hurry. Chewing your food and eating slowly helps the digestive process. Eating slowly will help stop over-eating. It takes time for your stomach to signal your brain that you are full.

Consider joining a weight management group such as Jenny Craig or Weight Watchers. Receive encouragement and support from others.

Be prepared when you visit your physician with the following information: countries/regions that you will visit, duration of travel, season of travel, planned activities (scuba diving, hiking, etc). Bring a copy of your vaccine record if available. Once your physician evaluates your overall health and assesses your travel plans, he/she can provide information about the health risks that you could potentially encounter and give advice to minimize these risks. A travel consult should provide you with peace of mind while travelling.

Vaccines – Vaccines provide valuable protection for people who wish to travel in good health. Your physician will determine if you need any vaccines. The vaccines you received in childhood may need to be updated. Depending on your destination, you may need vaccines for some of the following: Hepatitis A and B, Influenza, Japanese encephalitis, MMR, meningitis, pneumococcal, polio, rabies, tetanus, typhoid fever, chicken pox and yellow fever.

Food and water safety – precautions are necessary in areas where sanitation and personal hygiene is poor. Drink water from commercially-sealed bottles, carbonated beverages, and beer/wine. Use bottled or boiled water when brushing teeth. Steaming-hot, well-cooked food is safest. Avoid street vendors, raw/uncooked seafood or meat, unpasteurized dairy products. Peel fruits yourself. Do not eat raw vegetables.

Malaria prevention – Malaria is a serious infection spread by the bite of an infected mosquito. Antimalaria medication is recommended if travelling to certain areas.

Insect and tick bites – Insects and ticks can transmit potentially life-threatening infections. Avoid insect-infested areas. Use repellent containing DEET or picaridin. Wear protective clothing such as long sleeves and pants. Follow good personal hygiene. Certain areas may need mosquito netting over the bed.

Personal medications – Bring enough medication for your entire trip, in their original containers. Place in your purse or carry-on to avoid loss/theft. Obtain a letter from your physician documenting medical need if you require syringes to administer medication.

Bring a first-aid kit – consider including: your personal medications. An antibiotic in case of traveler’s diarrhea. Pepto Bismol, Imodium. Cough and cold medicines. Pain medicine such as Tylenol or Advil. Allergy medication. Benadryl in case of allergic reaction. Sunscreen. Antibiotic ointment, bandages. Hydrocortisone cream. Moleskin. Motion sickness medication such as Dramamine. Altitude sickness medication such as Diamox depending on travel destination. Scissors, tweezers, pocket knife, thermometer, mirror, nail clippers. Hand wipes, sanitizers.

Sexually transmitted diseases – STDs such as HIV, hepatitis B, gonorrhea, Chlamydia, syphilis, herpes are all transmitted by sexual contact. These STDs are often more prevalent in developing countries. Use barrier methods such as condoms to reduce the risk of STDs. Avoidance of sexual contact eliminates the risk of acquiring STDs during travel.

Blood clots – for flights longer than 6 hours, precautions should be taken to avoid getting blood clots. Sitting for prolonged periods may cause blood pooling in the legs, increasing the risk of developing a blood clot. Stand up and walk around every hour, stretch frequently, avoid dehydration, consider wearing compression stockings. Avoid medications that impair your ability to move around (sleep aids, alcohol).

Avoid transportation problems/accidents – avoid night driving, wear your seat belt, do not drink alcohol and drive, be familiar with local driving customs/laws, wear a helmet on motorized cycles.

You may consider purchasing extra traveler’s health insurance. Check your health insurance policy and know your coverage.

There are additional travel considerations necessary for people travelling with medical conditions such as pregnancy, Diabetes, HIV. Ask your physician for advice or refer to the CDC website below.

Further information can also be obtained at The Center for Disease Control and Prevention (CDC) website, www.cdc.gov/travel/. The World Health Organization (WHO) has a similar site: www.who.int/ith/.

A second type of donation is a living donor. Donors can give kidneys, lungs, or parts of livers. Dr Chuck Wright, a past member of the SBFMG family chose to do this and continues to live a full life as a State Department Physician in India. His donation was to an unrelated recipient, but many donors give their organs to members of their family. Both blood type and tissue type compatibility are important in doing this. The donor must be in good health and usually under sixty years old. Most hospitals that perform transplant are large medical centers such as UCLA, USC, and Cedars Sinai. However, your SBFMG physician will gladly assist you should you have further questions or be interested in becoming a live donor.

Major medical associations have conflicting recommendations regarding prostate cancer screening. The US Preventative Task Force and many European medical cancer societies do not recommend routine PSA screening to detect prostate cancer. The American Cancer Society (ACS) and the American Urological Association believe men that health care professionals should discuss the potential benefits and limitations of prostate cancer early detection testing with men before any testing begins. This discussion should include an offer for testing with the prostate-specific antigen (PSA) blood test and digital rectal exam (DRE) yearly, beginning at age 50, to men who are at average risk of prostate cancer and have at least a 10-year life expectancy. Following this discussion, those men who favor testing should be tested. Men should actively take part in this decision by learning about prostate cancer and the pros and cons of early detection and treatment of prostate cancer.

This discussion should take place starting at age 45 for men at high risk of developing prostate cancer. This includes African American men and men who have a first-degree relative (father, brother, or son) diagnosed with prostate cancer at an early age (younger than age 65). Men with female relatives who have breast cancer related to the breast cancer gene (BRCA) may also be at increased risk.
This discussion should take place at age 40 for men at even higher risk (those with several first-degree relatives who had prostate cancer at an early age).
If, after this discussion, a man asks his health care professional to make the decision for him, he should be tested (unless there is a specific reason not to test).
Screening should not be performed on men older who are 75 years old and older.

References
American Cancer Society. Cancer Facts & Figures 2009. Atlanta, Ga: American Cancer Society; 2009.

The fact is, our spines are not well designed for upright human activity, but would better serve a 4 legged creature! Thus, we are by nature more susceptible to back and neck injury. Add to this some lazy posture and extra weight and we have the “perfect storm” for back problems.

I emphasize three factors to prevent back pain:
1. POSTURE: Always try to keep your ears, shoulders and hips in line, even when bending or reaching for something. This really means more bending with your knees when standing and using some type of lumbar support when sitting, especially when sitting in a car or in front of a computer.

2. FLEXIBILITY: Stretching your neck, back, and leg muscles every day can help avoid pulls and strains. This is especially important after the age of 35 when we all gradually loose a lot of our normal tissue elasticity. Ask your doctor or a physical therapist for information on proper stretching to prevent injuries.

3. STRENGTHENING: Strengthening your back actually means strengthening your core muscles, especially your abdominal muscles; this can be done with simple “crunches” or by more formal training such as pilates or yoga. You do not need to life weights to make your back stronger!

When it comes to back pain (as with many other conditions), “An ounce of prevention is worth a pound of cure!”

There are many blood types most commonly referred to by the A, B or O system with a second designation referring to being positive or negative. This second designation refers to “Rh” factor. Some blood types are less common than others, but that doesn’t affect the need for all types to donate. The fact that some blood types are more common only means that there are probably more people needing that type.

Blood is checked carefully for diseases before being given. In California, no payment is made for blood. This is thought to eliminate any motivation for providing blood other than “the goodness of your heart”. It also reduces the risk that someone would provide blood with any risk of disease.

The effects on the donor usually last only one or two days and unless the patient has high blood pressure or heart disease, these effects are minor. The time of donation is less than one hour and blood can be given about once per month. The long-term effects on donors have not been shown to be harmful. In fact, some reports have shown that donors live longer than those who do not give blood.

Please let us help you experience the sense of helping and making a difference by giving blood. The life you save could be your own or that of someone you love. Contact The Red Cross or your local hospital blood bank (Torrance Memorial Hospital Blood Bank 310-325-9110)

HOW DOES ACNE DEVELOP?
Acne is caused when hair follicles under your skin get clogged. Hair follicles become blocked with normal skin cells. The cells combine with an oily substance called sebum to create a plug in the hair follicle. Sebum is a naturally occurring oily substance produced by glands called sebaceous glands. We all have several sebaceous glands on our face, neck, back, chest and shoulders. If our sebaceous glands produce too much sebum, it allows for overgrowth of bacteria that normally lives on our skin. This can cause inflammation that ruptures the follicle and forms a pimple.

Sebaceous glands produce more sebum in response to hormones called androgens that increase in adolescence. Hormone changes related to pregnancy, or starting/stopping the birth control pill can cause acne. Acne can flare just prior to a woman’s menstrual period. Oils and greases in hair products or oil-based cosmetics can contribute to and worsen acne. Stress may worsen acne. There is no strong evidence that diet plays a role in causing acne. There may be an association with cow’s milk, due to the hormones found in milk.

TREATMENT FOR ACNE
If your acne is mild, you can use non-prescription topical products such as benzoyl peroxide, salicylic acid, sulfur, alpha hydroxy acids, and tea tree oil. Wash your face twice daily with a gentle facial cleanser and warm water. Do not scrub too vigorously or wash excessively because this can irritate your skin and worsen the acne. Use your hands to wash your face. This helps remove excess sebum and helps control the acne. If you have oily hair, shampooing daily decreases the amount of oil from your hair that reaches your skin. Choose oil-free skin products labeled “non-comedogenic” (does not cause blackheads or whiteheads) or “non-acnegenic” (does not cause pimples). If you have oily skin, choose a gel-based moisturizer. If you have dry skin, choose a cream or lotion. Choose a moisturizer with SPF 15 or higher. When using hair products, shield your face to prevent product from getting on your skin. Men who shave and who have acne should test both electric and safety razors to see which is more comfortable. Soften your beard with soap and water before applying shaving cream.

Consult your doctor if you have moderate or severe acne, or if the over the counter regimens are not helping. Depending on the type of acne you have, your family doctor may treat your acne with a topical medication, oral antibiotic, and/or a hormonal treatment. Dermatologists also use laser and light-based technologies to treat acne. If you have severe acne with nodules or cysts, then you may need to see a dermatologist to discuss Accutane.

Acne treatments prevent new pimples from forming. It takes 1- 2 months to effectively treat acne. Do not pick, pop, or squeeze pimples while waiting for treatment to work. This can worsen the acne and cause scarring. Be patient and work with your family doctor to find a treatment that works for you!

A)Physiologic (how things are working) An EKG looks at the electricity going through your heart and sees what has happened, but rarely predicts the future. Scans often do.

1) Treadmills Pros: These see how the heart responds to stress. They show how long people can run compared to others, how fast the heart beats compared to other people at the same level of stress, they show if the heart beat becomes irregular under stress, and the doctor and computer look for signs of strain in the EKG (ST segments) under stress. This is probably the best bargain of all the tests. They predict really well who will and who won’t have a heart attack in the next year or two. They are done at SBFMG offices.
Cons: There must be about 80% blockage in the coronary arteries before these show a strain pattern and some people can’t walk fast or long enough to perform the test. As with all tests, there are no guarantees, only predictions with treadmills.

2) Echocardiograms (Echos or ultrasounds of the heart): Using dopler techniques the doctor can see blood flow through valves and the aorta.
Pros: Excellent to see how valves and muscles work and whether they are stressed by blood pressure, age, wear and tear or diseases. No x-ray, needles or dyes are used and they are done at SBFMG several days per week. They are usually covered by insurance as “diagnostic” to monitor a problem such as a murmur.
Cons: Moderately expensive and don’t’ see coronary arteries (too small) so little value in predicting heart attacks

3) Stress Echos: Pros: more sensitive (more likely to find blockage of arteries) in predicting heart attacks than regular treadmills, done at cardiologists’ offices rather than hospital, have no x-rays, dyes, or needles. Usually covered by insurance if you fail regular treadmill
Cons: Expensive, requires cardiologist, requires fast walking

4) Nuclear studies (like Cardiolyte tests): Pros: can be performed either with exercise or IV chemicals to make heart work as if you were running. They are more sensitive than plain treadmills in predicting heart attack risks. Insurance usually cover if you fail a regular treadmill. It lights up areas of heart if adequate blood supply exists through the coronary arteries instead of looking at the arteries themselves.
Cons: Usually done in a hospital, requires injection of trace amount of radioactive substance (less than most common x-rays), and very expensive

B)Anatomical (what thinks look like, not how they work)

1) CIMT (Carotid Intima-Medial Thickness). Pros: Using ultrasound the carotid arteries in the neck are measured for hardening compared to people in same age group. Done at SBFMG. Inexpensive at $295, but not covered by insurance as it is considered a “screening” test. It is different from inexpensive blood flow tests that take only a few minutes to check for stroke risk. It is the up and coming test used by universities to see if medications to prevent heart attacks are working. No pain, x-ray or needles.
Cons: Looks at neck not heart arteries and, therefore, doesn’t make sense that it predicts the relative risk of heart attacks (it does!) Gives percentile, not percentage of blockage (on a scale of 1 to 100, we know where you would stand relative to a problem, not what percentage each of your own arteries are blocked)

2) EBCT (now replaced by 64 slice CT scanner) Pros: Using x-rays the coronary arteries, which when blocked cause heart attacks, can be seen without dye or needles. It is inexpensive (about $395, but not usually covered by insurance) and “makes sense” because is looks directly at the heart’s arteries.
Cons: Only the calcium can be measured. It takes a few years of plaque being present before you can see the calcium deposits. The inside diameter, or amount of blockage, can’t be seen. As with CIMT a computer calculates what “percentile” (not percentage of blockage) the patient’s arteries are in and allows the doctor to determine if you are high, medium or low risk for a heart attack compared to others your age.

3) Echocardiogram (also described in physiology section) sees anatomy of muscles and valves, but not the coronary arteries

4) CT Coronary Angiogram: Pros: this adds intravenous dye (contrast) to the scan in #2 and allows us to find what percentage of blockage exists in the arteries. The arteries themselves are not punctured and it takes only an hour or two. Recent studies (i.e. Mayo Clinic) show it correlates really well with a conventional angiogram (#5)
Cons: It requires contrast (dye) to be placed in your veins and you could be allergic (rare). You must have a blood test first to be sure your kidneys are working well enough to get rid of the dye. It is rarely covered by insurance, costs at least $1,200 at current centers and has x-ray exposure.

5) Angiogram: Pros: this is the “gold standard” to see the anatomy of your coronaries and is needed to see if and where stents should be placed. It sees exactly how much blockage you have in your coronary arteries. It is almost always covered by insurance
Cons: requires all day in hospital, artery in groin is punctured (risks bleeding) through which a tube is maneuvered up to your heart to place the contrast right into the coronary openings. Allergic reactions, bleeding, x-ray exposure are all risks involved, but bleeding requiring transfusions is rare.

Tooth Decay
Teeth are covered in a hard, outer coating called enamel. Everyday a thin film of bacteria builds up on your teeth. Over time the bacteria can cause holes in the enamel. These holes are called cavities. Brushing and flossing your teeth can protect you from decay, but once a cavity appears, a dentist has to fix it.

Gum Disease
Gum disease begins when plaque builds up along and under the gum line. This plaque causes infections that hurt the gum and bone that hold teeth in place. Sometimes gum disease makes your gums tender and more likely to bleed. This problem, called gingivitis, can often be fixed by daily brushing and flossing.

To prevent gum disease:

• Brush your teeth 2 times per day with fluoride toothpaste
• Floss once per day
• Visit your dentist regularly for a checkup and cleaning
• Quit smoking. Smoking increases your risk for gum disease.

Oral health problems to report to your dentist

• Red, tender or swollen gums
• Gums that bleed when you brush or floss
• Gums that begin pulling away from your teeth
• Loose teeth
• Changes in the way your top and bottom teeth align with each other
• Unusual sensitivity to hot or cold