Everything Your Doc Wants You To Know

Navigating Life Changes

Life transitions can be exciting at times but can also contribute to isolation, depression, and anxiety. Some major life changes include the birth of a child, menopause, becoming an “empty nester,” retirement, loss of a loved one, and loss of independence in the elderly. We talk with Dr. Zielke, PhD, and Trishia Powell, LICSW, about identifying signs and symptoms of stress, depression, and anxiety; treatment options for these symptoms, and behavioral strategies to help reduce symptoms.

Dr. Desiree Zielke, PhD, LP - owner, President of Becoming Balanced. Clinical Psychologist. Obtained her Bachelor’s of Science degree and Master’s of Science in Clinical Psychology from North Dakota State University. Graduated with her Doctor of Philosophy degree in Clinical Psychology from Indiana University Purdue University-Indianapolis upon completing a one-year internship in Salem, Virginia at the VA Hospital. Received postdoctoral training at Sanford Health and worked as a Licensed Psychologist at Sanford Health for five years. Dr. Zielke is licensed in both North Dakota and Minnesota. She is an advocate for self care in women and is excited to open a clinic focused solely on women’s health and wellness. Dr. Zielke is married and is mom to two yellow labs and 30 chickens. She lives on a hobby farm with her husband and is an aspiring yogi.

Trishia Powell, MSW/LICSW - Co-founder of Becoming Balanced and Licensed Independent Clinical Social Worker. Obtained her Bachelor’s Degree in Social Work from Minnesota State University Moorhead and her Master’s Degree in Social Work from the University of North Dakota. Trishia has over 15 years of experience working in the mental health field in the Fargo-Moorhead area, including in the hospital, outpatient/clinic, and community settings. She has completed a certificate training in Peri-natal Mood and Anxiety Disorders through Postpartum Support International. Her clinical work over the past several years has focused primarily on Women’s Health, particularly working with peri-natal and postpartum mental health, infertility and pregnancy/infant loss. Trishia was diagnosed with multiple sclerosis in 2018 and can identify on a personal and professional level with individuals dealing with chronic conditions. Trishia is a wife and mom to three children and a dog. She enjoys time with family and friends, exercising, napping, and attending her children’s activities.

Resources:

Online meet up sites where you can find others with similar interests. www.meetup.com

Facebook events and activities

Becoming Balanced - therapy services to help women in the FM community find their balance. They offer some extended hours, treadmill/walking appointments, classes.

Facebook - Becoming Balanced PC

(701) 551-1840

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A Salty Note on Sodium Chloride

Salt or Sodium Chloride recommended daily intake 2300mg daily or 1 teaspoon

High salt diet can contribute to high blood pressure or hypertension as well as worsen congestive heart failure or worsen swelling in lower extremities from venous insufficiency or leaky veins

READ FOOD LABELS!

Salty six = deli meat, pizza, canned soups, breads, tacos, cheese

Also watch out for pickled items!

Health Pearl: Try a foam roller to roll out aches and pains!

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Eating for health

This week we discuss nutrition and eating for health.

Nutrition: healthful food to fuel your body.

Positive nutrition can provide energy, boost immunity, improve overall health

Harmful eating patterns can lead to diabetes, heart disease, strokes, other health conditions

What matters? Calories, fat, carbs, protein? Is there a magic bullet? Whole foods - veggies, whole grains, fruits, legumes, seeds, nuts

Try to target the 80-20 rule. Eat healthful foods 80% of the time and occasionally (20% or less) allow yourself to eat things that are less healthy.

We discuss how to find healthy food and what to look for on labels, ingredients to avoid (high fructose corn syrup, artificial sweetener, etc)

Eating out can pose a challenge to healthy eating. Even a salad can have hidden ingredients that may add calories or reduce the health value.

Food we eat affects the microbiome of the gut. Plant based diets can promote growth of healthy bacteria in the digestive system.

We can help restaurants change the food they offer by increasing the demand for healthy options

How to shift your diet - aim for the 80-20 rule

Consider joining a CSA or vegetable coop

Think of it as an adventure in eating

Prepare food yourself

Meal prepping for the week works well for some, meal planning is another option, or consider joining a meal delivery service

Avoid purchasing or baking foods that may get you off track. The once-in-a-while foods can be bought once per month or on an intermittent basis. Try to have similar healthier substitutes instead.

Even if you can change one meal a week, you’re making progress

Many of us continue to face challenges with healthy eating at work or school. Less healthy snacks are often readily available. We can work as a community to improve these over time.

“Eat food. Mostly vegetables. Not too much.” - Michael Pollan

Menu for a week

Day 1

Breakfast: 2 boiled eggs with a slice of whole grain toast

Mid morning snack: trail mix with nuts, seeds, dried fruit

Lunch: Mixed greens with quinoa, protein (chickpeas, grilled chicken, or tofu), peppers, cucumbers, chopped carrots with vinaigrette

Afternoon snack: apple slices dipped in peanut butter or sunbutter

Supper: Chickpea & broccoli burritos, side of berries

Dessert: Avocado dark chocolate mousse parfaits with strawberries

Day 2

Breakfast: Green smoothie (1/4-1/2 cup spinach, 1/4 or 1/5 banana, 1-2 tablespoon peanut butter or sunbutter, 1 tsp ground flax seed, soy or almond milk)

Mid morning snack: cheese slices

Lunch: Left over amazing chickpea & broccoli burritos

Afternoon snack: Cottage cheese with 1/3 fruit

Supper: Roasted asparagus with garlic and olive oil, baked salmon with parmesan herb crust, side of quinoa seasoned with turmeric

Dessert: Berry and chia seed parfait (I use 1/2 the maple syrup and only berries for the topping)

Day 3

Breakfast: Whole grain toast with avocado slices

Mid morning snack: 1-2 protein bites

Lunch: Left over parmesan salmon and quinoa over mixed greens with balsamic vinaigrette

Afternoon snack: Berry and chia seed parfait

Supper: Lentil tacos from Thug Kitchen

Dessert: Smudgies (2 mashed bananas mixed with 2 tbsp peanut butter or sunbutter between two graham cracker squares, wrapped in foil and frozen)

Day 4

Breakfast: Steel cut oatmeal with seeds, almond slivers, or cottage cheese stirred in. Add cinnamon +/- nutmeg if needed for a dash of flavor

Mid morning snack: Veggies with hummus

Lunch: Reheated lentil tacos

Afternoon snack: Avocado slices with whole grain crackers

Supper: Kirsten’s salad (inspired by a favorite at Market on Front in Missoula, MT): Green leaf or romaine lettuce, grilled or baked lightly seasoned chicken, chickpeas, roasted sweet potatoes, chopped dried figs or dates, quinoa, crumbled goat or feta cheese, balsamic vinaigrette

Dessert: Yogurt with berries

Day 5

Breakfast: Protein muffin

Mid morning snack: Apple slices with peanut butter or sunbutter

Lunch: Left over salad, add toppings from the week (remaining salmon or chicken, roasted sweet potatoes, chickpeas, quinoa)

Afternoon snack: Trail mix with nuts, dried fruit, seeds

Supper: Whole roasted cauliflower (this is amazing - first had it in NYC and had to make our own), Evolved lentil wrap, apple slices

Dessert: 2-3 pieces dark chocolate (70% dark or darker - this will prevent over-eating)

Day 6

Breakfast: Muslii with greek yogurt (be on the lookout for excess sugar in yogurt)

Mid morning snack: 1/2 protein muffin

Lunch: Left over lentil wrap, reheated roasted cauliflower

Afternoon snack: Honey peanut butter protein energy balls

Supper: Greek turkey sliders

Dessert: Apple nachos (apple slices drizzled with sunbutter or PB and sprinkled with dried unsweetened coconut flakes)

Day 7

Breakfast: Baked eggs in avocado from popsugar.com

Mid morning snack: celery sticks dipped in PB or sunbutter

Lunch: Left over greek turkey sliders (so good!)

Afternoon snack: cottage cheese with 1/3 fruit

Supper: Garlic butter baked halibut on bed of roasted asparagus or green beans

Dessert: Peanut butter and banana yogurt pops - good for dogs too!

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Episode 8 - Sleep

Insomnia = Sleep difficulties

Multiple causes of sleep disruption: Obstructive sleep apnea, the need to urinate, medication side effects, restless leg syndrome, heart burn, worry, mood disorders (anxiety, depression), uncontrolled asthma

Caffeine can disrupt sleep. If having difficulties would limit intake to before noon.

Alcohol- poor sleep quality even if you feel helps you get to sleep

Medications that can disrupt sleep: decongestants, antihistamines (allergy and cold meds), nicotine replacement, inhalers, stimulants, some antidepressants

Obstructive Sleep Apnea: pause in breathing, snoring, morning headaches, awaken feeling unrefreshed, fall asleep easily if driving, reading, watching tv. Underdiagnosed so bring attention to symptoms of concern. Untreated leads to uncontrolled hypertension, heart failure, weight gain, atrial fibrillation, etc

Restless leg syndrome can lead to poor sleep - discuss symptoms with your PCP

Lack of sleep leads to poor decision making, poor concentration, increased accidents, poor ability to deal with life stressors

7.5-9 hours sleep is considered adequate

Sleep Hygiene:

Exercise daily but not within 2 hours of scheduled bedtime

Consistency in bedtime and wake time.

Prebedtime routine: quite time away from lights (screens included)

Limit total time in bed to 9 hours no matter if you have slept or not

Reserve bed for sleeping only – read, tv should be done elsewhere

If not asleep in 30 minutes or not feeling sleepy leave bed and do something quiet. Return when tired

Limit daytime naps to 30 minutes or less

Cooler temperature

Dark room

Quiet environment or white noise

Cognitive Behavior Techniques

Squeeze muscle groups from head to toe 30 sec and relax

Imagery

Meditation- new apps like Calm or CBT-i coach

Set aside worry time or worry journal

Work with cognitive behavioral therapist

Other things to try

Sleepy time tea

Melatonin 3-6mg

Blue lights during day time

Usually recommend avoidance of over the counter PM meds that contain Benadryl or diphenhydramine because of side effect profile- if use do so for short term/limited basis

Prescription options: never intended for chronic daily use

Mirtazapine: especially in older adult with low appetite, and low mood

Ramelteon: works on melatonin receptors, cost has been prohibitive

Trazodone low dose often helpful

We are often avoiding medications like Ambien and Lunesta because of side effects- reasonable if using short term for certain conditions. Can be habit forming. Also avoiding benzodiazepines like clonazepam and lorazepam except for short term/intermittent use in certain conditions. Would avoid long term nightly use as linked to dementia etc.

www.deprescribing.org

Health Pearl: check out The Blue Zones www.bluezones.com

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Episode 7: Living Well with Dementia

Dementia - changes in memory and thinking that are beyond what is normal for age. It is progressive (worsens over time).

Treatment can slow progression of dementia, but there is no cure. It is felt that regular exercise, following a healthy diet such as the Mediterranean diet, and staying socially and cognitively engaged can help prevent dementia. Controlling chronic diseases such as high blood pressure, high cholesterol, and diabetes can also help with prevention.

Today we are joined by Deb Kaul, the owner of geriatric consulting service “Dignity Care” and one of the Co-founders of “Memory Café of the Red River Valley.” Deb has a bachelors degree in Business Administration from UND and a BSN from the University of Mary. She also has a Master’s certificate in Geriatric Care Management from the University of Florida. Deb considers the lessons she learned while caring for her parents - both of whom lived with dementia, the most valuable education she has ever received.

Deb provides recommendations for living with and caring for people living with dementia:

Keeping the diagnosis of dementia a secret from the person with dementia robs the individual of their autonomy. It also perpetuates the stigma related to dementia.

It is possible to live well with dementia.

Our responses to the diagnosis impact how a person responds to the disease. If they are diminished and de-humanized, they lose hope. 

How to engage with a person living with memory loss: Greet them with a compliment or information that reminds them about their life.  Tell them their story (“That is a beautiful/handsome sweater.” or “You did such a great job raising your children.”) Avoid quizzing them (“Did ___ come to visit you this morning?”)

For caregivers: Communicate about what’s occurring. Allow the person with memory loss to set goals for themselves. Avoid arguments with people living with dementia. They lose the ability to rationalize and reason, and it’s our job as caregivers to think creatively to solve problems.  Caregivers can apologize, redirect, distract to work around conflicts or disagreements “Live their truth.”  People with dementia are living in the present moment, so living with them in their truth/reality can help them and reduce conflicts. Engage trustworthy friends to build a village of support around them. People living with dementia should continue to have opportunities to make friends and maintain some independence. Communicate goals with physicians and other medical providers. Continue to pursue joy in life (both caregiver and person living with dementia).

Available resources:

“What the Hell Happened to my Brain?” by Kate Swaffer.   The author’s diagnosis resulted in “prescribed disengagement” by her physician. She was told to “get her affairs in order” when diagnosed at age 49.  She challenged these ideas and has achieved incredible things while living with dementia.

The Dementia Alliance International (DAI) - https://www.dementiaallianceinternational.org/

Alzheimer’s Association - https://www.alz.org/

Memory Cafe - free socialization and support for people with mild to moderate memory loss and their caregivers

Upcoming conference: Redefining Memory Loss, Living Well Throughout This Journey. June 6, 2019 at Hilton Garden Inn, Fargo ND

Update on measles vaccination (MMR)

If you received the vaccine prior to 1967, it was less effective. It is recommended that this group gets revaccinated.

If you were born in the 1950s or early 1960s, you may not have been vaccinated. 

Individuals born before 1957 are presumed to have immunity (likely had measles infection and so are immune to further infections) and do not need the vaccine (there are exceptions to this).

It’s safe to revaccinate if you’re uncertain of your vaccine history. 

Healthcare workers who received the vaccine before 1967 or didn’t receive it should be vaccinated. 

Health pearl: do something out of your comfort zone. “Go out on a limb, that’s where the fruit is!”

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Millions in US have diabetes or prediabetes but it is often PREVENTABLE

Diabetes Type 2: High blood sugar levels because of insulin resistance. Occurs when insulin released from the pancreas is less effective at moving sugar (glucose) from the blood stream into the cells.

Danger of high blood sugar levels over time- can cause blindness, numbness/pain in feet (neuropathy), kidney failure, heart attack/strokes, PAD (peripheral arterial disease), lead to amputations

Risk factors: diets high in sugars, refined carbohydrates (juice, soda, bread, pasta, sweets), sedentary lifestyle, obesity, genetics

Symptoms of high blood sugars: often no symptoms until very high blood sugars then can experience blurred vision, urinary frequency, excessive thirst

Diagnosed with blood test hemoglobin A1c level >6.5 (prediabetes 5.7-6.5, normal <5.7), or fasting blood glucose > 125

Treatment

Lifestyle modifications: diet, exercise, weight loss

Dietary changes: limit concentrated sweets, sodas, white breads and pastas. Change to whole grain/wheat breads and pastas or other pasta alternatives (edamame, lentil, chickpea etc). Limit white potatoes, choose sweet potato instead

1 carbohydrate serving is 15g: 9 grapes, half apple, 1/3 banana, 1/4 cup brown rice

Limit breakfast to 2-3 carb servings, lunch 2-3 carb servings, supper 3-4 carb servings

It matters what you eat with the carbohydrate. Absorbed more slowly (which is better) when eaten with protein or high fiber. So instead of drinking the glass of OJ eat the orange. Beans/lentils contain carbs but are a better carb choice because of high fiber/protein content.

Fill plate with ½ veggies, ¼ protein, ¼ fruit/healthy fat/grain

Medications: metformin, sulfonylureas (glipizide), GLP-1 agonist injectables (liraglutide) good for weight loss and heart disease, SGLT2 inhibitors heart and kidney benefit, DPP-4 inhibitors (sitagliptin), insulins

Health Pearl: Cucumber Quinoa Salad refreshing summer salad. Remember to rinse your Quinoa before cooking.

Additional resources:

Diabetes Food Hub

American Diabetes Association

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Episode 5: A Shot of Health

Today we focus on four adult immunizations: tetanus, pneumonia, shingles, and influenza.

Tetanus - a tetanus (Td) booster is needed every 10 years or less. Every adult should get Tdap once to protect against pertussis (whooping cough). Tetanus can be acquired from a skin puncture by rusty metal, and is also present throughout the environment, especially in soil.

Pneumonia - pneumonia is a lower respiratory tract infection / infection of the lungs. It can be caused by Pneumococcus bacteria, which has a thick outer shell that makes it more difficult for our immune system to fight. Generally pneumonia vaccines are started at age 65. They are given earlier for patients with a decreased immune system, compromised respiratory system (such as in asthma or COPD), and some other conditions. PCV 13 is the vaccine generally given first at age 65, and PPSV23 is given 1 year later. If given before age 65, they are given 8 weeks apart.

Shingles - shingles is caused by the chicken pox virus. After clearing chicken pox, the virus is dormant near the spine in nerve roots. Later in life, especially in situations of immune compromise, the virus can reactivate and cause shingles. The rash will affect one dermatome of the skin, which is the area of the skin supplied by nerves from a single nerve root. The older vaccine for shingles, known as Zostavax, was a live vaccine. Because it was live, certain populations couldn’t receive it. It also had lower efficacy, especially in older adults. The newer vaccine, Shingrix, is not live and has better efficacy.

Influenza - influenza is a viral infection that largely affects the airways and is worrisome when it causes viral pneumonia. Symptoms include fever, cough, body aches, runny nose, and headaches; this can progress to shortness of breath and difficulty breathing. We recommend the influenza vaccine yearly for everyone. Influenza can be life threatening even to healthy individuals. Yearly flu vaccines reduce mortality and severity of influenza infections.

Health Pearl: Tasty Lentil Tacos

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Episode 4: Urinary Tract Infections

We discuss the anatomy of the urinary tract: bladder, ureters, and kidneys

We discuss infection being a pathogen (bacteria) causing an illness. This is different than bacteria that live with us that do NOT cause infection (colonized or part of our microbiome)

We discuss symptoms of possible bacterial UTI: burning with urination, frequency, urgency, incontinence, pelvic pain/pressure, fever, chills, flank pain (pain over the kidneys)

Other possible causes of similar symptoms: urethral irritation, bladder irritation (over active bladder), postmenopausal atrophic vaginitis

We discuss the risk of antibiotics when true infection is absent

We discuss that urine odor is NOT indicative of infection

Change in cognitive status is not necessarily indicative of UTI (yes, infection can contribute to confusion but also dehydration, constipation, fatigue can - more likely causes UNLESS symptoms described above are also present)

We discuss new data that suggests even with true infection antibiotics in healthy individuals may not be necessary

Ways to prevent UTI: drink plenty of water, do not hold your urine too long, avoid irritants (douching, soaking in bubble bath, tight clothing, perfumed soaps), moisturize with Vagifem or Replens type products. Other bladder irritants include caffeine, alcohol, sugar substitutes, carbonated beverages, citrus which can contribute to over active bladder symptoms

Practicing what we preach recipe: The Girl on Bloor Sweet Potato, Squash and Kale Buddha Bowl

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Episode 3: Prevention of Cardiovascular Disease

We explain the “leaky faucet” analogy for reducing risk of heart attacks and strokes.

We discuss the population that benefits from aspirin to prevent heart attacks and strokes and the population for whom aspirin is no longer recommended.

We discuss the benefits and role of statin medications in preventing heart attacks and strokes.

Supplements - we talk about fish oil, Coq10, and red rice yeast extract.

We explain which foods are best to avoid in order to lower the risk of cardiovascular disease, including red meat and processed foods.

We review foods that have proven value. These include unprocessed whole grains, nuts, seeds, healthy fats, vegetables, fruit, and legumes.

We talk about green, yellow, and red food classification.

The American Heart Association recommends 150 minutes of exercise per week. We discuss what counts as exercise and how to work towards this goal.

Links:

Blue Zones

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Episode 2: Getting the most out of your clinic visit.

Although you’ve probably been attending doctor appointments for years, you may not know everything that happens around your visit. Lindsey and Kirsten discuss what to expect at an office visit and how to maximize the time you have with your clinician.

Setting an agenda can be a useful tool to ensure that concerns are addressed.

The difference between annual exams and rechecks is discussed.

New research and changing health status of our population has led to changes in the annual exam. The utility of a head-to-toe exam in patients with no symptoms is surprisingly low. Similarly, screening urine and some other routine labs when patients are asymptomatic is not helpful. Most parts of the physical exam that screen for cancer have not been proven to result in better outcomes and sometimes result in harm through further testing and procedures.

Depending on health status, an “annual exam” may not be needed every year. We discuss how frequent an “annual exam” or other appointment is needed for certain age groups and health conditions.

We discuss how we review your chart before seeing you in the clinic.

Follow up question: we explain the role of a primary care physician for a patient who sees multiple sub-specialists.

Health Pearl: Kirsten enjoys running. She has found the Nike Run Club app not only makes her runs more enjoyable, but assists her in becoming a better runner through in-app coaching. Check out Nike Run Club at the App store.

Email us with questions, comments, or suggestions for future topics at [email protected]