​Prairie Doc® Perspectives for week of December 1, 2019
How to Live 40 Percent Longer
By Richard P. Holm, MD
 
“Doc, I’ve started on this new diet and I wonder what you think,” said my patient. Then I hear about the patient’s latest weight loss plan. There are so many plans out there...the Noom® plan, the Shark Tank diet, the keto diet, the Mediterranean diet, the paleo diet, the sugar-free diet, the low-carbohydrate diet, the one day a week fast. Some diets increase the intake of water, of fiber, of antioxidants and the list goes on. Many of these new plans are variations of a low-carb plan, which I like. I also have found that a weekly fast seems to work for some people.
 
About 20 years ago, two huge studies compared the low-carbohydrate diet with the low-fat diet. Both studies showed the same thing. People liked the low-carb diet better and with it, they lost more weight easily and initially. After one year, however, most people from both groups regained the weight they had lost. Similar studies through many years showed the same thing, no plan seems to keep the weight off long term. The two questions commonly left unanswered are, is it good to eat less, even without weight loss; and how important is exercise in all this?
 
The most powerful studies have shown that when people eat 40 percent less than what they would eat if they had no limit, they live about 40 percent longer. It is the calorie count that matters, not weight loss. Add to this the multiple scientific studies that show if an overweight person is fit and in good condition then their risks of death are no greater than for a thin person who is in good condition.
 
When people ask me, I recommend starting with three to seven days of calorie counting and exercise measurement before any changes are made. The calorie goal depends on one’s height and age, but an average sized middle-aged woman or man needs fewer than 1800-2000 calories per day for maintenance and at least one mile of walking per day. By the way, I think a balanced diet with plenty of vegetables and fewer carbohydrates makes the transition easier to tolerate and is especially good if one is diabetic or pre-diabetic. The most important point remains…fewer calories.
 
Bottom line: Setting a goal to “lose weight” puts you at risk for disappointment. For heavy and thin people alike, your best chance for success is to be mindful of your calorie intake and exercise regularly. Then, love yourself as you are.
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.       

By Richard P. Holm, MD
 
Of the 40 million people with hearing loss in the U.S., 25 percent of those, or 10 million, have lost their hearing as a result of exposure to excessive noise. But how much noise is too much?
 
Measured as decibels (dB), the acceptable manufacturing noise standard is to allow a daily exposure up to but not over 85 dB in an eight-hour period. More than that can cause permanent injury to our hearing. This is likely due to wear and tear on the tiny hairs that vibrate when sound is introduced. It’s like a line of kids walking across one path on the grass day after day. A little is good, too much kills the grass.
 
The average conversation, for example, is usually around 50-60 dB, street noises at 70-80, and an operating lawnmower at about 90. Noise levels above 90 come from surprising places like screaming babies, convertibles driving at 60 mph, marching bands, leaf blowers, hand and hair driers, and those noisy electronically amplified concerts. Single loud sounds like gunfire at about 150 dB can also be damaging, but the time exposed to lower volumes are the most significant and unrecognized danger we face daily.
 
A recent social trend has created a new threat. Tuning out the world with ear buds, while turning up the tunes for hours, can be like riding on the two-cylinder John Deere tractor with no cab all day while cultivating corn. Those old two-cylinders were loud, and so it can be with ear buds! Ear bud volumes at 100 dB for as short as 15 minutes can damage hearing. Again, it’s the volume multiplied by time that makes it so bad. One study showed that 97 percent of third graders had documented exposure to hazardous sound levels. Another showed that 12.5 percent of 6 to 19-year-olds in the U.S. already had hearing loss directly attributed to noise exposure.
 
What’s more, if the volume is too loud, ear buds can be even more dangerous as they may prevent us from hearing the noises that help us avoid danger. For example, walkers, runners, and bicyclists need their ears to hear when a truck might be coming from behind.
 
Of course, it isn’t just noise that can reduce our hearing. Infections, trauma, and even medications like antibiotics, chemotherapy drugs, or pain medications can do it too. Seek medical help if you notice your hearing is changing.
 
The bottom line: Protect your ears by avoiding exposure to too much noise, get help if your hearing changes and beware of ear bud risks.
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.                

By Richard P. Holm, MD
 
A muddle and mixture of family and friends surrounded the dying elderly woman like she was a campfire. They came to honor and pay their respects; many generations, from all over the country. This group seemed well educated, well-read, and the intellectual discussions were tossed around in that room like a basketball. She had said, to all, that it was time. “Please stop the dialysis,” she insisted, and, it was stopped. At first, she was almost holding court, but over the days, as she was slipping across to the other side, the hymns started filling the room, spilling out into the hospital halls, helping to carry her home. Tears of sadness, appreciation, joy and family love flowed freely the night she died.
 
Hers was a story about language, literature, ethics, music and spirit. Take away language and literature, and the appreciation she deserved for years of pushing for education and learning for her family and friends would have passed without notice. Take away ethics, and the patient wouldn’t have known she could stop dialysis. Take away music and spiritual energy, and the family wouldn’t have grasped the true depth and value of the woman or the connection and love they shared with her and each other. The humanities give us meaning, but, from where and why did they begin?
 
There is no record or hard evidence as to how or when Homo sapiens began speaking, but there are plenty of theories. The one I like the most asserts that, at first, we sang and drummed descriptive sounds while pantomiming hunting stories around the campfire until, over hundreds and thousands of years, words and lyrics evolved. Much later, words became literature when written down in a retrievable way, first on clay tablets, then, on papyrus, parchment, paper and, now, computers.
 
More than one linguistic expert has theorized that it was language which facilitated the Homo sapiens species to grow and dominate. When ethical words about a common virtue, or rule, convinced, inspired and unified large collections of tribes, these ancient groups became empowered. Words from The Golden Rule, “Do unto others as you would have them do unto you,” or the Code of Hammurabi, “A bag of barley is worth two shekels of silver,” and even song lyrics like, “Kyrie eleison (Lord, have mercy),” have pushed civilization forward.
 
The history of humanity has been made bright by language, literature, ethics, music and spirit. Also bright was that room with the elderly dying patient and her loving and singing family and friends.
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.                

By Richard P. Holm, MD
 
If you don't use it, you'll lose it. I bet I've heard and repeated this age-old aphorism a million times. But can it be over-used?
 
The adage about using it certainly fits when trying to enhance wellness for all sorts of medical systems: working the brain with puzzles and conversation helps ward off memory loss; walking fast enough to cause one to huff and puff, keeps the heart and lungs strong; regular sexual activity helps prevent impotence; filling the gut with a high fiber diet keeps the bowels in shape and makes you a regular sort-a-guy.
 
But what can you do when it hurts to move those old joints? Should you rest or should you exercise a joint with degenerative osteoarthritis? Experts say this depends on the state of that arthritis. If it is a hot and inflamed joint, it's better to address it first with expert advice, medication and time and not to force a lot of movement until later when it is cooled down. If, however, it is the cool-yet-stiff type of arthritis, then that’s a different story.
 
I always go back to a famous study that involved older people with very bad osteoarthritic knees, the kind that the orthopedic surgeon would call bone-on-bone. Scientists divided these arthritic patients into two groups. The first group continued their sedentary habits and the second group was pushed to regularly walk, stretch, and move on those worn out knees. Which group do you think did better? You guessed it, the members of the exercise group rated themselves to be in less overall pain, were better able to stay mobile and considered themselves happier in general than the sedentary group. One physician friend advised me once that, “Motion is the lotion for keeping those stiff joints moving.”
 
The American College of Rheumatology gives us the following recommendations:

• Though some of the joint changes of osteoarthritis are irreversible and sometimes surgery is required to get a severely arthritic person moving again, most patients will not need joint replacement surgery;
• Keep in mind that symptoms of osteoarthritis can vary greatly among those affected;
• Exercise is an important part of what we do to decrease joint pain and increase function.

 
So, say it again to yourself every morning while looking at the person in that mirror: "Use it or lose it."
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.                

​By Richard P. Holm, MD
 
The elderly patient came back to our rural hospital from a hospital in a nearby larger city after having had major surgery and feeding-tube placement. The care from the bigger hospital was superb except that the patient was getting too much nutrient and fluids and was a bit “overloaded.” Also, the family was concerned that perhaps they had been too aggressive in getting stressful surgery for their elderly mom, whose memory had begun to slip. As her physician, I cut back on the feeding-tube supplements, stopped the intravenous fluids, provided a little diuretic and did labs and X-ray for dementia. I took plenty of time with family and patient learning about their wishes should our patient again deteriorate. All agreed to emphasize comfort from here on out, and if she started to fail, we would do our best in her home hospital and not transfer her care again.
 
I had been that patient’s primary care doc for years. Practicing outpatient and inpatient care in a smaller town gave me the experience to see what was happening. The patient and family knew me, trusted me and appreciated the time I spent listening to her. Quality care reviewers, government oversight people and insurance companies also know the value of a well-trained rural primary care provider who not only understands how to care for complex patients, but also, knows when and where to refer when specialized care is needed. In fact, experts believe an ideal system would define a primary care provider for every person.
 
Unfortunately, there are not enough rural primary care docs. Many speculate as to why this is; however, I believe the need has resulted from misinformed med students and residents who think the lifestyle in rural America is not satisfying enough. In the July 2019 issue of South Dakota Medicine, a survey of family physicians practicing in this state found much lower burnout rates in family docs practicing in rural areas (25 percent) compared with those practicing in larger metropolitan areas (51 percent). Evidently, some social aspects of rural practice seem to confer a protective effect against burnout. This new data should be helpful when young physicians are looking for the most satisfying places to practice.
 
My elderly patient went home in about a week, happy with our community hospital and the care she received. Her doctor was also pleased, as he had the reward of successful care, the honor of satisfied family and the joy of truly helping someone while practicing in a rural setting.
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.       

By Richard P. Holm, MD
 
I am a physician who believes in evidence-based science. I am also old, approaching my own “last chapter” from pancreatic cancer. I share this, not to engender pity . . . none. Rather, I share this in order to give you a sense of my potential bias as I write about the question; do we have a spirit or soul that is more than a brain-chemical reaction that will go away at death?
 
Of course, the ultimate answer to that question is, nobody knows. Some archeologists believe that religion first began when someone wondered what happened to the life force or spirit of a young boy after he died. Where did it go? Archeologists speculate that “job one” for the early church (and, for that matter, churches of today) was to reassure and comfort the family after the death of a dear one. However, just because it reassures us, doesn’t prove the soul exists, but there are other experiences that do.
 
I remember my mother explaining to me one night before prayers that there is so much more going on than we know, so much that cannot be explained by physics and chemistry. She described waking up in the middle of the night in Minneapolis during WWII, filled with dread at the same moment that my dad was landing on some Pacific Island in full combat. That was something about which she could not have known due to radio and mail silence. How DID she know? Do we have spiritual connections we simply don’t understand?
 
During my career, at least three patients described a near-death-experience with all its typical raiment including an out-of-body experience, a warm and comforting light, a life-review (like a movie) and reassurance that there is nothing to fear about dying. A recent meta-survey indicated that this happens in 17 percent of people who are resuscitated and in equal percentages throughout all cultures and religions. It is also amazing to learn that the warm light is seen even by people blind from birth.
 
Even as a stubborn science-based guy, together with years of experience as a geriatric internist and hospice director, I truly find a community faith with a loving and inclusionary church very reassuring. I have reason to believe that there is a spirit within us that connects us all and that doesn’t die with our bodies.
 
I have been at the bedsides of many dying people, while their spirits lift from the body and pass through the porthole of eternity. Being there has brought me to believe that the soul is more than a brain-chemical reaction that goes away after death.
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPTV most Thursdays at 7 p.m. central.        

By Richard P. Holm, MD
 
Years ago, a family brought a 25-year-old farmer into the emergency room with a gunshot hole over his heart and with no pulse or breathing for more than ten minutes. It was a self-inflicted wound and this young farmer would farm no more. The family was besides themselves with loud and sorrowful wailing that wrenched my soul. They told me that the impending harvest looked poor, the loan was coming due, and he had been isolating himself, drinking more and getting angry at every little thing. They had no clue he was at risk of suicide. Sure, he was a little down, but not this! He picked a permanent answer to a temporary problem.
 
Significant thoughts of suicide occur in one of four women and one of eight men. Although there are more attempts by women, more deaths occur by men. In 2017 there were 1.4 million attempts and 47,000 deaths due to suicide, and despite these high numbers, the money invested in depression and suicide research is sadly low.
 
Risk factors for suicide include family history or prior experience of depression or manic depression, a history of being abused or being an abuser, excessive use of alcohol, sleeping pills or substance dependence, a recent emotional loss or a significant medical illness. Also, there is higher risk during local epidemics of suicide in youth especially on reservations. Sometimes depression and suicide have no reason whatsoever.
 
How can any of us help ourselves or a person at risk? First, remember it never hurts to ask, “Are you thinking about suicide?” Those words will NOT bring it on but could encourage the person to find someone to give lifesaving assistance. If you sense there is an emotional downward change happening, encourage that person to get help. If depression is milder and NOT at the suicide level, nonmedicinal treatment can give relief. Examples abound such as daily 30-minute walks, regular interaction with friends and family and the regular opening of one’s heart to spiritual connectedness. If more help is needed, talk with your physician or care provider and consider medicines that effectively work for depression. Although two thirds of people with depression do not seek or receive help; when the one third who do get help are treated, four out of five of those folks are better in a month. Get help if needed.
 
Finally, if you are in crisis, call the Suicide Prevention Lifeline at 1-800-273-TALK (8255) which is available 24/7. Please don’t chose a permanent answer to a temporary problem.
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPTV most Thursdays at 7 p.m. central.            

By Richard P. Holm, MD
 
The world of radiology began in 1895 when a European physicist Wilhelm Röntgen noticed fluorescence behind heavy cardboard when a cathode tube was activated nearby. Röntgen used his wife’s hand to demonstrate for the first time how these unknown rays, or X-rays, could penetrate the soft tissue of a hand and illustrate the bones that lay within. Röntgen generously refused to patent his discovery which allowed the explosive growth and development of a new industry.
 
Unfortunately, the first researchers were unaware of the dangers of too much X-ray exposure and, during the early years, harm was done even causing death to some experimenters before safeguards were established. Over time, as technology advanced and more X-rays were being utilized in medicine, interpreting the images became a more difficult challenge and the field of radiology developed. Physicians trained in X-ray INTERPRETATION helped other physicians make better clinical decisions.
 
I was a first-year resident at Emory University Hospital in Atlanta in the fall of 1975 when the hospital purchased one of the earliest computerized tomography (CT) scanners. It was called an EMI scanner named after the British company, Electric and Music Industries, that took the financial risk for developing the technology. Years earlier, EMI had signed with the Beatles as their recording company. Having amassed a fortune from the exponential rise of Beatles popularity, EMI was able to fund the theoretical work of Godfrey Hounsfield. His invention took X-rays of the head from all directions while a computer compiled the results. “With a little help from his friends” at EMI, Hounsfield’s brainchild happened.
 
I was rotating through neurology when the results of the EMI scans started making an impact. We were amazed how they showed tumors, blood clots and lesions inside the skull. We thought it was going to change everything, and indeed it did!
 
Jump to the present and see how INTERPRETIVE radiologists have expanded into INTERVENTION. Now, instead of simply identifying a tumor or abscess with ultrasound, X-ray, CT or MRI, radiologists, under the guidance of an imaging modality, can pass a needle into a deep tumor and take a biopsy, drain an abscess, open-up a blocked tube and much more. Procedures that, in the past, would have required open abdominal or chest surgery, now can be done with minimal trauma, with minimal pain and with quick recovery.
 
As a patient who has benefited under the expert image-guided hands of an INTERVENTIONAL radiologist, I too can sing loud and clear, “I get by with a lot of help from my friends.”
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPTV most Thursdays at 7 p.m. central.            

By Tom Dean, MD
 
Health care costs too much. The U.S. spends twice as much as other wealthy nations and yet we have poorer outcomes. Patients in this country visit physicians less frequently and spend less time in hospitals than residents of other wealthy countries. So, why such high costs? It's a complex issue with no simple answer.
 
Experts have identified three major factors contributing to this situation. The most significant is higher prices, followed by costly administrative complexity and finally, the use of ineffective or overly aggressive medical interventions that provide little benefit to patients.
 
What about prices? The average U.S. hospital discharge costs over $29,000 compared to $18,000 in the Netherlands and $16,000 in Canada. The average MRI price in Australia is $350 compared to $1145 in the U.S.  Prices, especially drug prices keep going higher. Lantus insulin introduced nearly 20 years ago at about $35 per vial now sells for $260. The U.K. price is $26. Gleevec, a remarkably effective drug for leukemia, introduced in 2001 at $26,000 per year, more recently sells for $120,000. The generic form sells for $96,000.
 
Trying to control costs in the U.S., both the government and insurance companies have applied complex regulations resulting in the addition of administrative staff and steadily increasing expenditures. Studies show that 20 to 30 percent of health care expenditures now go to cover admin costs, a much higher rate than other countries.
 
What to do? As a society we have depended on market forces to control prices. This is effective when selling groceries and gasoline but in health care it has failed. The simple explanation is that health care providers do not compete based on price. Even when patients have comparative cost information, they all too often do not select the most cost-effective approach.
 
Too little incentive exists for providers, especially physicians, to seek out the most efficient approach to care. In fact, existing financial incentives often push physicians and other providers in the opposite direction – the more you do the more you are paid.
 
Bottom line: As a society we in the U.S. have never figured out where health care fits in the spectrum of economic activity. Is it a commercial product like automobiles and blue jeans where those with more resources can purchase more elaborate products, or is it a basic human service like public education or fire protection to be made available to everyone?
 
In the words of the late Professor Uwe Reinhardt, one of the giants of health policy analysis, what we have is a philosophical and ethical challenge not an economic one.
 
Tom Dean, MD of Wessington Springs, South Dakota is a contributing Prairie Doc® columnist who has practiced family medicine for more than 38 years. He served as a member of the Medicare Payment Advisory Commission. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPTV most Thursdays at 7 p.m. central.   

​By Andrew Ellsworth, MD
 
What if there was something you could drink that could help you live longer and was free? Would you drink it? What if I offered something else to drink that could shorten your life and would cost you one dollar? Would you want to buy it?
 
As you might have guessed, the initial question refers to water, which is healthy and free, for the most part. Meanwhile, the latter question refers to a less desirable alternative, soda pop.  
 
A recent study involving half a million people in Europe found that drinking soda pop was associated with a greater risk of death from any cause. What’s even more interesting is how this study found that both regular and diet soft drinks were bad for your health. Drinking sugar sweetened beverages, such as regular sodas, increases your risk of digestive disease deaths. Meanwhile, drinking artificially sweetened beverages, like diet sodas, increases your risk of dying from cardiovascular diseases. 
 
I’m sorry to say, but that diet soda may increase your risk of a heart attack or stroke. These findings were most significant when people drank two or more sugar or artificially sweetened beverages per day, compared to less than one per month.  
 
This study was published in September 2019 in the Journal of the American Medical Association Internal Medicine. It showed associations, which means it saw connections, but it doesn’t necessarily prove a cause and effect relationship. However, this was an impressive study involving half a million people followed for over 16 years. It excluded people if they already had cancer, diabetes, stroke, or heart disease and it tried to account for body weight and smoking as well. Furthermore, other studies have found similar results. 
 
If you really want a soda pop, it’s not going to kill you to have one, but you probably don’t need several every day. If you do, why not try cutting down? If you don’t feel like drinking a glass of water, consider trying a sparkling water, or maybe take a glass of water and put a slice of lemon in it. Maybe try a natural sweetener like honey. Or, have a glass of milk.  
 
In the last several years, people are drinking less soda pop, and the large soda corporations are listening to consumer demands. You may notice some alternatives the next time you walk down the beverage aisle at the grocery store. However, pay close attention to what’s in them. Many are still loaded with sugar, and others have artificial sweeteners. Be wary of sports drinks, juice, supplement drinks and other alternatives.  
 
My recommendation is to enjoy a tall glass of water. It’s good for your health, good for your pocketbook, and you just might feel the satisfaction of self-care. 
 
Andrew Ellsworth, MD of Brookings, SD is a contributing Prairie Doc® columnist who has practiced family medicine for more than seven years. He is immediate past president of South Dakota Academy of Family Physicians. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPTV most Thursdays at 7 p.m. central.