family doctors
The Calorie Creep
But Doctor I am not eating that much…
While there are always exceptions rarely does one become overweight by not eating.
The balancing act of creating a calorie deficit is key for weight loss. Please see my prior blog post regarding the fundamentals of weight loss:
Calories Consumed < Calories Expended= Weight Loss
It can be one misstep in your day that will sabotage all your good efforts. Stealing the term introduced to me by an inspiring patient, I would like to bring “the calorie creep” to life in the pictures below:
Keep in mind it does not have to be junk food that can be your calorie creep–avoid the creep in whatever form!
Ann Riggs, DO
Sneezing, Runny Nose, Itchy Eyes are Here
ALLERGY SYMPTOMS
- Cough
- Runny nose
- Sneezing
- Itchy nose
- Sore throat
- Watery eyes
- Puffey eyes
- Itchy eyes
- Asthma flares
- Difficulty breathing
TIMOTHY GRASS ALLERGIES
One of the most common allergens is grasses and specifically timothy grass. We are seeing these right now. While preventive treatment is ideal, treatment is currently focused on relieving the symptoms. There is a new option for allergy sufferers of common grasses for future seasons. The middle of freezing temperatures is when the grasses are dormant. It is that time that preventive treatment needs to start.
The newest option to treat for the timothy grass allergen is Grastek. This is immunotherapy in a pill. For those that have endured the weekly shots this is a novel, relatively painless approach to immunotherapy that can be done in the comfort of your own home.
Grastek covers Timothy grasses but also has cross coverage to other grasses.
It should be started for seasonal care 12 weeks ahead of pollen and throughout the season or taken consecutively for 3 years.
Click on the following link for more information on administration of Grastek.
RAGWEED ALLERGIES
Another common allergen that is on the horizon is ragweed. Fortunately, our timing of discussing this form of treatment is ideal. The same manufacturer of Grastek has developed a similar treatment for ragweed with the prescription drug Ragwitek.
Ragwitek like Grastek should be taken 12 weeks before the allergen season. In this geographic area the typical ragweed season begins about August 15. That gives an estimated start date of the medication in mid-May.
Ragwitek is taken similarly to Grastek with pre-seasonal and seasonal administration or continuous administration for 3 years.
TRADITIONAL ALLERGY CARE
Many other treatments remain the mainstay for allergy treatment: 
Oral Medications:
Antihistamines
- Cetirizine–Zyrtec
- Diphenhydramine–Benadryl
- Fexofenadine–Allegra
- Loratadine–Claritin, Alavert
Decongestants
- Phenylephrine
- Pseudoephedrine
Leukotriene Antagonist
- Montelukast Sodium–Singulair
Nasal/Ocular Medications:
Steroids
- Flonase
- Nasacort
- Nasonex
- Qnasl
- Rhinocort
Antihistamines
- Astelin
- Pataday
- Patanase
- Pazeo
- Zaditor
Decongestants
- Ephedrine
- Oxymetazoline–Afrin, Sinex
- Phenylephrine
Cromolyn
- Nasalcrom
Anticholinergics
- Ipratropium Bromide–Atrovent
Nasal Irrigation
- Navage
- NeilMed
- Neti-Pot
Avoidance:
While avoidance can be difficult here are some pointers that may help:
- Stay indoors when the pollen count is high especially between 5AM to 10 AM when pollen counts are highest
- Wear a mask when mowing or avoid mowing altogether
- Choose grasses for your lawn that produce less pollen–dichondra and irish moss are some examples
- Mow frequently to keep grass short
- Keep windows closed
- Avoid attic fans
- Bathe pets frequently
- Do not dry clothes outdoors
- Minimize alcohol intake as it leads to dehydration and increased sensitivity to allergens
Another topic to come…How do I know what I am allergic to?
Ann Riggs, DO
Richer in More Ways than One…
Smoking Cessation
No better time to discuss smoking cessation than when we are at the new year and resolutions are starting to fade while the freezing temperatures outside continue. I tell my patients that are contemplating smoking cessation that if successful they will be richer in more ways than one. The health benefits of smoking cessation are clear. The often overlooked benefits of smoking cessation are the return of significant time and money.
Health Benefits
decrease in bronchitis, COPD- decrease in blood pressure
- decrease in heart rate
- decrease in ALL cancers
- decrease in diabetes
- decrease in osteoporosis
- decrease in rheumatoid arthritis
- decrease in erectile dysfunction for men
- decrease in ectopic pregnancies, miscarriages, small birth weight in pregnancy
- decrease in second hand smoke decreases sudden infant death syndrome, ear infections, respiratory illnesses, and asthma
Non-Health Benefits
We never seem to have enough of either time or money and smoking cessation recaptures both.
- Money
- Time
- Time=Money
The actual cost savings can be calculated here. The following depicts the savings realized when smoking 1 pack per day with a cost of $5.70 per pack:
The amount of time spent smoking is estimated at 6 minutes and 20 seconds per cigarette. Calculations for smoking 1 pack per day equates to over 2 hours per day. 
If you extrapolate the value of your time then your costs rise exponentially.
Smoking Cessation Aids
So you are ready but want some help. There are over-the-counter, prescription, and alternative options to help you be more successful.
Over-the-counter options:
- Nicotine patches
- Nicotine gum
- Nicotine lozenges
Prescription options:
- Nicotine inhalers
- Nicotine nasal sprays
- Bupropion is a common anti-depressant medication that was once marketed as Zyban. This medication can diminish the cravings and withdrawal symptoms from the nicotine.
- Chantix is for smoking cessation only and can diminish the cravings and withdrawal while also blocking nicotine effects from smoking.
Alternative options:
- E-cigarettes–long term safety has been unclear but recent studies identify significant concerns on safety and effectiveness
- Hypnosis
- Acupuncture
- Support groups
No better time than the present to kick the habit as you will be richer in more ways than one!
Ann Riggs, DO
Alternative Affordable Healthcare “Insurance” Option
The Alternative
My patients often prove to be my best resource in providing patient-driven affordable healthcare. A viable health coverage plan eludes many of us and often those with a plan quickly discover its shortcomings. One of our earliest members at Direct Medical Care introduced me to a great alternative to healthcare “insurance”–health cost sharing plans that are truly affordable. These plans have been around for over 20 years and I anticipate they will become more and more favorable with the current direction of healthcare.
Health Cost Sharing Plans
- Health Cost Sharing Plans(HCSP) do qualify as approved health insurance coverage by the Affordable Care Act.
- The general philosophy is in line with Direct Medical Care’s as HCSPs “seek to return health care to a private, patient-centered model” and “(are) designed to restore and protect the doctor-patient relationship.”
- Our patients using these plans attest that their experiences have exceeded their expectations.
Check out the following cost sharing plans:
SAMARITAN MINISTRIES
Samaritan Ministries was established in 1994. Their focus is Christians helping Christians. Not only are they focused on the financial burdens taken on by the community of Christians but the physical, emotional, and spiritual burdens as well.
MEDI-SHARE
Christian Care Ministries was established in 1993. Their focus is on carrying each other’s burdens while utilizing not only financial resources but individual talents, networks, and their faith.
LIBERTY DIRECT
Liberty Direct was also established over 20 years ago and interestingly has the same share amounts today that they did when they began. They focus on helping like-minded individuals who are committed to their individual health and well being of their community.
Ann Riggs, DO
To Flu or Not to Flu
“I have the flu…”
Influenza strikes every year and leaves much to be discussed. The flu statistics reveal that the highest risk groups are those 65+ years of age followed by those 0-4 years of age. The other high risk groups include pregnant women and those with chronic respiratory illness or those with weakened immune systems.
Seasonal influenza is typically the following with rapid onset:
- fever
- chills
- profound fatigue
- headaches
- joint pain
- runny nose
- cough
- sore throat
Seasonal influenza is not typically:
- nausea
- vomiting
- diarrhea
Diagnosis
The only absolute is a positive influenza swab. Unfortunately the test can 
be inaccurate. Some studies suggest the influenza swab is only 30% accurate while others suggest 70% accuracy. The best case scenario it misses 3 out of 10 individuals with influenza. This makes clinical suspicion and evaluation by your physician key in diagnosis.
Treatment
Tamiflu or other antivirals are the only prescription form of treatment but have their 
limitations. They need to be started within 48-72 hours of onset of symptoms. Antivirals when started early in the course of the illness can decrease the severity of symptoms and length of course but are not a cure. Large families or those with high risk individuals may opt to take antivirals as preventive or prophylactic care when a known influenza carrier has been diagnosed.
Supportive care is the true mainstay of care for anyone with influenza:
- fluids
- rest
- acetaminophen
Flu Vaccine
There are always lots of opinions regarding vaccination. While it is not a perfect vaccine as far as guaranteed coverage for influenza, it is safe.
The CDC recommends annual vaccination for everyone 6 months of age and older.
Vaccination is one way to protect yourself from influenza and can reduce the severity of illness if contracted and prevent hospitalizations in addition to doctor visits and time off work.
Common questions:
- Does the flu shot cause the flu?
No but can cause a flu-like response with mild headache, joint pains, and fever
- How long until I am covered after receiving the vaccination?
2 weeks
Common Sense Prevails
- avoid contact with those with symptoms
- wash your hands
- eat healthy
- exercise
- rest
Stay well!
Ann Riggs, DO
As the Sun Sets…Vitamin D Deficiency
Vitamin D Deficiency
I often joke with patients that we never checked Vitamin D levels until Dr. Oz brought it to the forefront. Thankfully he did and we are identifying more and more individuals with vitamin d deficiency and treating appropriately.
The Centers for Disease Control and Prevention (CDC) reports that 32 percent of children and adults throughout the US are vitamin D deficient. Estimates of over 95 percent of elderly are deficient.
Vitamin D Deficiency Symptoms
- Fatigue
- Bone pain
- Muscle pain
- Memory issues
- Depression
- Cardiovascular Disease
- Diabetes
- Hypertension
Vitamin D AKA the Sunshine Vitamin
How much sun is enough? You need your skin exposed without sunscreen or protective clothing interfering to be able to convert/produce Vitamin D. There is an interesting calculator here to shed some “light” on it: Sun Exposure Calculator. Keep in mind there really are so many factors(skin color, time of year, cloud cover, time of day, etc.) and to depend on the sun for your vitamin D is not ideal.
Vitamin D in our Diets
- Fish
- Egg yolks
- Fortified dairy
- Fortified grains
Risk Factors for Vitamin D Deficiency
Diets limited in the above food sources- Limited sun exposure due to occupation, climate, or darker pigmented skin
- Age
- Obesity
- GI issues that impact absorption
Vitamin D Supplementation
First and foremost check your levels before supplementing above the daily recommended allowances. Vitamin D is a fat soluble vitamin and too much can lead to toxicity issues. Basic guideline for baseline supplementation is 800-1000 International Units daily. Multi-vitamins often fall short of the baseline supplementation. Verify how much you are truly getting. If you are found to be deficient supplementation would be much higher.
Ann Riggs, DO
Tired, Foggy, and Numb?
Vitamin B12 deficiency May be Making you tired, foggy, and numb…
TIred?
Fatigue is one of the most common complaints I hear from my patients that unfortunately can be caused by many things. Vitamin B12 is one of those causes and it is quite common. Vitamin B12 plays a crucial role in energy as it aides the conversion of our foods to energy for the body.
Foggy?
Patients often complain of difficulties focusing, forgetfulness, and just a general fuzziness. Vitamin B12 helps in cognition with overall brain health. Deficiencies can also lead to general mood disorders, depression, and insomnia due to its role in production of certain natural brain chemicals.
Numb?
The classic presentation of B12 deficiency is a “stocking-glove distribution” of numbness. The hands and feet are described as numb or tingling. Vitamin B12 is utilized by the body in the maintenance and repair of the nervous system.
Other Symptoms?
- pale skin
- tongue changes–smooth, burning, or red
- heart palpitations
- shortness of breath
- diarrhea or constipation
- vision difficulties
Am I deficient?
If you have any of the above mentioned symptoms it is worth getting a simple blood test to evaluate your levels.
Risk Factors:
- age
- vegetarian/vegan
- medications that decrease absorption–classically antacid medications
- disease processes that affect absorption such as pancreatitis and inflammatory bowel diseases like Crohn’s Disease or Ulcerative Colitis
- gastric surgery for weight loss
Vitamin B12 Dietary Sources
The human body doesn’t make vitamin B12 so dietary sources are essential. Common dietary sources:
- meat
- poultry
- seafood
- dairy
- eggs
Vitamin B12 Supplement Options
Vitamin B12 supplements come in pill form, sublingual tablets, nasal sprays, and injectables. Many people can’t absorb vitamin B12 through the gut so nasal absorption, oral absorption, or injections are often preferred.
Vitamin B12 deficiency is easily detected and easily treated if you look for it…
Ann Riggs, DO
Cold Laser Therapy
Cold laser therapy is a novel, non-invasive approach to treating inflammation and promoting healing.
It is FDA approved and has been utilized in America for over 16 years.
Contrary to its name it is not cold at all–it is a pulsatile, low-level laser that will not burn.
Cold laser therapy has also been referred to as:
- low-power laser
- low-light therapy
- soft laser
- biostimulation laser
- therapeutic laser
- laser acupuncture
We introduced cold laser therapy in our office over 6 months ago. We have been impressed with its results for back pain, shoulder pain, elbow pain, heel pain AKA plantar fasciitis, and much more.
The cold laser is thought to work by decreasing inflammation and thus pain by decreasing the following:
prostaglandin E2- prostaglandin-endoperoxide synthase 2
- interleukin 1-beta
- tumor necrosis factor-alpha
- neutrophil granulocytes
- oxidative stress
- edema
- bleeding
The greatest advantage is that there are NO serious side effects. It is a great option to try to avoid medications and surgery.
While insurance is variable on recognizing cold laser therapy as a reimbursable treatment, we are pleased to announce we have had patients receive reimbursement for this service at Direct Medical Care.
In as little as 2-4 treatments per week, we have seen 80-90% improvement in symptoms.
If no improvement by the 4th treatment alternate treatments can be utilized. Combining therapies can maximize healing and return to health.
Ann Riggs, DO
Sun…friend or foe?
So it’s summertime right? …time for the beach, lake, swimming pool, water park, and baseball games. You pack up all your gear and head out to have some fun in the sun. And sometimes it’s hard to remember to pack the sunscreen, apply it, not to mention reapplying it all-day-long. Then there’s that nice tan glow we all love to have in the summer. But…..
“More than 3.5 million cases of non-melanoma skin cancer are diagnosed in the US each year, and more than 73,000 cases of melanoma are expected to be diagnosed this year.”
One in five Americans will develop skin cancer in their lifetime, melanoma being the most deadly form. In fact, an estimated 9,940 people will die of melanoma in 2015. Prevention is obviously key when it comes to skin cancer. Daily use of a sunscreen with SPF 15 or higher reduces your risk of developing squamous cell carcinoma by 40 percent and melanoma by 50 percent.
It’s an easy thing to over-look…I mean it’s the sun, we go outside, we go inside, it’s our world, and therefore easy to forget. But trust me, for those of you that have been blessed to not have gone through it in your life, there’s nothing scarier than hearing that your best friend, your 36 year old sister, has been diagnosed with Stage II Melanoma. And there’s no time that is longer or goes by slower than the time it takes for lymph node biopsy results to come back. There’s no exposure, from the sun or tanning bed that is “better” for you or less harmful than the other. Sunless or “spray tan” is a good option to consider if you feel like you need some color or that summertime glow.
Another important step is having annual skin checks, as well as watching for any changes to existing or new moles on your body. This one, to me, is a no-brainer. Skin cancer is the one form of cancer that allows you to see your tumor…right there, in plain sight, on the outside of your body. The woman with the lump deep in her breast, guy with a tumor on his kidney or deep in his brain, or child with cancer in their bone marrow didn’t have that chance. It was hidden inside, not able to be seen, causing harm, just waiting to be found. So take advantage of the chance to have this particular cancer identified and stopped in its tracks as soon as possible.
“Each year there are more combined incidences of skin cancer than the combined incidence of cancers of the breast, prostate, lung, and colon.”
There are some key characteristics, known as the ABCDEs of skin cancer, that you can look for to help identify a potentially dangerous mole.
- Asymmetry
- Border
- Color
- Dimension
- Evolving
So get outside this summer and have a blast enjoying this time of year and all the activities that go along with it! Just remember to drink plenty of water and make sure to wear sunscreen to protect yourself from the harm that our sun’s rays can cause….and hey, take heart in knowing that you’re preventing all those future wrinkles.
Submitted by Kim Moppin
Direct Medical Care 
