The Risks and Benefits of Menopausal Hormone Therapy in Younger and Older Women

Posted By SHL Librarian

Presented by: Marcia Stefanick, Ph.D.
Professor, Research, Stanford Prevention Research Center
November 16, 2006

Lecture Overview:
In one of the most stunning turnarounds in modern health care, it is no longer considered appropriate to give hormones to women to replace estrogen lost in the natural process of aging, i.e., at the time of menopause. According to Dr. Marcia Stefanick a series of myths became embedded in our culture, some of them actually hazardous, about using Menopausal Hormone Therapy (HT). In fact, it is now recommended that hormones are only given to menopausal women who have severe enough symptoms, for example, hot flashes and night sweats, that they feel they cannot carry on their normal lives, a far cry from the enthusiasm that once surrounded the use of HT with the expectation that it would prevent heart attacks, bone fractures, and dementia, and preserve youth. Dr. Stefanick discussed the landmark clinical trials that proved HT can, in fact, be harmful, by increasing heart attacks, strokes, blood clots, and dementia. Dr. Stefanick’s lecture recounted the highlights of several clinical trials that proved the new thinking on hormone use.

Furthermore, the truth is that there is relatively little known about hot flashes and night sweats or what a woman can to do, besides taking estrogen, to relieve these common symptoms. According to Dr. Stefanick a few useful hints include: dressing in layers that can be peeled off depending on the temperature, not wearing turtlenecks, and avoiding alcohol, caffeine and hot or spicy foods. Women are delighted by the simplicity and truth of this valuable advice. It is based on the fact that menopausal women do not dissipate heat well. There is also evidence that paced breathing might help. This is valuable advice indeed, as women everywhere await the results of new research initiatives that will hopefully yield a better understanding and clearer definition of menopause.

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Links to the Clinical Studies:
The Framingham Study

The SWAN Study

The HERS Trial

Links to Dr. Stefanick’s Stanford Profile and her work:

Farewell to Falls

Posted By SHL Librarian

Presented by: Ellen Corman, MRA
Injury Prevention Coordinator, Trauma Services
Stanford Hospital & Clinics

Lecture Overview:

  • Fifty percent of adults 80 and older fall each year
  • Most falls take place at home
  • Older adults who fall are two to three times more likely to fall again
  • Take proactive steps in your home to avoid falls by installing handrails, removing clutter and keeping floors clear
  • Exercise to maintain strength, balance and coordination
  • Have your physician check your medications

Nearly 1 million older Californians experience a fall each year. For people 65 years and older, falls are the most common source of injury resulting in a visit to the emergency room.

The odds of falling each year after age 65 are about one in three; after age 80 the chance of a fall is about 50-50. People are more likely to fall as they get older because of common, age-related physical changes and medical conditions, along with the medications prescribed to treat such conditions, weakness related to a sedentary lifestyle, and home and environmental obstacles. About 20 to 30 percent of the people who do fall face reduced mobility, and many people-even those who are not injured-develop a fear of doing it again.

“Older adults who have fallen are two to three times more likely to fall again within the next year,” said Ellen Corman, MRA, injury prevention coordinator for trauma services at Stanford Hospital & Clinics, who gave an hour-long presentation at the Redwood City Public Library on April 30. “The older you get-and the more risk factors involved-set up an even greater chance of falling.”

Corman asserts that falls do not take place because “I wasn’t watching,” or “I just tripped.” The reasons behind a fall can range from being tired and not lifting your feet properly to poor vision, distractions, slower reaction time and medications that cause dizziness or lightheadedness. Other factors can include physical weakness, cognitive impairment, depression, dehydration or a balance disorder.

But many falls can be prevented by making even small adjustments in three specific areas: your home environment, your medications and your exercise routines.

Taking Positive Steps
“When it comes to home safety, there are specific changes you can make to control your environment. Be proactive. There is usually a combination of factors so it’s important to take a multifaceted approach to making changes,” said Corman. “Most falls are preventable.”

Because more than 60 percent of falls occur at home, she stressed the importance of making some simple modifications to make it safe:

  • Get rid of your throw rugs. Hang them on the wall or give them to someone who will appreciate it.
  • Remove clutter-including papers, pet toys and the grandkids’ playthings.
  • Move electrical cords out of the way.
  • Wear thin-soled, non-skid shoes, sneakers or slippers, especially in homes with hardwood floors.
  • Use nightlights, and bring a nightlight with you when you travel.
  • Install grab bars in the bathroom. An occupational therapist can aid in making an accurate assessment of where to place the bars to suit your height and movements.

“My dream is that all homes have grab bars in the bathrooms, no matter what the person’s age,” Corman said.

Fitness is Key
Older adults generally score between 20 and 49 percent lower on strength tests-an impairment that makes them three times more likely to fall. While today’s older adults realize that exercise is important and tend to remain active in their later years, for too many people retirement means a sedentary lifestyle.

Corman mentioned one study of men and women aged 88 to 92 years involved in a simple exercise program: All participants showed improvement in strength and balance after only eight weeks.

“It’s never too late to start some kind of exercise,” she advised. “Keep moving, and try to mix it up.”

Corman recommended tai chi or a walking routine in a safe, flat location such as a mall or school track. She also emphasized the importance of including weight training to maintain strength.

Check Medications
The number, type and combination of medications can affect a person’s balance, perception and reaction time. Medications should be checked for side effects listed like lightheadedness or dizziness as these drugs could contribute to the potential for a fall. Check regularly for expiration dates, and be aware of possible complications from polypharmacy-the use of multiple medications that may interact.

Corman suggested that all medications be placed in a plastic bag and brought to a physician or pharmacist for review.

Support System
Stanford established the Farewell to Falls program in 2005 to assess potential trouble spots for seniors at risk for falling. The home-based program, free for Santa Clara and San Mateo county residents 65 and older, provides two home visits from an occupational therapist who evaluates the home for potential problems, performs a sensory-motor review and does a health risk interview. The therapist then offers individualized suggestions and a review of medications from a pharmacist. Participants also receive an exercise video to help improve strength and balance.

In addition to the home visits, participants receive periodic follow-up phone calls from volunteers to see how they’re doing. One year after the start of the program the occupational therapist returns to reassess the risk factors and to provide additional fall prevention tips.

“We’re hoping that seniors take advantage of this opportunity to participate in a program that can help them to maintain their independence,” said Corman, who added that more than 200 people take part in the program each year.

About the Speaker
Ellen Corman is the Injury Prevention Coordinator in the Trauma Service at Stanford Hospital & Clinics and has been involved in injury prevention activities for more than 20 years.

She is an occupational therapist and has a master’s degree in rehabilitation administration. Corman participated in the California state injury prevention strategic planning workgroup and is an active member of the California Stop Falls Network. She developed and manages the Stanford Hospital & Clinics Farewell to Falls program and co-chairs the San Mateo County Fall Prevention Task Force.

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Stanford Hospital & Clinics Farewell to Falls

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Fall Prevention Center of Excellence

American Geriatrics Society

Lifestyle and Safety Management

Posted By SHL Librarian

Presented by: Candace Mindigo, RN, BSN
Manager, Stanford Aging Adult Services
Stanford University Medical Center
October 28, 2009

Lecture Overview:

  • Diet and exercise are among the most important tools for maintaining health.
  • Keep blood pressure down by following a Mediterranean or DASH diet.
  • Keep your legal papers up to date and have copies located in one place so they are easy to find.
  • Modify your home to prevent falls-the No. 1 reason people come to the emergency room.
  • Stimulate your brain cells by taking on new mental challenges

With more and more adults living longer, it’s important to be aware of the many things you can do to make your later years healthful and stimulating, and keep you out of the hospital.

Heart disease, cancer, and stroke are responsible for 70 percent of all deaths. Certain steps can help lower the chances of developing these disorders.

Weight control. Many aspects of heart disease are preventable by developing healthy lifestyle habits, said Candace Mindigo, RN, manager of Stanford Aging Adult Services, at a presentation sponsored by Stanford Hospital Health Library. About one-half of deaths in the United States are attributable to preventable risk factors, particularly physical activity. Few Americans exercise enough, and 80 percent of men and 70 percent of women between the ages of 65 and 74 are overweight or obese.

Studies have shown that regular exercise can lower the risk of heart disease; delay onset of diabetes; improve blood pressure; reduce risk of falls and osteoporosis; and enhance cognitive function.

“To age well you need to maintain a healthy weight through diet and regular physical activity,” she said. “Even adding a small amount of exercise to your routine shows immense benefit. And as far as diet goes, less if better.”

Diet. Mindigo suggests following a Mediterranean or DASH (Dietary Approaches to Stop Hypertension) diet to keep blood pressure down. These diets are low in salt and emphasize generous amounts of fruits, vegetable, healthy fats, and whole grains. She suggested a diet that includes about 25-35 grams of fiber daily, three to four servings of fish a week, and only one or two servings of red meat a month. A good guideline, she suggested, is to compose your diet of 40-50 percent complex carbohydrates, 20-30 percent protein (chicken, salmon or white fish, eggs, tofu and soy products), and 30 percent monosaturated fat (olive oil, avocado, nuts).

Each person should know what his or her healthy weight and BMI (body mass index) should be, as well as cholesterol and glucose levels. It’s also important to keep up with annual screenings and booster shots, and to keep in touch with your primary care physician.

Because of increased longevity, more adults are living with multiple chronic conditions and are taking medications that can interact, affecting both physical and mental well-being.”Because the body’s metabolism changes as we age, it’s important to keep your physician up-to-date on your medications to avoid negative drug interactions,” Mindigo said. “Many people end up in the emergency room because they do not see a doctor on a regular basis.”

She also suggests finding ways to reduce stress, whether using guided imagery, meditation, or joining a support group. “The important thing is to take time during the day to do something you enjoy,” she said. “It helps to lower the heart rate.”

Paperwork. Be sure to bring all your legal papers up to date and have copies located in one place so they are easy to find. Older adults should complete an advance health care directive, living will, durable power of attorney for health, financial power of attorney, living trust, and conservatorship. Simplify finances by arranging for direct deposit and automatic bill payments, and minimize the number of accounts you maintain.

“People often don’t want to think about these things, but it is important to have them done,” Mindigo said. “You want to make your own decisions about your health, and it’s a gift to your children if you can be organized now, before anything goes wrong.

“Out-of-control paperwork, such as unopened mail, unusual purchases, disorganized paperwork, or late bills, is a warning sign for concern, she added.

Home safety. Falls are the No. 1 reason people come to the emergency room. Thirty percent of people over age 65 fall each year, which rises to 50 percent in people over age 80. Exercises that strengthen legs allow you to catch yourself in a fall, and Mindigo suggests taking calcium and Vitamin d daily to reduce the chance of osteoporosis.

Stanford established the Farewell to Falls program to assess potential trouble spots for seniors at risk for falling. The home-based program, free for Santa Clara and San Mateo county residents 65 and older, provides home visits to evaluate potential problems. Participants receive individualized suggestions and periodic follow-up phone calls from volunteers.

Because more than 60 percent of falls occur at home, Mindigo stressed the importance of making some simple modifications for safety:

  • Get rid of all throw rugs.
  • Remove clutter.
  • Use bright lights.
  • Use shoes with good support.
  • Keep items in easy reach.
  • Move electrical cords form walkways.
  • Install grab bars in the bathroom.
  • Have your vision checked regularly.

 Driving. “Giving up driving is a major step and needs to be grieved as a loss,” Mindigo said. “As your vision changes, you lose depth perception and have slower reaction time.  The time to back off is when driving makes you nervous. Or have a family member come with you and see if they’re comfortable with your driving skills.”

Cognition.  Exercising the mind is just as important for mental agility as physical activities are for a healthy body. While some occasional forgetfulness is normal, losing track of activities, forgetting how to accomplish common activities, repeating phrases, or having trouble handling money are not. “Keep your brain cells stimulated by taking on new challenges,” said Mindigo. “Maintain a balance of mental and physical activities, and stay socially active. Connecting with family and friends is good for you at every level.”

About the Speaker
Candace Mindigo, RN, BSN, is manager of Stanford Hospital’s Aging Adult Services, a program that provides specialized care and access to resources for older adults. The program’s extensive network offers consultations and assessments, assistance with appointments, physician referrals, advocacy, coordination of services, access to community resources, and educational workshops. Most of these services are free to community members.

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The Fatigue Prescription: Four Steps to Renewing your Energy, Health, and Life

Posted By SHL Librarian

Presented by: Linda Hawes Clever, MD
Clinical Professor of Medicine, UCSF
Thursday, November 4, 2010

Modern life is full of annoyances, irritations, frustrations, and demands. There are the big concerns like work and family and health, and there are the little things like traffic, dishes, barking dogs, and lost to-do lists. These stresses, great and small, can take a heavy toll, and for many people the constant barrage causes a real drain-physically, emotionally, and spiritually.

Chronic exhaustion can undermine your day-to-day functioning, said Linda Hawes Clever, MD, a clinical professor of medicine at University of California, San Francisco, at a presentation sponsored by the Stanford Health Library. Dr. Clever wrote a book called The Fatigue Prescription: Four Steps to Renewing Your Energy, Health, and Life, which provides some tips she has developed to treat physical and spiritual exhaustion. The trick is to develop tools to keep you going while you stick to your values, personal strength, and inner motivation.

Dr. Clever’s insights come from personal experience. Fifteen years ago she was barraged by bad luck: both of her parents died, she lost two jobs, and her husband was diagnosed with cancer-all in the span of 18 months. She took her years of expertise as a clinician and researcher, interviewed thousands of people about how they maintained their energy, and came up with four steps to put her theories of personal renewal into practice.

“We tend to take better care of our cars than we do of ourselves,” she said. “We need to find ways to renew and refresh ourselves. The way to do that is to find meaning in your life. By that I mean getting back in touch with your basic values and organizing your life around them.”

Whether your stress and fatigue come from dramatic events or just from the daily grind, Dr. Clever said one key is to identify the activities that refresh your spirit and to make room on your calendar to take part in them. Her approach involves personal reflection to help you rediscover your lost energy.

“Most of us want to have meaning in our lives,” she said. “Happiness comes from finding meaning, not from looking to be happy. In our search for purpose we can also find ways to renew, which replenishes our ability to be creative, optimistic, and energized.”

One of Dr. Clever’s tools is called a Renew-O-Meter, a series of questions designed to measure how well you juggle your commitments. Questions range from how many sit-down dinners did you have with your family or friends in the past week to when did you feel bold enough to take a risk to how many times did you really laugh yesterday?

Rating a high score in your willingness to take a risk reflects on your self-esteem and personal efficacy-feelings that can pervade all aspects of your daily life. In that way the meter can help raise self-knowledge, she said.

She highlighted four basic steps that can be used to renew your energy:

  • Awareness assesses the nature of your fatigue and its external and internal causes.
  • Reflection enables you to probe the sources of your feelings and to identify the positive people, activities, and experiences that support you.
  • Conversation creates opportunities for heartfelt openness in communication and feedback from loved ones and associates; it implies a willingness to share and to learn.
  • Plan-and-act allows you to develop a process of systematic change made up of small steps.

“Most of us tend to want to act but don’t love change,” she said, “so we need to change incrementally. By making a plan with small steps, your change is like stepping off a curb, not jumping out of an airplane.”

It’s important to note what aspects of your nature or habits can stop you from changing, and to be aware that resisting change can actually cause more fatigue. Your guidepost should be your personal values-the things that give you direction and satisfaction. Dr. Clever said a good way to define your values is to think about what you want written up in your obituary.

“Think about how you would like to be described. By living your values you can find meaning and have joy in your life,” she said. “Talk about them with your partner or family-shared values keep a family or community together and create common ground.”

She also discussed five traits of people who consider themselves capable of dealing with the vagaries of a stressful life. These people tend to:

  • Have close relationships with family and friends
  • Have a strong sense of spirituality or religious beliefs
  • Take care of their health
  • Like what they do for a living
  • Have a certain level of acceptance of their situation: They feel they can play the hand that’s dealt them.

“We can learn to exert power over ourselves,” said Dr. Clever. “You can find the freedom to choose your attitude, and that will energize and sustain you.”

About the Speaker
Linda Hawes Clever, MD, is a clinical professor of medicine at University of California, San Francisco, and the founder of RENEW, a nonprofit dedicated to helping people find purpose and direction. She received her medical degree from Stanford, where she completed her residency and fellowships, and she now serves as the medical school’s associate dean for alumni affairs. Dr. Clever is board certified in internal medicine and occupational medicine.

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Starting an Exercise Program: How Your Doctor Can Help

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Presented by: Paul Wang, MD
Director, Stanford Cardiac Arrhythmia Service

Nawal Atwan, MD
Clinical Instructor, Internal Medicine
Stanford University Medical Center
October 21, 2010

Lecture Overview:

  • Many heart conditions often have no symptoms, so it is important to screen young athletes before they start a sport or activity.
  • Screening should include a health history and a complete physical, which may include an electrocardiogram.
  • People over 40 who have symptoms of chest pain or shortness of breath should have a stress test before starting a new sport.
  • Mix up your routine to include exercises for cardiovascular health, weight training for strengthening muscles, and stretches for flexibility and balance.
  • Start with a plan and steadily increase your goals to measure improvement.

Most people know the many benefits of exercise. Including workouts into your routine has shown to increase longevity, reduce the risk of heart attack and stroke, improve cholesterol levels, lower blood pressure, prevent diabetes, and make you feel better. It helps with weight loss, strengthens bones, and enhances cognitive function-all concerns that affect the quality of life as we age.

Screen for Heart Conditions The only paradox to exercise is a very slight increase in the risk of heart attacks or death from cardiac arrest. Sudden cardiac arrest-when the heart ceases to beat without any warning-is one of the largest heart health problems in the United States. The heart’s electrical system goes awry, making it unable to pump blood to the rest of the body.

The chance of successful resuscitation drops 10 percent every minute, said Paul Wang, MD, director of the Stanford Cardiac Arrhythmia Service and Cardiac Electrophysiology Laboratory, who spoke about cardiovascular evaluation and screening at a presentation sponsored by the Stanford Health Library.

There are more adults with congenital heart defects than ever before, due in large part from improved surgeries. According to the 36th Bethesda Conference, which establishes guidelines for people with cardiac disorders, most congenital heart disease patients have a reduced ability to exercise. Experts are still debating how much exercise is appropriate and whether teens with a heart condition should be allowed to participate in sports.

Many heart conditions often have no symptoms, so it is especially important to screen young athletes before they start to participate in a sport or activity. In athletes younger than age 40, the most common underlying cause of heart problems is known as hypertrophic cardiomyopathy. This rare genetic disease causes the heart muscle (myocardium) to become abnormally thick, making it harder for the heart to pump blood.

The condition tends to manifest in the late teens, and the risk remains an ongoing concern, said Dr. Wang.

“If you’ve had an arrhythmia once, or have a condition that could lead to arrhythmia, the likelihood is higher that you can suffer from cardiac arrest,” he said. “The recommendations are that you should be excluded from most competitive sports.”

There are other conditions that young people should be screened for before taking on a strenuous sport, including anomalous coronary artery, a rare condition that can be detected by an angiogram. These youths should also be restricted in their athletic activities, said Dr. Wang.

In older athletes, the most common cause of problems is coronary artery disease-the buildup of plaque inside the blood vessels. Other conditions of concern include myocarditis, an inflammation of the heart wall, and Marfan syndrome, a disease that weakens the walls of the aorta.

Dr. Wang recommends that all young people see their doctor for a complete physical that includes a health history. An electrocardiogram may be helpful in some cases, but experts are still discussing its benefits. Athletes over 40 who have possible symptoms of heart disease such as chest pain or shortness of breath, and sedentary people with risk factors for heart disease should have a stress test before starting a new regimen. These tests can provide clues to help your physician uncover underlying disease.

“Screening athletes is an important aspect of safety,” he said. “Then follow-up is essential.”

Before You Start to Exercise Nawal Atwan, MD, provided more detail about the benefits of exercise and how to start a healthy regimen. She recommended working out at least 30 minutes five times a week and mixing activities for cardiovascular health, strengthening muscles, and stretching.

She suggested that you start with a plan and steadily increase your goals to measure improvement. Use a pedometer for inspiration, and be realistic about what you can and can’t do. Start with lower goals and then build up the intensity and frequency, she said.

Dr. Atwan suggested a visit to the doctor before starting a new exercise or to assess risk. The physical should assess your blood pressure, heart rate, cholesterol, body mass index (BMI), percentage of body fat, gait, balance, and hand grip. Your doctor may recommend an electrocardiogram or a stress test to measure your heart capacity.

Talk to your physician if you have joint pain or how to prevent developing joint problems. If you have arthritis, you may benefit from a low-impact activity like swimming or water aerobics, which studies have shown can decrease pain, she said. All participants should be sure to stretch as a warm-up and cool-down, holding each position for at least 30 seconds.

“There are lots of excuses to not exercise: no time, no motivation, it’s boring, it hurts. But it’s a matter of getting out there and doing something,” Dr. Atwan said. “Exercise is the cheapest drug around-you can get the same benefits as some medications and without any side effects.”

About the Speakers
Paul Wang, MD, is a professor of medicine (cardiology) and director of the Stanford Cardiac Arrhythmia Service and Cardiac Electrophysiology Laboratory. He received his medical education at the College of Physicians & Surgeons at Columbia University in New York, did his internship at New York Presbyterian Medical Center, and did his fellowship at Brigham and Women’s Hospital at Harvard Medical School.

Nawal Atwan, MD, is a clinical instructor of medicine (internal medicine) who specializes in women’s health, athletic health, and chronic disease management. She received her MD from Harvard Medical School and did her residency at Stanford. She joined Stanford in 2009. She is Board Certified by the American Board of Internal Medicine.

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WebMD: Starting an Exercise Program

Prescribing Drugs for an Aging Population

Posted By SHL Librarian

Presented by: Mehrdad Ayati, MD
Clinical Assistant Professor, Medicine
April 24, 2013

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In 1950, 8 percent of the U.S. population was 65 and older; by 2050, thanks to increased longevity and a dwindling birth rate, that number is expected to increase to 21 percent. In developing nations, the growth rate of the senior population is even more pronounced, opening up important questions about how these countries’ infrastructures and cultural traditions will need to change to accommodate a virtual tidal wave of older citizens.

Modern medication is a key reason why people are living so much longer. About a third of all medications today are prescribed to patients 65, and it’s projected that more than half will be prescribed to seniors by 2030. Part of this increase is because chronic diseases that arise in a person’s 30s and 40s tend to show complications at age 60-70. In addition, comorbidities tend to arise over time, which often leads to multiple medications, also known as polypharmacy. Comorbidities refers to more than one disease that develops in addition to a primary disease.

Increased Numbers

In today’s health care system, a patient may have several physicians, which can result in a situation known as a prescription cascade. A cascade occurs when a new medicine is prescribed to treat an adverse reaction to another drug because it appears that a new medical condition requiring treatment has developed. A second drug can cause another adverse reaction or increase the severity of the first response, according to Mehrdad Ayati, MD, a clinical professor of medicine, who spoke at a presentation sponsored by the Stanford Hospital Health Library.

Dr. Ayati described the process: A patient has trouble with sleeping and is prescribed a sleeping pill. Feeling drowsy, she receives a stimulant, which gives her heart palpitations. Her doctor prescribes a beta blocker for her racing heart, which make her depressed. She is prescribed an antidepressant.

“In six months a person like this could be on six medications,” he said, “though the real problem was simply the first drug. It’s a very typical situation, especially for older people.”

Polypharmacy can lead to a greater possibility of adverse drug events, which account for between 5 and 28 percent of acute admissions to both hospitals and clinics. Adverse drug events include errors in the way the medicine is used and reactions from the pharmacological properties of the drug itself, either alone or in combination with other medicines.

“The best prevention of an adverse drug event is knowing what is happening in the body,” Dr. Ayati said.

Different Metabolisms
Pharmacodynamics is the study of the biochemical and physiological effects of drugs on the body. Pharmacokinetics is how the body reacts to the drug and includes the processes of absorption, metabolism, distribution, and elimination. While absorption in the stomach and small intestine is the same biologically for both young and old, as you age, steady changes that can affect your ability to absorb medications, from changes in Ph balance to ongoing stress.

Most drugs are metabolized in the liver, which Dr. Ayati described as the body’s “central post office” organizing drug delivery by “Zip codes.” The liver’s cytochrome (CYP) system is responsible for 75 percent of drug metabolism by activating different enzymes that inhibit or metabolize a drug. Different metabolic rates will determine the effect of a drug, and a physician needs to know how fast a person’s metabolism is to avoid overprescribing and to avoid interactions that could lead to an adverse drug reaction.

“Slow metabolizers means that the drug stays active longer, so less is needed. In fast metabolizers the drug will dissipate quickly,” he said. “There’s not a universal response to a medication. For pain medication, for example, some people may need more frequent or larger dosages—which does make them drug addicts. Their body simply metabolizes differently.”

Important steps are being made toward personalized medicine—technology that uses a person’s unique genetic makeup to predict, monitor, and treat disease, including prescribing medication based on genetic background. Personalized medicine can identify people who have certain mutations in their CYP system, allowing physicians to know in advance how fast they will metabolize a drug.

Mixing Medications
Drug-to-drug interactions (DDI) occur in more than 80 percent of patients taking more than six medications at a time and in about 13 percent of patients using two medications or more. Interactions can be caused by over-the-counter medications, such as multivitamins, fish oil supplements, baby aspirin, or herbal remedies like St. John’s wort, garlic, echinacea, or gingko biloba. Herbal medicines are not regulated by the FDA and almost a third of them cause a drug-to-drug interaction. Even diet can affect a drug’s efficacy: Grapefruit is known to inhibit CYP for short periods after consumption.

“People often don’t realize that over-the-counter medications are pharmaceutical agents. There’s such an enormous number that no doctor can know them all,” Dr. Ayati said.

Once a drug is absorbed it is distributed around the body in the bloodstream. Drug distribution is affected by the changes in body composition associated with age, such as more body fat and lower hydration. The decreased muscle and tissue mass that accompanies aging also influences the distribution of certain drugs, as will the reduced blood flow to tissues and organs. And even healthy adults lose some renal function as they age, which affects elimination.

Drugs that require high levels of water and muscle to be absorbed may require lower dosages that are increased slowly or current dosages may need to be reduced as a patient ages. Drugs that are distributed through fat may require a larger volume for distribution and may take longer to be eliminated. Other drugs need to bind to albumin, a protein in the blood plasma; since older adults have less of this protein medications can compete for the available resource, making one stronger and the other impotent.

Be proactive
To optimize drug therapy, Dr. Ayati advised that patients and physicians work together to develop the most beneficial approach. “Start slow and low,” he said, “and don’t start to medications at the same time.”

Patients should ask some fundamental questions:

  • Is this medication necessary?
  • Will I die if I don’t take it?
  • What is the benefit?
  • What is the risk?
  • How can I assess the benefit?
  • What is the potential DDI?

Patients should also let all their doctors know of all their medications, prescribed and over-the-counter, and bring their prescriptions with them to office visits to avoid prescription cascade.

About the Speaker
Mehrdad Ayati, MD, is a Board Certified geriatrician. He is the Stanford medical director of the Sunnyvale Health Center and the Los Altos Subacute & Rehabilitation and Palo Alto Rehabilitation centers. He received his medical training from the Iran (Tehran) University of Medical Sciences and did his residency in the UC-Davis School of Medicine and his fellowship at Stanford.

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Living Longer, Living Well: Adult Children and Their Parents Plan for the Future

Posted By SHL Librarian

Presented by: Yusra Hussain, MD
Medical Director, Stanford Aging Adult Services
Stanford University Medical Center

Lecture Overview:

  • Many health concerns are not a natural part of aging and can be avoided or controlled by smart lifestyle changes
  • A healthy lifestyle is one that is rich in social activities, emotional relationships, physical activity, intelligent behavior choices and mental stimulation
  • Diet and exercise are the most important tools for maintaining health
  • Depression is not a normal part of aging and can be held at bay through social connections and by managing disabilities that induce isolation

The search for longevity goes back millennia-but is the quest a question of mortality or of quality of life? With today’s medical advances, adults are living longer and longer, many of them celebrating good health along with longevity. It’s important to be aware of the many components of aging, including physical health, mental agility and emotional well-being.

There are specific steps that can be taken to prolong good health and delay the onset of illness, said geriatrician Yusra Hussain, MD, medical director of Stanford Aging Adult Services, at a presentation sponsored by the Stanford Health Library. With positive lifestyle habits, plenty of exercise and activities, and strong social support, seniors can look forward to personal fulfillment and a long, healthy life.

“Many of what we consider geriatric conditions-such as incontinence, falls, cognitive decline-are not necessarily a natural part of aging,” she said. “There’s a huge difference between a 70-year-old who is independent and active, and one who is ill.”

Many of the ailments of old age are avoidable-or at least controllable-by making lifestyle changes. About one-half of deaths in the United States are attributable to adaptable risk factors, particularly physical activity. Fewer than half of Americans exercise enough, and 26 percent do no physical activity at all. More than two-thirds of the adult U.S. population is overweight or obese.

So what is a healthy lifestyle? Hussain defined it as one that was rich in social activities, emotional relationships, physical activity, intelligent behavior choices and mental stimulation. “Stay busy, eat well and control risk factors,” she said. She cited several specific areas that affect how we age:

Physiologic Change
“As we age, our metabolism changes, leading to less muscle mass and more fat,” Hussain said. “We have reduced liver and kidney function. And while we have less brain mass, we actually have more synaptic connections. New research shows there is great malleability in the brain, and new functions can be learned even later in life. I’m very optimistic about this and truly believe we do get wiser as we age.”

These physical changes cause us to eat lesser quantities and also affect how our bodies metabolize medication. Since older people are more likely to be on several prescriptions, it’s important to keep your physician up-to-date on your medications to avoid negative drug interactions.

Even adding a small amount of exercise to your routine shows immense benefit, said Hussain: It lowers the risk of heart disease; delays onset of diabetes; improves blood pressure, functional status and performance; reduces risk of falls and osteoporosis; and enhances mental health and cognitive function.

Choose an aerobic, resistance or balance routine that you can follow for a total of 60 minutes four or five days a week. Use light weights to improve muscle strength, and try to get up to your target heart rate (220 minus your age).

“Exercise is of paramount importance,” she said. “Find something you enjoy, and listen to your body. I see patients all the time who push themselves too hard. Make your body the judge of how much exercise is enough.”

Your diet should be rich in vegetables and fruits, low in simple carbohydrates, fats and cholesterol, and moderate in protein and dairy.

“I have a strong belief against artificial sweeteners, soda and processed food,” Hussain said. If you are eating a healthy diet, you don’t really need supplements.”

The exceptions, she added, include calcium and Vitamin D, since even in California, with its adequate sunshine, many people have a deficiency. Studies have not shown proven benefit to taking folic acid, Vitamin E, antioxidants or co-enzyme Q-10.

“If you do feel the need to take supplements, read the label, use standardized products made in the U.S. or in Europe, and review it with your doctor,” she said. “Be aware of your medications, including herbal supplements. My feeling is, unless your life or well-being depends on it, don’t take it.”

“In general, as we get older we gain weight,” Hussain said. “A little extra weight is actually a good thing because it acts as a reserve when we get ill. That said, there are myriad problems associated with excess weight. I’ve had patients who lost weight, and I literally crossed medical problems off their list.”

Cognitive Function
Mental exercises have been proven to improve brain health, she said. Data on the potential benefits of medications such as NSAIDs, statins and ginkgo biloba is inconclusive and still being studied.

Frailty is not really a disease but rather a combination of the aging process and a variety of medical problems, including heart conditions, osteoporosis and cognitive decline. Though common, it remains poorly understood: Part of the problem is that it defies exact definition.

Frailty can strongly affect how an elderly person will respond to medical treatment, as well as how long and how well they will live.

“Do not equate frailty with aging,” said Hussain. “Frailty is a syndrome by itself. I believe if we are diligent about screening and overall health, we can avoid this condition. It is not a normal part of aging.”

Emotional Health
Depression is associated with reduced levels of the neurotransmitter serotonin, impairing the body’s ability to respond quickly to external situations. Good emotional health involves finding ways to reduce stress and anxiety.

“Depression is not more common in the elderly. The only thing that remains steady in life is your personality,” said Hussain. “You have the same personality at age 86 as you did at age 26. Aging does not cause a change in personality.”

Hearing or vision problems are especially problematic in the elderly because they can affect social interactions and quality of life, leading to depression or isolation. Hussain described a patient who was being screened for dementia because he refused to interact with others; after his hearing was tested, she found his mental abilities were fine-he simply could not hear what was going on.

Other screenings, including tests for cancer, need to be done with a perspective toward quality of life rather than mere survival.

“Personal values affect both the need and the benefit,” she said.

Home Safety
“Make use of home health assessment agencies and LifeLine to keep your home safe,” she said.

About the Speaker
Yusra Hussain, MD, is a clinical instructor of geriatrics and the medical director of Stanford Hospital’s Aging Adult Services, a program designed to meet the unique demands of older adults by providing specialized care and access to resources. The program’s extensive network offers consultations and assessments, assistance with appointments, physician referrals, advocacy, coordination of services, access to community resources, and educational workshops. Hussain received her MD from Hahnemann University in Pennsylvania and has been at Stanford since 2005.

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Stanford Aging Adult Services

Stanford Medicine Magazine: Special Issue on Aging

Stanford Center on Longevity

Travel Medicine: What You Should Know Before You Go

Posted By SHL Librarian

Presented by: Brian Blackburn, MD
Assistant Professor, Medicine – Infectious Diseases
Stanford University Medical Center
May 10, 2012

Watch the video

Getting sick is not usually on the itinerary when planning a trip. Unfortunately though, travelers can be exposed to a wide array of diseases that are uncommon at home that can wreak havoc on even the best-laid vacation plans. International visitors often forget that exotic destinations can be dangerous and can put themselves in jeopardy if they don’t prepare for potential health problems.

As international and adventure excursions increase in popularity, physicians are recognizing the importance of understanding the special medical needs of travelers, overseas workers, and adventurers. It’s estimated that more than 760 million people will cross international borders this year and that number is expected to grow, according to Brian Blackburn, MD, a clinical assistant professor of infectious diseases and director of Stanford’s new Tropical Medicine and Travelers Health Clinic, who spoke at a presentation sponsored by the Stanford Health Library.

Despite the escalating number of people leaving for foreign lands, only 35 to 60 percent seek any medical advice before leaving home, and only 10 to 20 percent visit a travel health clinic, he said. But between 25 percent and 65 percent report some sort of health problem while overseas or after returning home.

People visiting friends or relatives (VFR travelers) take travel health precautions even less often but tend to report getting sick more and require more hospitalizations. VFR travelers often consider themselves to be at little risk because they are simply “going home” or because they consider themselves immune since they were exposed when young. “These people are actually at higher risk, so they should see a physician before a visit overseas,” he added.

The numbers back him up: Only 9 percent of tourist travelers to Africa who developed a fever had malaria, compared to 45 percent of VFR travelers. And more than 90 percent of all travelers report taking a risk by not following appropriate health precautions regarding eating and drinking.

“Much of travel health involves using common sense and being safe,” said Dr. Blackburn. “Avoid insects by using bed nets, proper clothing, and repellents with DEET. Be safe with food and water. Don’t swim in fresh water in certain areas. Drive carefully: Traffic accidents are the most common problem abroad—more than infectious diseases.”

Malaria is the most deadly parasitic disease in the world, said Dr. Blackburn, causing nearly 1 million deaths a year worldwide. Usually transmitted by a type of night-biting mosquito, malaria can be fatal in a matter of days. It causes fever and flulike symptoms, which usually take between a week and month to manifest. It’s most common in sub-Saharan Africa, Oceania, Asia, and South and Central America.

There are several effective medications available that can prevent malaria. All involve taking the drug before, during, and after travel to an area with malaria. The choice of drug depends on the travel destination and resistance patterns of malaria in that area, so talk to a physician about your itinerary to determine the most appropriate medication.

These chemophrophylaxis drugs include malarone, chloroquine, mefloquine, doxycycline, and primaquine, which vary in terms of cost, treatment regimen, and possible side effects.

International travelers should be up to date on vaccinations for measles and mumps, influenza, and hepatitis B. Most U.S. residents are immune to polio, but a one-time booster shot is recommended for adults going to certain countries in Africa and Asia.

Hepatitis A is now a routine childhood immunization, and requires two doses over six months although most people develop good immunity after the first dose.

A type of bacterial meningitis can be rapidly fatal, even with antibiotics. Immunization is recommended for travelers to certain countries in Africa and the Middle East. Re-vaccination is required every five years for those at continued or renewed risk.

Japanese encephalitis, a viral disease endemic to much of East, South, and Southeast Asia, is spread by mosquitoes in the (summer and fall. Despite its rarity for travelers, about one-third of people who show symptoms die from the disease. Long-term travelers to these areas or those spending time in rural sites should be vaccinated.

Rabies immunization is optional for most travelers since the disease is not common and vaccinations are expensive. However, for high-risk travelers, such as wildlife workers, veterinarians, or people expecting prolonged stays or rural exposure where medical facilities may be unavailable, a rabies shot may be a good idea. “Rabies is nearly 100 percent fatal. There’s essentially no treatment, so the only approach is to prevent it,” said Dr. Blackburn. With any bite, it is very important to clean the wound thoroughly, and seek medical attention immediately.

Some countries require proof of immunization against yellow fever for entry. Common in tropical areas of Africa and South America, this viral disease is spread by mosquitoes and is fatal in 20-50 percent of those infected. The risk of exposure is about 10 times higher in Africa than in South America.

With no cure available, vaccination is the most important measure against yellow fever. Re-vaccination is required every 10 years and needs to be done at least 10 days before departure. About 10 to 30 percent get a mild reaction to the vaccine, which can range from flulike symptoms to headache. Infants, pregnant women, people with a thymus condition, and immunocompromised patients should not get the vaccine, and the risks of the vaccine are also higher in people over age 60, said Dr. Blackburn.

Travelers to most of the developing world should receive the typhoid vaccine. Typhoid is a bacterium acquired by consuming contaminated water or food, and causes fever, abdominal pain, and other symptoms. The injectable vaccine is given as a single shot that lasts about two years; the live vaccine requires four oral doses over eight days and lasts about five years.

Travelers’ Diarrhea
Even the most experienced globetrotters, using all recommended food and water preparation precautions, can suffer bouts of travelers’ diarrhea. The most common ailment affecting overseas visitors, diarrhea is caused by bacteria (80-90 percent), viral infections (5-10 percent), or parasites (less than 10 percent). High-risk areas include most of Asia, the Middle East, Africa, Mexico, and Central and South America. Daily doses of Pepto-Bismol can decrease the possibility of acquiring diarrhea, although this is not routinely recommended. A course of antibiotics can treat rather than prevent the condition.

About the Speaker
Brian Blackburn, MD, is a clinical assistant professor of infectious diseases and the director of Stanford’s Tropical Medicine and Travelers’ Health Clinic. He received his MD from Chicago Medical School and did his internship, residency, and fellowship at Stanford. His research and clinical work has brought him to Liberia, Nigeria, Kenya, India, and Bangladesh. He is certified by the American Society of Tropical Medicine and Hygiene in tropical medicine and travelers’ health and by the American Board of Internal Medicine in infectious diseases and internal medicine.

About the Clinic
Stanford’s Tropical Medicine and Travelers’ Health Clinic was established to provide consultation and treatment for visitors abroad. It is located at:
900 Blake Wilbur Drive
Second Floor
Palo Alto, CA 94034

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Stanford Tropical Medicine and Travelers’ Health Clinic

Division of Infectious Diseases and Geographic Medicine

Centers for Disease Control / Travel

CDC Yellow Book (Guide for Travelers)

The Dawn of Personalized Medicine

Posted By SHL Librarian

Presented by: Euan Ashley, MD, PhD
Assistant Professor, Cardiovascular Medicine
Stanford University Medical Center
June 7, 2012

We know that genes play a crucial role in influencing how we look and act, as well as our susceptibility to disease. Now scientists are trying to use that knowledge in exciting new ways, such as preventing and treating health problems based on therapies tailored to an individual’s unique genetic makeup.

But to understand the future of genetically based personalized medicine, it’s important to understand the basics, says Euan Ashley, MD, PhD, an assistant professor of cardiovascular medicine and director of the Stanford Center for Inherited Cardiovascular Disease, who spoke at a presentation sponsored by the Stanford Health Library.

Human DNA is contained within 23 pairs of chromosomes, one half pair from each parent; genes are segments of DNA that determine specific characteristics, such as hair color or height. Some characteristics come from a single gene, while others come from gene combinations. Humans have about 20,000 genes (and so do worms), and the complete instructions they carry are called the human genome.

Genes hold the instructions for making the proteins that manage cell growth and function. When cells duplicate, this genetic information is passed along to the new cells. The genes may mutate over time, causing disease, and such variants can be passed along from parent to offspring. There are more than 3 billion units of information (letters) in the human genome.

Organizing the Information
But the human genome is not quite that straightforward. When mapping the genome, scientists found that blocks of DNA, called haplotype blocks, tend to stay together. By measuring single letter variants called SNPs in each of these blocks, they were able to look across the whole genome at once.

Using a chip to look at the genes or the cell messages that come from the genes was developed at Stanford and now is used as a tool by researchers worldwide. Over the past couple of decades, using such chips, researchers have identified more than 4,000 single genetic variants associated with disease. Most diseases, however, are caused by a multitude of variants acting together.

“Gene chips allowed researchers to look at large populations and associate a genetic variant with a disease,” said Dr. Ashley. “There was a deluge of strong associations within just a few years. Sequencing (spelling out the letters)  the entire genome has come down in price dramatically: 10 years ago a human genome sequence cost about $100 million; today it runs close to $1,000, making the process accessible to most labs and hospitals, and moving toward the day when the genome is used as a routine part of medical practice.

New Clinical Tool
Another enormous step occurred when a Stanford scientist sequenced his entire genome three years ago. He had a family history of severe heart disease that was reviewed by Dr. Ashley—a genetic heart specialist—which made Dr. Ashley the first physician with access to a patient’s complete genome. He put together a team of Stanford scientists to help analyze it.

“Having the patient’s genome available allowed us to look at the possibility of disease, the clinical risk, and what drugs he would or would not respond to,” said Dr. Ashley, referring to pharmacogenetics. “Access to a person’s genome enables us to look at the genetic information in a way that makes sense for clinical medicine. We can look at a patient’s potential response to medication based on their individual genetic makeup.”

Whole-genome sequencing could identify and help prevent heart problems—and other life-threatening diseases—in patients who seem healthy but may be at risk because of an inherited predisposition, he added. Because he could review his patent’s genome, Dr. Ashley was able to make a list of drugs to avoid based on genetic variations associated with reactions with common medicines. His analysis indicated that the patient would respond well to statins.

“Personalized medicine is about individual risk for disease and targeted preventive care,” said Dr. Ashley. “We are only now taking the first steps toward integrating this information into clinical care, and we still have a lot to learn in terms of interpreting the data.”

For now, he adds, clinical applications for an individual’s complete genome have more potential in challenging cases such as rare family syndromes, and studies are underway for genetic response to stent restenosis and drug resistance.

About the Speaker
Euan Ashley, MRCP, DPhil, FACC, FAHA, is an assistant professor of cardiovascular medicine and director of the Center for Inherited Cardiovascular Disease, a multidisciplinary program that coordinates care for adults and children with genetic disorders of the heart and blood vessels. He is a member of the leadership group of the American Heart Association’s Council on Functional Genomics, deputy director of the Stanford Cardiovascular Institute, and a member of the roundtable on genomics of the Institute of Medicine. An exercise physiology graduate of the University of Glasgow, Dr. Ashley received his PhD in molecular cardiology from the University of Oxford and his MRCP in medicine from the Royal College of Physicians. He joined Stanford in 2003.

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Dr. Ashley’s Research Laboratory

About the Human Genome Project

Diabetes and Exercise

Posted By SHL Librarian

Presented by: Baldeep Singh, MD
Clinical Assistant Professor, Medicine

Kathleen Wasowski, DPT
Senior Physical Therapist, Orthopedics and Sports Medicine

November 13, 2014

Type 2 diabetes, once known as adult-onset or noninsulin-dependent diabetes, is a chronic condition that affects the way your body metabolizes sugar (glucose). Patients with type 2 diabetes do produce insulin—just not enough to keep their glucose levels normal. Maintaining proper sugar levels not only prevents serious complications to the body’s organs and tissues but also improves resistance to infection, increases, energy, and sustain overall health, said Baldeep Singh, MD, a clinical assistant professor of medicine, at a presentation sponsored by the Stanford Health Library. The evening was part of a three-part series on the major concerns related to type 2 diabetes.

Dr. Singh suggests patients take a simple, “ABC” approach to controlling their blood sugar that focuses on attitude, blood sugar, control, diet, exercise, and fortitude. Exercise, in particular, is one of the most important ways to control diabetes 2 and has been shown in multiple studies to control insulin and reduce the onset of the disease.

“It’s all plus and no minus,” he said. “Tackling pre-diabetes (when blood sugar levels are above normal) early can prevent it from becoming full-blown disease.”

Positive Impact
Exercise helps the body run more efficiently and improves circulation, energy levels, sleep quality, muscle strength, cognition, and recovery from injury, said Kathleen Wasowski, DPT, a senior physical therapist. It also burns excess body fat, helping to decrease and control weight.

People who are physically active for about seven hours a week have a 40 percent lower risk of dying early than those who are active for less than 30 minutes a week. The Centers for Disease Control and Prevention (CDC) recommends at least 30 minutes of moderate-intensity physical activity five or more days of the week or at least 20 minutes of vigorous-intensity physical activity three or more days a week. Moderate-intensity exercise can include day-to-day activities like gardening or walking, while vigorous-level activities include swimming, biking, or running.

Research has found that 10 minutes of activity three times a day has the same benefit as 30 consecutive minutes, making it easy to get started or work with a busy schedule and still get good results. Older adults or those with chronic conditions should be as physically active as their abilities allow.

“For all individuals, some activity is better than none,” she said. “Physical activity is safe for almost everyone, and the health benefits far outweigh any risks.”

Set a Goal
Using the rate of perceived exertion (RPE), you should feel effort, not exhaustion.

Maximum heart rate can be obtained by subtracting your age from 220. Target heart rate for moderate activities should be 50 to 70 percent of maximum; vigorous intensity physical activity would require 70 to 85 percent intensity of maximum heart rate.

There are four main types of exercise:

  • Aerobic exercise raises your heart rate and keeps it up for an extended period of time. It is the most important exercise for diabetics and for general health benefits.
  • Strength/Resistance training builds muscle mass and is recommended twice a week after an aerobic workout. It includes lifting weights, elastic bands, and exercises that use your body weight such as squats, lunges, and push-ups. Strength training makes your body more sensitive to insulin and can lower blood glucose.
  • Flexibility/Stretching keep your joints flexible and prevent stiffness. Yoga, tai chi, and pilates can help develop the routine of exercising also help to strengthen the core.
  • Balance is critical for improved safety, especially for people with joint probems or neuropathy. Keep safety in mind by standing near a wall or stable surface if you are unsure about your balance.

There are many chances to be active throughout the day; the more you move, the more calories you burn. Incorporate activity into your daily life by taking the stairs, parking far from your destination, garden, or do housecleaning at a more energetic level.

Moderate exercise can increase glucose usage by up to 20 times the normal rate, helping to lowers blood sugar levels.

But intense exercise can have the opposite effect and temporarily increase blood glucose levels right after you stop because the body perceives intense exercise as a stress. Diabetics may need to check sugar levels after exercise. To reduce the risk of hypoglycemia if you have diabetes, follow a regular routine of exercising, eating your meals, and taking your medicines at the same time each day. If your blood sugar is very high, you may need to hold off on intense exercise.

Create a Habit
To start incorporating exercise, be realistic about your current levels of activity and start slowly, she advised. Find something you like to do and set realistic, measurable goals. Increase intensity only about 10 percent every few workouts so you don’t “crash and burn.”

“Doing something is better than nothing,” Ms. Wasowski said. “Five minutes of exercise done daily is far better than 30 minutes done occasionally. It also is a great way to start a habit of moving regularly that you can gradually build up.”

About the Program
In type 2 diabetes, your body does not use insulin properly, a condition called insulin resistance. The pancreas makes extra insulin at first, but over time it is not able to produce enough insulin to keep blood glucose levels normal. When glucose builds up in the blood, instead of being used by cells for energy it can starve cells and lead to organ and nerve damage. Type 2 diabetes usually gets worse over time if steps are not taken to curb its progression. This series addresses some of the biggest concerns related to type 2 diabetes: prevention, exercise, and nutrition.

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General Medicine Disciplines

Strong for Life

Types of Activity – American Diabetes Association

Staying Motivated – American Diabetes Association

Centers for Disease Control