I know this is a somewhat alarming title…does it refer to environmental, political, economic or terrorist calamities that can threaten our survival?  Not this time; it connotes survival without the chronic illnesses and diseases that can befell us after middle age.

This term (you have to admit it got your attention) was used by Dr. Qi Sun and other researchers from the Harvard School of Public Health in an analysis of 25 years of follow-up of the more than 13,000 participants in the Nurses Health Study (published in the Archives of Internal Medicine). They defined successful survival as a goal for woman who are living to at least age 70 with no impairment of their cognitive function, no limitations on moderate activities, only moderate limitations on demanding physical activities (OK you can’t run like you used to but you can walk briskly), no mental health limitations, no cancer, diabetes, major heart disease, stroke, kidney failure, chronic obstructive pulmonary disease, Parkinson’s disease, multiple sclerosis or amyotrophic lateral sclerosis (Lou Gerhrig’s Disease). Sounds like a goal we would all like to reach.

Before I tell you what the women in the study did to get there, let me address my first personal query…How many of them made it?  Out of the 13,535 women participating in the Nurses Study, 1,456 or approximately 11% did. The women (all nurses…duh!) were assessed initially in 1976 when they were 30 to 55 years old and have been followed ever since. The type, timing and intensity of their physical activities were calculated in 1985, when their mean age was 60 years. The title of successful survivors was bestowed (if they were worthy) once they had a follow-up between the years of 1995 to 2001.

So what helped their successful survival? Physical activity in mid-life! A positive association between physical activity and successful survival was strong within each group of women no matter what their body mass, even if they were overweight! The activities in mid-life particularly associated with successful survival included jogging, running, playing tennis, aerobics and WALKING. Yes, just walking at a moderate pace (which means fast enough to work up a teensy bit of a sweat but not so fast that you cannot carry on a conversation with someone who might be walking with you.) They calculated that compared to women whose walking was at a leisurely pace, women with a moderate walking pace had a 90% increase in the odds of successful aging and that women whose walking pace was brisk or very brisk (sort of speed walking) increased their odds 2.68 fold  (that’s 268%).

Walking is something that is usually quite sustainable and should be fairly easy to incorporate into our daily schedules, especially here in Southern California. No gym, special equipment, or trainers necessary! After reading this study I made my dog walk faster so that I could do my daily exercise with some extra briskness. Thirty minutes could help both of us successfully survive.

As many of you know I travel abroad 3 or 4 times a year, mostly to visit family or go to conferences.  So many of us have gone global… there are 30 million travelers who fly from the US for destinations that are at least 5 or more time zones away from their home. Most suffer from jet lag upon arrival at their destination and then, alas, upon return. A recent review of jet lag appeared in the New England Journal of Medicine. I thought it appropriate (as I prepare to fly 7,000 miles in early April,) to share this pertinent information with you.

Jet lag is due to a temporary misalignment between your internal clock (termed the circadian clock) and local time. Your brain’s time and function follows a light-dark cycle set by the sun. And this internal clock does not readjust at the speed of jet travel. As a result, many travelers experience insomnia, daytime sleepiness, mood changes (I get grumpy) and fatigue. Fatigue may also be due to the fact that you are immobile, don’t eat right, become dehydrated and stressed with log-distant air travel. (And I am not even considering the stress that must have accompanied that recent “delayed flight” on Virgin Atlantic lasting 17 hours from LAX to JFK!)

There are a number of factors that contribute to jet lag:

  • The number of time zones crossed: Obviously, the more the worse it gets, and if the trip is long, even if the number of crossed time zones are not great (i.e. the same latitude), travel fatigue can cause symptoms.
  • Direction of travel: It is usually more difficult traveling east then west .Most people find it is easier to lengthen the day than to shorten it. (Unless like me you are a “morning type”, in which case the reverse can happen.) It’s estimated that the circadian clock resets an average of 92 minutes each day on a westward flight and 57 minutes earlier each day after an eastward flight.
  • Sleep loss during travel: Chances are if you are in coach you will not be able to stretch out and go to sleep.
  • Loss of light cues (exposure to natural light at your destination): If it’s the “wrong” time or if you arrive in non sunny weather, you don’t get the sun light that helps your brain adjust.
  • Ability to tolerate circadian misalignment: Some people just can….hope it’s our politicians! Tolerance seems to decrease with age. Oi!

There are a few strategies that seem to somewhat mitigate jet lag:

  • Optimize light exposure: Try to get  bright sun light in the evening if traveling Westward, not the early morning  and seek exposure to bright light in the morning if traveling Eastward (you get up much earlier so try to take a morning walk.)
  • Take melatonin: Melatonin is the hormone that is secreted for about 10 to 12 hours at night and is a darkness signal. You can purchase melatonin without prescription. To promote shifting of the body clock to a later time when you travel westward take 0.5 mg during the second half of the night until you become adapted to local time. If you are traveling eastward take 0.5 to 3mgs at local bedtime nightly until becoming adapted.
  • Schedule sleep changes ahead of time: Try to go to sleep 1-2 hours later than usual for a few days before your westbound trip and go to sleep 1-2 hours earlier for a few days before your trip east.
  • Sleep medications. They help; you might try taking medications such as Ambien or Lunesta at bedtime for a few nights until you have adjusted to local time.
  • Agents that promote alertness: Caffeine works, but avoid it after midday so it won’t adversely affect your sleep. Armodafi (Nuvigil)l and Modafinil (Provigil) which are drugs approved for narcolepsy and for shift workers (to improve alertness) have been show to reduce symptoms of jet lag if taken in the morning. They are not yet FDA approved for jet lag. Side effects include headache and nausea.
  • On the plane: If possibly fly after you have had a good night’s sleep. Travel in business or first class (but know your health insurance won’t pay for this, even if your doctor recommends it). Drink lots of water, don’t consume caffeine if you expect to sleep on the flight, and don’t imbibe alcohol if you take a sleeping pill. You can try taking a short acting sleep medication such as Sonata. If the flight is more than 10 hours you can consider taking a longer acting sleeping pill such as Ambien or Lunesta.  (Make sure the flight takes off and is OK before taking any of these.)
  • Exercise when you are at your destination…it can have an impact on your circadian rhythms.

So here’s hoping you have a safe and uneventful trip and that a few of these tips will help you enjoy the first few days of your arrival and return. I will be off trying all these jet lag preventions during the first 2 weeks of April. I’ll be back in the office and seeing patients after the 15th. I intend to be alert!

Many of you have asked for a follow up on what Save the Children is doing in Haiti. (I am on the board.) I know that at the onset I stated that some of the employees were missing. Sadly, one young man who worked in accounting died. Other employees have lost their relatives. Here is a summary of the situation and our ongoing programs as of the end of February:

Forty-five percent of those affected are children. Their status and future is now horrifically complicated by the rainy season. The Direction for Civil Protection (DCP) estimates that the death toll from the 12 January earthquake is now 222,517 people. Shelter and sanitation continue to be the most urgent priorities especially with the upcoming rainy season. The need to provide people with waterproof shelter materials and identify suitable land for construction of transitional shelter is critical. Organizations are working through the Shelter cluster to distribute as much plastic sheeting as possible. To date, more than 66,000 families (330,000 people) have received emergency shelter materials, about 30 percent of the estimated 1.2 million in need of shelter.

The number of people who have left Port-au-Prince has increased to 597,801 people from the previous figure of 511,405. An estimated 160,000 persons have come from Port-au-Prince to the border area with the Dominican Republic. Clusters are working closely with their Government counterparts to identify populations who have not yet received sufficient assistance; some clusters are moving towards organizing distributions outside camps, in order to meet the needs of those who stay elsewhere and to avoid an additional influx of people into the already overcrowded sites.

The Ministry of Education indicated that children in affected areas should resume school by early April 2010. Note that this is a significant delay to previous timeframe and there is growing concern regarding the lost time for education.

Overview of Save the Children Response

There are now 501 national staff and 66 international surge staff supporting their response.
Save the Children plans to provide emergency assistance to save lives, alleviate suffering, and support the recovery of 800,000 people (including 470,000 children) affected by the earthquake in Haiti. We plan to transition into longer term rehabilitation and reconstruction to ensure a better future for Haiti’s children.

Number of beneficiaries we plan to reach         800,000
Number of total beneficiaries reached so far:       *517,305

*number includes distributed medical supplies and medicines to support beneficiaries over 6 wk period

I will follow up with more updates in the coming months. You can download information at savethecholdren.org. Thank you for your interest and support.

Most of us plan our medical appointment based on symptoms and complaints, need for check up, schedule and of course, the availability of our physician or health care practitioner. There are only so many early morning openings, and these may be further diminished when doctors make hospital rounds and/or perform surgeries before arriving at the office. If you don’t want to leave home without breakfast in the morning or you have to make a late afternoon appointment, you may not be willing or able to fast for blood tests. (I encourage everyone to eat their breakfast…I won’t leave home without it. This may be the time to mention that individuals who don’t eat breakfast have a shorter life span….fasting from dinner until lunch will result in an overly aggressive i.e., high, insulin response to the delayed meal. Elevated insulin levels can cause fat to accumulate in unwanted places and increase the risk of cardiovascular disease.)

So there you are at the doctor’s office, you have not fasted and you are told that the blood test for diabetes (and perhaps heart disease) can’t be done…Thus is no longer inaccurate. An article just published in the March 4 issue of The New England Journal of Medicine reported that a non fasting blood test called glycated hemoglobin (also known as hemoglobin A1c) will diagnose risk of diabetes just as well or better than a fasting blood sugar (glucose) test and can also strongly indicate risk of cardiovascular disease and death from any cause!

Until recently, the standard measure used for diagnosis of diabetes was a fasting blood sugar. Glycated hemoglobin is a test that reflects your previous 2 to 3 month exposure to glucose and will include spikes that occur after eating. It doesn’t vary from hour to hour or day to day and is not dependent on what you just ate. It is essentially the glucose “truth meter” for what you have consumed and your blood glucose response over the past few months. It has traditionally been used for the determination of glucose control among those who have already been diagnosed with diabetes and are on therapy. But this and other reports will eventually make glycated hemoglobin the test “of choice” for diagnosis and assessment of diabetic risk in everyone.

The Atherosclerosis Risk in Communities (ARIC) is a community -based prospective study of middle-aged adults from four U.S. centers. It was started in the late 80’s and continues to present time. During the study, the researchers measured the glycated hemoglobin in blood samples from 11,092 adults who did not have a history of diabetes or cardiovascular disease. More than 55% of those tested were women. Their ages ranged from the mid-forties to mid-sixties. For the individuals who were found to have glycated hemoglobin of 6.0 to 6.5%, the risk of diabetes (the technical term was multi-variable-adjusted hazard ratio) was 4.48. (Those who had values of 6% to 6.5% were 4.48 times more likely to develop diabetes then individuals used as a reference who had glycated hemoglobin of less than 5.5%). For those individuals who had a level greater than 6.5% the risk was 16.47. The researchers then checked to see who developed coronary disease and stroke. The hazard ratio for a value of 6 to 6.5% was 1.76 and over 6.5% was 1.95 (or a 95% increase over those with low glycated hemoglobin levels.) They also looked at death from any cause and found that the higher the glycated hemoglobin, the greater the risk of mortality. Moreover glycated hemoglobin levels were found to be more predictive of disease than fasting blood sugar levels.

Studies have show that among people in the United States who do not have a diagnosis of diabetes, over 2.4 million have a glycated hemoglobin higher than 6.5% and 7 million have a value higher than 6.0%. This is an ill inspiring number.

Bottom line: A non-fasting blood test for glycated hemoglobin can help determine whether you are at risk for development of diabetes, cardiovascular disease and even early death. Hopefully it will be less than 6.0%. Most of us now know our cholesterol and lipid levels; it may be just as important to know your glycated hemoglobin level. If it’s too high you and your doctor will need to discuss the necessary behavioral changes and therapies that will help you to maintain your health.

I just returned from New York, so I am in “a talk about air travel” frame of mind.  (The reason for the trip was a board meeting for Save The Children. They are doing some amazing work to help children, mothers and families in Haiti as well as the USA and developing countries around the world….please go on their website http://www.savethechildren.org for more information.)

As usual, I felt that the flight was interminably long, the air was dry and the food….well, I won’t discuss it here, I already did a segment about microbes on the plane. But what I haven’t addressed in the past is whether it is safe for pregnant women to fly.  ACOG (the American College of Obstetricians and Gynecologists) issued a new committee opinion in October 2009. Here is a brief summary…

If there is a complication in pregnancy, it will usually occur in the first or last trimester (bleeding and miscarriage initially, premature labor and delivery the last trimester). Most commercial airlines allow pregnant women to fly up to 36 weeks. Some may be more restrictive when it comes to international flights. (I know my daughter was told she could not fly on El AL after 32 weeks and she had to bring a letter from her obstetrician to show that she was less than that on her last flight).

Air travel is certainly not recommended during pregnancy for women who have medical problems (especially cardiac) or obstetrical problems. (The latter would include bleeding, a possible impending miscarriage, pre-eclampsia, a history or risk of premature labor, a pregnancy complicated by hypertension, diabetes or failure of normal growth of the fetus). The airlines and your doctor do not want you to go into labor on a long flight, begin to hemorrhage, or rupture your membranes (even if you are the at-that time-Alaskan governor!)

All travelers should avoid dehydration and immobilization for long periods of time; we all know about the risk of deep vein thrombosis… this is even more of an issue if you are pregnant. So wear support stockings, drink plenty of water (my advice is a 6 ounces for every hour of flight), move your lower extremities (well, if you drink enough you’ll have to make frequent trips to the bathroom!), avoid restrictive clothing (no tights) and don’t consume gas-producing drinks (carbonated sodas) or foods before flying.

And remember, there is no way to predict sudden turbulence. So keep that seat belt fastened below your hipbones while seated.

Now, let’s consider radiation exposure which increases at high altitudes. The current recommendation is not to be exposed to more than 1mSv over the course of a 40-week pregnancy. Even the longest intercontinental flights will expose passengers to no more than 15% of this limit. (So round trip should be 30%.) For the “average” pregnant flier, this should not be a problem. But if you are a frequent flier or are a part of the air crew, you should check with your employer and the Federal Aviation Administration.

Final recommendation by ACOG: “In the absence of a reasonable expectation for obstetrical or medical complications, occasional air travel is safe for pregnant women.”

And I would like to add… especially if you don’t have to fly coach!

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