Dangers of Winter

Winter is here! Some people have died. Some have exacerbation and/or complication of their pre-existing conditions. Some have broken bones. Some have flu. Some are depressed.

The lucky ones – if that is an appropriate word for them – are in Hawaii or Florida. Some are in Arizona or Palm Springs. Some are on a cruise in Bahamas or South America. Some are on the big mountains, gyrating down the slopes on their ultra super speed skis.

The big chill does create a new dynamics in peoples’ lives. As soon as the leaves start gathering on the ground, we are gripped with fear or joy depending on what we have planned for the snowy days.

But we carry on. Sometimes smiling, sometimes annoyed and sometimes angry. Each morning, we get ready for work in our best winter clothes. At work, the heating is on and the windows are shut. Your comfort level goes down. Your smile fades and your layers start coming off. You look out of the window for some inspiration and comfort. You see a pile of snow. You feel trapped

Do you find this stressful? Does this affect your health?

“It is well known that in all except equatorial regions, the death rate increases in winter,” says Dr Caralee Caplan, in the recent edition of Canadian Medical Association Journal.
About 50 percent of deaths in winter are related to coronary artery disease and blood clots in the brain.

Studies have shown that most deaths occur 24 hours after cold days. This appears to be due to brief rather than prolonged exposure to cold. Resulting in rapid changes in the blood viscosity, formation of blood clot and increase demand for oxygen by heart muscles.

Those who are already known to have coronary artery disease are prone to spasm of these vessels. This further aggravates the risk of heart attacks. Asthmatics run the risk of aggravating their condition by inhaling cold air especially during exercise.

The precise mechanism of cold-induced changes is being hotly debated by the experts. Engorgement of blood vessels and release of substances which produce spasm of lung vessels are responsible for asthmatic attacks.

Patients with Raynaud’s disease suffer significant spasm of blood vessels of hands and feet when exposed to cold. This occurs mainly in young healthy women. Their blood vessels are extremely sensitive to cold or emotions.

Dr Caplan says that no one is immune to the effects of hypothermia, frostbite and seasonal infections and injuries. In most of these conditions, the underlying mechanism appears to be the effect of cold on blood vessels.

Can we prevent heart attacks after shoveling snow and asthma attacks from winter sports? Yes. “The best prevention is, of course, avoidance,” says Dr Caplan.

Asthmatics, who want to enjoy winter sports, should keep inhalers (bronchodilators) handy at all times. People with heart problems should wear a light face mask to maintain a favorable air temperature and humidity during exertion. Warm clothings, mittens, gloves and socks should protect the rest of the body from the big chill.

Remember, better safe than sorry! We still have almost three months of winter to enjoy. Keep smiling!

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Miscellaneous Health Topics

Do you believe that “if it tastes that good, it can’t be healthy”? I do!

Do you believe in Benjamin Franklin’s maxim “early to bed and early to rise makes a man healthy, wealthy, and wise”? I do except for the “wealthy” part!

Well, if you think the way I do then we may need to change. Do you want to know why? Then read this and surprise yourself.

1. Life is sweet: candy consumption and longevity

This paper appeared in the British Medical Journal. It was picked up by Associated Press and published as a news item in the Medicine Hat News recently.

The authors are from the Harvard School of Public Health. They feel that since candy (sugar candy and chocolates) has existed for centuries, it cannot be totally unhealthy. They decided to investigate whether candy consumption was associated with longevity.

The authors note that an American consumes 5.4kg of sugar candy and 6.5kg of chocolates annually.

The subjects of the study were 7841 healthy men entering Harvard University as undergraduates between 1916 and 1950. In 1988, these men were surveyed about their health habits (smoking etc) and candy consumption. Death certificates for men who died up to the end of 1993 were obtained.

The authors found that a man who does not consume any candies is older, leaner and more likely to smoke. He drinks more, ate less red meat and vegetables or green salad, and is more likely to take vitamin or mineral supplements.

They also found that consumption of candy was associated with greater longevity. This could be due to the presence of antioxidant phenol (a substance known to decrease the risk of coronary heart disease) in the chocolates. A 41g piece of chocolate contains about the same amount of antioxidant phenol as a glass of red wine.

It is interesting to note that greater consumption of candy (3 or more times a week) did not progressively lower mortality. In fact, the lowest mortality was amongst those who consumed candy in moderation (1-3 times a month).

Of course, the authors had vested interest in the study. They confess to a weakness for chocolates and consume to an average of one bar a day each!

2. Larks and owls and health, wealth, and wisdom

This study was funded in the United Kingdom by the Department of Health and Social Services and published in the British Medical Journal. Object of the study was to test the validity of Benjamin Franklin’s maxim “early to bed and early to rise makes a man healthy, wealthy and wise”.

1229 men and women aged 65 and over took part in the survey. A lark was defined as a person who went to bed before 11pm and was up before 8am. An owl went to bed at or after 11pm and was up at or after 8am.

The authors, from Southampton University, looked at several outcome measures- income, standard of living, state of health and mortality during 23 years of follow up.

Their conclusions? The findings did not support Franklin’s claim. A “late to bed and late to rise” lifestyle has no adverse effect. What is interesting is that sleeping for more than 8 hours a night was associated with increased mortality.

Authors’ final comment: There is no justification for early risers to affect moral superiority.

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Carbon Monoxide Poisoning

Recently, a man died from carbon monoxide poisoning in Medicine Hat. The Medicine Hat News has publicized this tragedy with a fair amount of educational material. How many of us have taken the trouble of securing our homes to prevent such a tragedy?

Do you know how and why so many people get killed by this deadly gas?

Do you know why the Manitoba taxpayers lost $70million between 1989 and 1998?

Find out more about these issues from the medical journals summarized in the following paragraphs.

Carbon Monoxide poisoning:

Approximately 600 accidental deaths due to carbon monoxide poisoning are reported annually in the United States. Intentional carbon monoxide-related deaths is 5 to 10 times higher, says a Review Article on this subject in the New England Journal of Medicine.

A severe winter is associated with increased number of carbon monoxide injuries. This is due to the poorly ventilated gasoline-powered generators used in winter months. The intentional deaths occur through out the year.

What is the level of normal carbon monoxide in the atmosphere? Less than 0.001 percent. We all have low levels of carbon monoxide in our blood. Levels amongst non-smokers are 1 to 3 percent. Compare this to a smoker – the level could be 10 to more than 15 percent higher.

What are the other sources of carbon monoxide besides smoke? Motor vehicle exhaust fumes, poorly functioning heating systems, propane operated forklifts, cleaner fuels like propane and methane.

According to the authors of this paper, the majority of the deaths in US were from motor vehicle exhaust fumes – 57 percent. Of these, 43 percent were due to faulty exhaust systems, 39 percent to operation in an improperly ventilated structure, and 18 percent to the use of a fuel-burning heating device in the passenger compartment.

Why is the gas so deadly? It is a colorless, odorless gas that is easily absorbed through the lungs. It has 200 to 250 times greater affinity to hemoglobin than oxygen. Thus depriving our body of oxygen. Resulting in destruction of vital organs and tissues.

In a confined space like a garage, the blood level can rise to dangerous levels within 10 minutes. Clinical features are vague and often mimic a non-specific viral illness. Hence delay in diagnosis.

Treatment consists of removing the person from the site, administrating 100 percent oxygen and transporting to the nearest hospital for further management by the experts.

Tragedies from carbon monoxide poisoning can be reduced or eliminated by preventive measures. Fuel-burning heating systems require regular professional maintainance, say the authors. Motor vehicles with engine running should not be in a confined space. Outdoor gas grills should not be operated indoors. Carbon monoxide detectors should be installed but they are not a substitute for proper maintainance of appliances, say the authors.

Why Manitoba taxpayers are losing millions of dollars?

Manitoba doctors earn 15 percent less than doctors in Ontario, Saskatchewan and Alberta, reports The Medical Post (Nov 24/98).

Between 1989 and 1998 about 400 medical graduates left the province at a cost of $150,000 per family physician and $200,000 per specialist. That is a loss to the taxpayers of $70 million. That does not include the cost of replacing 1800 practicing physicians who left Manitoba for greener pastures.

What is the solution? The executive director of the Manitoba Medical Association says,”The main problem in Manitoba is compensation. If you fix that problem, you stop losing doctors to other areas of Canada and U.S.”

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Staying Healthy

“Doc, I am worried about 1999. I will be 41 and I want to stay healthy. How can I do it?”

Although Dave likes to plan ahead, he has difficulty remembering the five commandments of good health. He has been busy travelling and has no control over where he eats, what he eats, and how often he eats.

Dave has no time for regular exercise. His business lunches and dinners are not without good wine and alcohol. He forgets that alcohol is heavy in calories and devoid of nutrition

Dave has been working hard to quit smoking and get his weight under control. He finds this stressful. There are two other sources of stress in his life: dealing with difficult people and time management.

Dave feels trapped. He feels helpless. He wants to get control of his life.

“Doc, when I was growing up, my father used to say: son, your health comes first, your family comes second and your work comes third. Doc, in my case it is in reverse order!”

Dave cannot afford to give up his present job. The money is good. His wife, Susan, has a good salary as a legal secretary. They need two incomes to raise children, have a decent lifestyle and save money for holidays and retirement. Unfortunately, Dave’s lifestyle is anything but decent.

It is time to get tough. Dave, the first commandment of good health is to quit smoking. If you are unable to do so then get help. There are many programs to chose from. Pick one and stick to it.

Dave, the second commandment is to exercise daily. In your travels, pick hotels with swimming pool and health club. Get up early and start your day with 30 to 60 minutes of exercise. This will make you feel good, boost your morale and encourage you to follow healthy habits rest of the day. Regular exercise is the ultimate feel-good pill.

The third commandment is to control your weight by healthy eating. Eat diet with high fiber and low fat. Dave, do not forget that fruits and vegetables are good for you! Healthy eating, along with regular exercise, should make you a winner.

Dave smiles. I am serious. He should know, the pressure is on!

“Go on doc,” says Dave, looking little relaxed than when we started.

Dave, the fourth commandment is to have a regular physical checkup with your family doctor. Your doctor will recommend to you screening tests which may help detect conditions in early stage when it can be cured or controlled.

Finally, the fifth commandment is to control your alcohol intake. Besides being devoid of nutrition, it plays an adverse role in your weight control. Excessive alcohol intake leads to health and social problems which destroys your hard work and all your dreams.

“Doc, I promise you, next year things are going to be different. I know the odds are against me but I have to do it, for my family and me.”

Good luck, Dave. May peace be with you.

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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New Year’s Resolutions

Are you one of the millions of people who is planning to go on a weight reducing diet soon after New Year’s eve party? Are you excessively infatuated with being thin?

Are you a retired, non-smoking, healthy man who is wondering: Am I going to live long enough to enjoy my retirement?

Read on to see who is saying what in the medical journals!

Losing Weight – An Ill-Fated New Year’s Resolution:

It is a well known fact that come January, within few days to few months, most people will give up on their New Year’s resolution to lose weight. Why? Because losing weight and sustaining the loss is a difficult task. This leads to guilt and self-hatred.

An Editorial, published in the New England Journal of Medicine on January 1st, 1998 estimates that at any given time, 15 to 35 per cent of Americans are trying to lose weight. They spend about $30 to $50 billion yearly on diet clubs, special foods and over-the-counter remedies. These remedies are not always harmless.

Why do people want to lose weight? First, there is enormous social pressure to look thin. Second, being overweight has some health risks: heart disease, high blood pressure, diabetes, and a variety of other problems.

Why is it that some people cannot lose weight? The old view is that if intake of calories is more than expenditure then the weight goes up. The new view is that there is a “fairly stable set point for a person’s weight that is resistant over short periods to either gain or loss, but that may move with age.”

This set point can be changed with extreme measures like diet and exercise. But when this measures are discontinued then the body weight returns to its original level. Heredity also plays a significant role.

So, what is the best approach to weight control and staying healthy?


“Encouraging lifelong, regular exercise in children may well have the greatest effect in terms of preventing obesity, as well as numerous other benefits,” say the authors. This should be combined with healthy eating habits.

What about those who are already overweight? In authors’ views, overweight people should be advised to lose weight if only it would be required to improve their health or if they ask for help.

Want to live longer after retirement?

A study published in the New England Journal of Medicine says that, “Encouraging elderly people to walk may benefit their health.”

Among the 707 men included in this study, the average distance walked was about 2.9 km (1.8 miles) per day. These men had 12 years of follow-up.

Results? Those who walked less than 1.6 km. (1 mile) per day, the death rate was 43.1 per 100 men. For those who walked more than 3.2 km (2 miles) per day the death rate was more than halved (21.5 per 100). Age had negligible effect on the out come. Time for another New Year’s resolution?

Wait a minute! Consult your doctor before you go wild!

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Ovarian and Uterine Cancer

“Dr. B, can we discuss early detection and prevention of cancers of the ovary and uterus?”

Sure, Susan. I will give you some information today and you discuss this further with your family doctor and/or gynecologist. Remember cancer of the uterus can be either in its body (endometrial) or in its opening (cervix).

In 1993, 606 Alberta women were diagnosed with invasive (beyond the superficial layer) cancers of the female genital organs: endometrial 256, ovary 203, cervix 122 and others 25. This does not include 1517 women who were diagnosed with in-situ (confined to the superficial layer) cancers of the cervix.

“What symptoms would I have if I had cancer of the ovary or uterus?”

Susan, unfortunately the early symptoms are none or very vague. Early diagnosis of ovarian cancer is more a matter of chance. Irregular vaginal bleeding may be the only early sign of uterine cancer. Hence, most of the gynecological cancers are picked up at a late stage. Of course, the Pap smear has completely changed the outcome of cervical cancers.

“Doctor, are there any risk factors which I should be aware of?”

Susan, for ovarian cancer, the risk factors are age (steady rise up to age 80) and family history. For endometrial cancer – age, obesity and estrogen therapy are major risk factors. For cervical cancer, the risk factors are well recognized. These are: some types of sexually transmitted disease(s), early age at first intercourse, and having multiple sexual partners.

“Doctor, what about screening tests?”

Susan, for ovarian and endometrial cancers, there are no recommendation for screening. But for cervical cancer, Pap smear is highly recommended. In U.S., this has reduced the incidence and death rate by 70 percent in the last 40 years.

Invasive cervical cancer is usually diagnosed between the ages of 45 and 50. But the average age of women with carcinoma in-situ is between 25 and 30 with evidence of increase in younger women. This could be related to risky health practices, such as experimenting with new ideas, relationships and activities during adolescence which may have long term adverse consequences.

“Dr. B, final question! How often should a woman get a Pap smear?”

Susan, for those who are not at high risk, first Pap smear should be done soon after the age of 18 or once the woman is sexually active. If this is normal and the one after a year is also normal then repeat after every three years until age 70.

It is very important for every woman to discuss her risk factors with her family doctor and/or gynecologist. Recommendations may vary. Any unexpected vaginal bleeding should be reported to your doctor to see if further investigation is required.

“Thank you, doctor,” Susan said as she got ready to leave my office. She continues to strive for good health for herself and her family. I admire her dedication.

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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Do we really need disgruntled doctors?

Published on the editorial page of The Medicine Hat News, Wednesday, December 2, 1998, Page B6. At that time Dr. Bharwani was Regional Chief of Staff, Palliser Health Region, Medicine Hat, Alberta.

People keep asking me how the Palliser Health Authority got dragged into a situation which should be a Provincial issue?

It is a good question, but I do not have a good answer. What I know is that we have three very unhappy, angry Obstetricians – Obstetricians who have served this Region well for several years. They have kept our obstetrical care at the highest level in the Province, and they are fine family people who want to be appreciated and remunerated appropriately for what they do.

We are seeing a very sad situation. Angry, unhappy Obstetricians with a Health Authority strapped for money and pushed against the wall. “Give us the on call money or we quit” say the Obstetricians. But the Regional Health Authorities are not funded to pay for services provided by physicians.

The Obstetricians’ anger is only the tip of the iceberg. Physicians, in general, are angry and frustrated. They say, compare our hourly take home pay and lifestyle with those of dentists, lawyers, accountants, realtors, stockbrokers, bankers, etc.

This year the Canadian Medical Association conducted a survey on doctors’ attitudes and activities. This revealed that almost two-thirds of Canada’s physicians (62 percent) feel they are over worked, and more than half (55 percent) say that their family and personal life has suffered because they chose medicine as a profession.

Physicians feel that their income is declining even though their hours of work have increased. With the explosion of medical information on the Internet, the patient’s expectations have risen dramatically. In the era of cut backs, the physicians feel great pressure to satisfy their patients’ needs.

In a 1997 national survey of doctors, done by The Medical Post, the young doctors nationwide expressed extreme unhappiness with the health care system.

In Defense of the Obstetricians, From Where I Sit – 2

In the U.S.A, the situation is no different. In an editorial in The New England Journal of Medicine, Dr. Jerome Kassirier wonders if a health care system functions effectively if a sizable fraction of physicians are disgruntled. He asks, “Are patients well served by unhappy physicians?”

Physicians in the United States working in managed care organizations get financial incentives, which depend on limiting referrals, and care which would compromise their work. Physicians feel that incentives, which reward quality of care and provide patient satisfaction would offer better job satisfaction.

In his book “Paging Doctors”, David Woods, a medical journalist says, “The doctor’s dilemma, as George Bernard Shaw defined it in his play of that name, was the moral one imposed by getting paid for operating and not getting paid for not operating.” Bernard Shaw also raised some broader questions about the relative worth of people and objects. How do you define worth?

Finally, sixteen years ago, Modern Medicine of Canada wrote, “Doctors surely are stressed. The strain comes mainly from the profession that bears the most direct responsibility for other peoples quality of life and the nature and timing of their deaths. In fact, there is hardly a single human being living in a developed society who has not been treated by a physician several times in his life. But no matter how strenuously a doctor has toiled or how miraculous the results, it is all taken for granted and in this day and age, gratitude is minimal”.

So where do we go from here? The Palliser Health Authority would love to have happy doctors providing excellent quality service in an environment, which would recognize and reward their special skills. How can we do this?

I will leave you with these questions which were asked earlier: Can a health care system function effectively when a sizable fraction of the physicians are disgruntled? Are patients well served by unhappy physicians? Think about this, and tell me how we can keep our doctors happy and satisfied.

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