HCG and Weight Loss: What is the HCG Diet Protocol - Doctablet®

HCG and Weight Loss: What is the HCG diet protocol?

Nutrition, Weight Loss

Many patients have seen their doctor for general checkups and have been advised to lose weight. But getting help losing weight is a different story. Doctors often don’t have the time to review diet and exercise plans at length, though they can refer you to a nutritionist or offer help with medications. Unfortunately, approved medications to help patients excel on a calorie-restricted diet are not very effective for long-term success. The Food and Drug Administration (FDA) requires that weight-loss medications help a patient lose at least 5% of their body weight to get approved. These medications not only have side effects, but also can be quite expensive, and many are not covered by insurance. Also, the proven amount of weight loss is quite small. For these reasons and others, many patients seek out alternative therapies and supplements for weight loss that might not be scientifically proven.

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What is HCG?

Human chorionic gonadotropin (HCG) is a naturally occurring hormone made by the placenta during pregnancy. The levels produced are very high and can be detected in the urine of pregnant females. That’s right! HCG is the same hormone that is measured by home pregnancy testing. HCG helps support a healthy environment for the unborn baby. HCG is also released — small amounts of it — by other tissues in both men and females that are not pregnant.

What is HCG? Human Chorionic Gonadotropic

Doctors can prescribe HCG at high doses to help patients with fertility issues, but it is also used in an “off-label” way for weight loss protocols. Off-label use of a prescription medication means that it is used for something that was not approved by the FDA.  This type of prescribing is very common and entirely legal.  In fact, approximately 20% of written prescriptions are considered to be off-label.

Does prescription HCG cause weight loss?

Whether or not prescription HCG causes weight loss requires a little background to answer. The original HCG diet protocol recommends a daily HCG injection in combination with severe calorie restriction: around 500 calories per day. The science suggests that people lose weight on the HCG diet because of the small amount of calories they eat, not because of the HCG injection! The FDA has reviewed all of the studies on the effectiveness of the HCG diet protocol. They have concluded there is NOT enough evidence to support that HCG given in addition to an intense diet works better than just diet alone.

The HCG diet Protocol: diet plus HCG is not better at weight loss than diet alone

What is the HCG diet protocol?

The HCG diet dates back to the 1950s, but has become popular over the last ten years. The initial work with HCG and diet was done by a famous British endocrinologist, Dr. Albert T.W. Simeons.  He first noticed that when HCG was injected into boys with low levels of the male hormone testosterone, the patients lost body fat. Dr. Simeons went on to study HCG and its effect on weight for many decades, later sharing his findings with the world in 1967 in a famous manuscript called “Pounds and Inches: A New Approach to Obesity.” 

What Dr. Simeons discovered is that at low doses, HCG mobilized fat breakdown. At the same time, HCG protected the patient from the muscle loss that often accompanies low-calorie diets. HCG also helps to suppress appetite and combat the decreasing energy levels that patients often feel while eating very few calories. Now, before we describe the original protocol in more detail, please remember that many studies done on HCG in the 1970s did not show that adding HCG to a strict diet helped patients to lose more weight. Please consult a medical professional to make sure a very low-calorie diet and HCG are safe for someone like you. This protocol was, and still is, designed to be used under medical supervision. As we mentioned, the original Simeons HCG protocol called for daily HCG injections in addition to a very low-calorie diet of approximately 500 calories. Compare that to the 4,500 calories an average American consumes on Thanksgiving day.

What can I eat on the HCG diet protocol?

During the diet protocol, most foods are removed — especially fatty and starchy ones. The diet participant eats the following:

  • 2 servings of lean meat per day

  • 2 servings of vegetables per day

  • 2 fruits per day

  • The option for 2 Italian Grissini breadsticks daily

  • Breakfast is typically replaced with a large glass of lemon water instead.

During the protocol, the dieter is also encouraged to avoid applying oil-based makeup and moisturizers. Depending upon the individual, the diet plan and injections last from a minimum of 21 days to a maximum of 40 days. We have described the original protocol, but today the menu plan has been modified many times to include different versions.

Where is the HCG used in the HCG protocol derived from?

Most of the HCG commercially available in the United States is actually extracted from the urine of pregnant females. These preparations are highly purified and free from bacteria. Alternatively, a single brand also produces HCG using recombinant DNA technology.

The HCG for the HCG Diet Protocol comes from the urine of pregnant women.

What about over-the-counter HCG and HCG diet drops? 


The FDA has taken a strong stance on over-the-counter homeopathic HCG products like oral pills, lozenges, drops and sprays that are marketed for weight loss. They have issued seven warnings to companies making false claims that their supplement causes weight loss. At this time, all drug products that include “homeopathic” HCG are considered by the FDA to be marketed illegally.

If you happened to purchase or start using “homeopathic” HCG, the FDA recommends you stop immediately and discard the product.

Vegetarians or vegans and the HCG protocol.

Vegetarians should expect about one-half the weight loss on the HCG protocol as compared to those who eat meat. Vegetarians on the HCG diet protocol must drink 500 milliliters of skim milk daily for protein intake, but milk has sugar, which the unaltered protocol is quite low in. Beans, wheat and nuts are not allowed on the HCG diet plan, so vegans cannot safely participate, as they would have too little protein intake.

What are the side effects of HCG (HCG diet protocol)?

Before we let you go, we need to leave you with one last warning. Like all medications, HCG has side effects. Those on the HCG protocol can also experience consequences from the very low-calorie diet itself. Side effects from the HCG diet protocol can include blood clotting, gallbladder stones and attacks, electrolyte problems, fatigue, and depression. If a blood clot travels to the lungs, a pulmonary embolism can occur, which can result in cardiac arrest and death.

Call your doctor to see if a very low calorie diet is safe for you

Again, please consult a medical professional to make sure a very low-calorie diet and HCG is safe for someone like you. In addition to the FDA’s warning, many medical institutions have published opinions discouraging patients from attempting such an aggressive diet.

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Last Modified: May 19, 2018 @ 11:06 pm
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Chris Palmeiro D.O. M.Sc.

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Dr. Palmeiro is Chairman of Endocrinology at the HealthAlliance of the Hudson Valley, he also serves patients with intellectual and developmental disabilities at the Westchester Institute of Human Development in Valhalla, New York. He has a Masters of Science degree in clinical nutrition and is a diplomate of the American Board of Internal Medicine. His interests within the realm of endocrinology include nutrition support, obesity counseling and the progressive management of diabetes.

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What is GLP1, Glucose Like Peptide 1 - Doctablet®

What is GLP-1, Glucagon Like Peptide-1

Blood Sugar Levels

What is the GLP-1 Hormone and where does it come from?

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GLP-1 (Glucagon-like peptide-1) is a naturally occurring incretin hormone made in the intestine in response to food.  GLP-1 is one of the two most important incretins—hormones that stimulate insulin secretion in response to a meal.  But GLP-1 does more than simply increase insulin secretion. In fact, it has several important roles in the body. They can be summarized into two main functions.

GLP-1 affects levels of insulin and glucagon to decrease elevated blood sugar levels in two ways:

  • GLP-1 increases the body’s own natural insulin secretion in response to a meal.

  • GLP-1 lowers levels of the hormone glucagon after eating. Glucagon works opposite insulin and raises blood sugar levels, so deceasing glucagon levels helps to lower blood sugar.

GLP-1 increases satiety or makes an individual feel full

  • GLP-1 slows stomach emptying, so food is delivered more slowly to the intestines to continue digestion. If the food is digested more slowly, carbohydrate absorption is prolonged.

  • GLP-1 suppresses appetite in the brain’s hunger center (hypothalamus).

GLP-1 in a person with diabetes
GLP-1 in a person without diabetes
GLP-1 in a person with diabetes
GLP-1 in a person with diabetes

What is a GLP-1 analog/agonist?

GLP-1 analogs or agonists act like naturally occurring GLP-1 by stimulating the same receptor as a person’s own GLP-1 hormone. Rewind the clocks back to the early 1990s, when an endocrinologist discovered a special molecule similar to human GLP-1, which was being studied around the same time. Dr. John Eng found this special protein in the last place you could imagine—the saliva of the Gila monster, a poisonous lizard. This substance, called exendin-4, is 53% similar to human GLP-1 hormone, but is more resistant to being broken down. This makes it more useful as a treatment option. Scientists reproduced exendin-4 in the lab, calling it exenatide. Exenatide was first made available for type 2 diabetes management in 2005 as Byetta®, a twice-daily injection.

GLP-1 levels and type 2 diabetes

Turns out that patients with diabetes are not only likely deficient in their own GLP-1 hormone but, more importantly, the cells that make insulin are resistant to stimulation by GLP-1This means patients might have less of this important hormone, and what they have left clearly does not stimulate insulin as well.

Why not just treat patients with the GLP-1 hormone?

The body’s own naturally occurring GLP-1 has a very short half-life in the bloodstream. Within minutes, hormones like DPPIV break down GLP-1.  Due to this rapid degradation, treating patients with GLP-1 hormone directly has never been shown to be a useful option.

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Last Modified: May 6, 2018 @ 3:17 pm
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Chris Palmeiro D.O. M.Sc.

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Dr. Palmeiro is Chairman of Endocrinology at the HealthAlliance of the Hudson Valley, he also serves patients with intellectual and developmental disabilities at the Westchester Institute of Human Development in Valhalla, New York. He has a Masters of Science degree in clinical nutrition and is a diplomate of the American Board of Internal Medicine. His interests within the realm of endocrinology include nutrition support, obesity counseling and the progressive management of diabetes.

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What causes high blood pressure and essential hypertension - Doctablet®

What causes high blood pressure and essential hypertension

Hypertension

High blood pressure is one of the most common medical conditions humans face. An estimated 75 million Americans have it. High blood pressure is a topic of intense discussion in the medical world. One example of this is the fact that the definition of what hypertension is was recently changed. We review the way the body maintains a normal blood pressure, ideas behind what causes high blood pressure and what situations can cause it in people who don’t have it.

How does normal blood pressure work?

Hypertension causes: Understanding how normal blood pressure works is key

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The blood pressure inside our arteries and veins keeps us conscious and alive. Blood pressure is the result of the pumping of the heart, the squeezing and relaxing of the arteries and veins and the amount of blood inside the body.  To maintain constant blood pressure at all times, the body has a fine-tuned system that can adapt quickly to any challenge. The system is constantly adjusting itself to changes in our activity, the effect of gravity, diet, outside temperature and even changes in our emotions. Many different parts make up this complex machine, including organs like the heart, brain and kidneys; hormones like aldosterone and epinephrine; and the arteries and veins. There are sensors in the arteries of our neck that constantly monitor the blood pressure, cells in our brain that measure how much salt there is in our blood, and special filters in our kidneys that can remove water from our body depending on what is needed. Depending on the situation, some parts may crank up their functions while others relax. This miracle of engineering has evolved over millions of years and works so well that most of us never notice it.

Causes of high blood pressure

To understand what causes high blood pressure, you can think of three different categories.

  • Things you do, take, eat or drink

  • Essential High Blood Pressure

  • Medical conditions that cause high blood pressure

Identifying the cause of high blood pressure is very important, because the way we treat the problem depends on it. It is often necessary to take the time and effort to identify the cause of the problem, because all not all hypertension gets treated the same way. Finding the right treatment for your high blood pressure will help you reduce the need for medication and the risks of their side effects.

High blood pressure that is caused by things you do, take, eat or drink

The first cause of hypertension is the easiest to explain: there are things that cause blood pressure to go up in most people, even in those who do not have the medical condition called hypertension. By removing these things you can potentially lower blood pressure without the need for medication. The things that cause high blood pressure are as following:

Alcohol as a cause of high blood pressure.

Alcohol 

The fact that alcohol causes high blood pressure is well known. How exactly alcohol raises blood pressure is complicated. Its effect on blood pressure depends on the amount of alcohol a person drinks and the time of the day the alcohol is drunk. The effect on blood pressure also varies depending on ethnicity.


Medications that cause high blood pressure: NSAIDS elevate blood pressure as a result of their effect on the kidney

N.S.A.I.D.’s

Non-steroidal anti-inflammatory drugs (known as NSAIDs) are commonly used for treatment of pain, arthritis and fever amongst others. People who take NSAIDs regularly have a higher chance of being diagnosed with hypertension and being prescribed medication to treat it. Also, for people already on blood pressure medication, regular use of NSIDS can cause a blood pressure that is more difficult to control. Why this happens is complicated and is likely the result of the effect NSAIDs have on the kidney.


Medications that cause high blood pressure: Stimulants activate the nervous system and cause high blood pressure

Stimulants

Medications and substances that stimulate the nervous system are well known to raise blood pressure in a variety of ways including raising the heart rate and causing blood vessels to clamp down. Examples of this type of substances include medications used to treat attention deficit disorders like prescribed amphetamines, herbal supplements like Ma Huang (also known as ephedra) and so-called “recreational” drugs like cocaine.


Medications that cause high blood pressure: Contraceptive raise blood pressure by mechanisms that are not clearly understood.

Contraceptives

Long term use of estrogen containing contraceptives can cause hypertension. The effect can be delayed as far as 6 years after starting them. Developing high blood pressure as a result of contraceptives is more likely if you are older and taking them, have been pregnant in the past, have kidney disease or are obese; how exactly this happens is still under investigation.


Medications that cause hypertension: Prednisone and other steroids raise blood pressure by causing salt retention.

Steroids like Prednisone

Prednisone and other steroids are mainstays in the treatment of conditions like asthma. These medications cause salt (and therefore water) retention the body. This in turns causes blood pressure to rise. Any person in need of long-term use of steroids should have their blood pressure monitored closely.

Does coffee raise blood pressure?

The correct answer to this very common question is yes, but the details here matter. The increase in blood pressure that coffee causes usually happens soon after drinking it and is very short lived. Most people that drink coffee are not affected by this. Drinking coffee throughout the day in large quantities should be reduced in a person with new high blood pressure as it could help improve this condition.

“Essential” high blood pressure

High blood pressure is defined today as an abnormal elevation in either systolic or diastolic blood pressure. Its definition has changed over time, as we continue to learn more about the consequences of high blood pressure in the body. High blood pressure is in fact is so widespread that for the majority of human history we thought of it as “essential” to our lives, and literally untreatable. Hence its name: “Essential” high blood pressure.

Why does “Essential High Blood Pressure” happen?

Modern humans exist in a very different environment than we evolved as cavemen. Human beings evolved in the plains and savannahs of Africa and now inhabit the whole planet, moving from hot to cold climates and across parallels of space. We evolved eating from nature and now cook everything, salting and processing our food for easy consumption.

As cavemen, we needed to be very fit to survive but now have machines that do a lot of our work for us. All of this has an impact on our finely tuned cardiovascular system, the machine whose purpose is to maintain our blood pressure. 
 Essential hypertension happens to about 1 in 3 people; but why? A good way of understanding this is that certain humans have trouble adapting their highly evolved system to the conditions of the modern world.

Understanding survival is the key to understanding essential hypertension

Our ancestors evolved genes that helped them survive a huge number of incredible challenges among them starvation, temperature and drought. We learned how to change our behavior to adapt to new environments and so did our bodies evolved too. One of the ways the body learned how adapt was by enhancing parts of its cardiovascular system. Now that conditions are plenty, the adaptations that tended to make our cardiovascular system to “overcompensate” for the lack of something do not match our current environment. It is possible that one of the ways we fail to adapt to our new modern situation is by developing high blood pressure. A large number of genes that have evolved over centuries are responsible of this situation: genes that provided the humans who had them an advantage over others when dealing with harsh conditions. Some of these genes move forward and appear in the next generation, some genes don’t. Others only become a problem when we move from the environment we grew up in.  

Modifying our environment

If we understand essential hypertension to be the result of a mismatch between the things we have to help us survive and our new rich environment, the then changing the environment you live in makes sense. Returning your body to a more “natural” situation that is similar to what we experienced in the past may offer a way to manage this condition and limit the need for medication. One way to do they is to step out and become active like your cavemen ancestors needed to be. A daily 30 minutes of walking can lower your blood pressure by an average of 5 mm of mercury.

Also, remember this, humans did not evolve in a situation where every day they filled themselves up with large quantities of food. Eating less will also help you approach the goal of behaving more “naturally”. And finally eating fresh foods you make, as opposed to preserved or or processed foods you buy already made its an important part of this plan too. By simply doing this you reduce the amount of salt your body takes in.

Medical conditions that cause hypertension

Obesity and Obstructive Sleep Apnea and two of the most common medical conditions that cause hypertension.

Obesity as a cause of hypertension

In general terms, medical conditions that cause hypertension are rare, with one formidable exception: obesity. Obesity, defined by a body mass index of over 30, is rampant. More than 1 out of every 3 American adults is obese. By some estimates obesity is responsible for 40 to 70% the cases of hypertension we see. The one good thing about this fact is that by getting rid of obesity we can actually get rid of hypertension. A person who sets out to lose weight can expect about 1 mm of mercury reduction in their blood pressure (for example 150/90 to 149/89) for each kilogram of weight they lose. This may not sound like much, but remember this: as pounds drop off, so will the need for blood pressure medication. 

Expect about 1mm of mercury reduction in blood pressure (for example 150/90 to 149/89) for each kilogram of weight lost

Obstructive Sleep Apnea (O.S.A.) as a cause of hypertension

Another medical condition that stands out as “low hanging fruit”, that is well known to cause hypertension is obstructive sleep apnea (commonly referred as “O.S.A.”). The way obstructive sleep apnea causes hypertension is complicated but we know that as many as half the patients with O.S.A. have hypertension and many patients who have difficult to control hypertension probably have OSA. Long term treatment of O.S.A. has a important impact of blood pressure control, and has additional benefits to the heart apart from its blood pressure lowering effects. Of the other medical conditions that cause hypertension two more are worth mentioning as they make up a large percentage of blood pressure that is not considered “essential”. The first one is kidney disease and the other one is excessive and inappropriate production of aldosterone in the body.

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Last Modified: Mar 29, 2018 @ 7:03 pm
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Jose Taveras M.D. F.A.C.C.

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Dr. Taveras is a non-invasive cardiologist in the Montefiore-Einstein Center for Heart and Vascular Care in Bronx, New York. He trained in both internal medicine and pediatrics and is currently an assistant professor of medicine at Albert Einstein College of Medicine. Dr. Taveras is a fellow of the American College of Cardiology. He is the co-creator of Doctablet.

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DEXA Scan and the Bone Density Test: A Complete Guide - Doctabet®

DXA Scan and the Bone Density Test

DXA, Medicine, Osteoporosis

Is it a DEXA or DXA?

The DEXA (DXA) scan measures bone mineral density, which is often abbreviated as BMD. The scan uses invisible beams of energy to calculate the strength of your bones and helps diagnose osteoporosis. With these results, your risk of developing a broken bone, or fracture, can be determined. DEXA is an abbreviation for Dual Energy X-ray Absorptiometry. Dual Energy X-ray Absorptiometry is also shortened to DXA, which is considered to be the newer and correct way to abbreviate it.

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What does Dual Energy X-ray Absorptiometry (DEXA, DXA) mean?

Let’s break this term down into its individual parts:

  • DUAL ENERGY

    Dual Energy means the test uses two types of energy. One energy beam is absorbed best by the softer tissues around the bone (like muscle and fat), while the second beam is absorbed by the bone itself.

  • X-RAY

    An X-ray is an invisible wave of energy that passes through the tissues of the body. X-rays are painless and you cannot feel them.

  • ABSORPTIOMETRY

    Absorptiometry refers to the amount of energy that is absorbed by the tissue and not allowed to pass through it.

In summary, the DEXA (DXA) test uses two types of invisible X-ray beams to measure how strong the bone is by studying the amount of energy it absorbs.

What does DXA mean? Dual Energy XRay Absorptiometry

DEXA scan procedure

The DEXA (DXA) scan is usually performed on the hip and lower (or lumbar) spine, but can also include the non-dominant forearm. Images are taken while you lie on a large, flat table usually made of glass. The exam does not require you to move. Instead, the scanner moves over the top of you. When examining and taking X-ray pictures of the lower (or lumbar) spine, the technician will place a soft, cushioned box under your legs. The box is strong enough to support supports your legs fully and helps flatten your spine for better pictures.

To determine the bone density of the hips, the technician will place your foot into a brace that rotates it slightly toward your other foot. This rotation allows the hip to be in a position for the best picture. When you are positioned correctly and the test is about to begin, the technician will inform you that they are about to activate the machine. The machine is turned on after the operator steps behind a protective wall or into the next room.


The bone density test will take about 15 to 30 minutes.

How is a DEXA scan procedure done?

What is the cost of a DEXA scan?

The costs of medical tests can vary widely depending on where you live and your insurance coverage. The typical cost of a bone density test for patients without health insurance ranges from $150 to $250. Discuss the fees with the facility staff and with your insurance provider.

DEXA scan side effects – How much radiation is there with a DEXA scan?

The DEXA (DXA) scan is a painless test and is considered to be a simple and quick study. Think of it like having an X-ray (with far less radiation). For some patients, the most challenging thing about undergoing this test can be lying flat for a short period of time.  As a rule, bone mineral density machines use very low radiation doses.   The radiation dose from older machines, which use a skinny, pencil beam, are lower than newer ones that use a fan beam for higher resolution pictures.

It was once thought that the dose of radiation from completing a DEXA (DXA) scan was about one-tenth. However, newer studies suggest the radiation exposure to the patient undergoing a DEXA scan is much lower—up to 200 times less than someone going for dental X-rays! It is important to tell the technician if you are pregnant before undergoing a DEXA (DXA) scan, because X-rays can be dangerous to a developing baby.

How much radiation does a DXA scan give you?

What are the DEXA scan guidelines?

Medicare is considered the authority in determining when a bone mineral density test will be covered by insurance. There are several different task forces that have set guidelines on when DEXA studies should be performed. The most important are the United States Task Force, the National Osteoporosis Foundation and the International Society for Clinical Densitometry.

It is agreed that bone density tests should be performed for the following patients:
      • Women age 65 or older

      • Women younger than 65 with risk factors causing their fracture risk to be equal to or greater than a 65-year-old Caucasian woman

      Bone density testing should be strongly considered for the following patients:
        • Men age 70 or older

        • Men age 50-69 with risk factors (low body weight, high-risk medications, medical conditions associated with low bone mass)

        • Adults older than 50 with an adult-age fracture


        How often bone mineral density testing should be repeated depends upon the specific needs of individual patients. In general, repeat testing is performed every two years, but this recommendation is based more on insurance coverage than evidence. If you are on a medication to treat osteoporosis, the National Osteoporosis Foundation recommends a bone density test every one to two years. Discuss your individual needs with your physician.

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        DEXA scan preparation – What happens if I take calcium before a DEXA scan?

        Calcium supplements should not be taken for 24 hours before your bone density test. Because the spine lies behind the stomach, undigested calcium in the stomach can give false readings about the bone density in the spine. Calcium supplements include things you might not know have calcium, like your multivitamin and antacids like Tums® and Rolaids.

        How should I prepare the night before or morning of the test? 

        There is no special preparation necessary, aside from the medication precautions above. 
        Some testing centers require you wear a gown, so choose clothes that are comfortable and easy to change out of. Try to choose clothes without metal buttons, belts and zippers if possible. If you have valuable jewelry, it would be a good idea to leave it at home, as you will be asked to remove it before the test. 

        What happens if I take calcium before a bone density test

        What to expect when you arrive for your bone density procedure.

        On the day of your procedure, after registering at the front desk, expect to meet a technician with experience in performing bone density testing. Be sure to tell the technician if you recently underwent any other radiology testing. It is most important to mention tests that required you to swallow contrast, such as computerized tomography CAT or CT scans. If this is true in your case, you will need to wait about two weeks before completing the bone density scan. Before undergoing the DEXA, you will be asked to fill out a questionnaire. Your answers help the technician enter your information correctly into the software (computer program). This personal information is extremely important, as it will help determine your FRAX score, which measures your risk of developing a fracture. using a tool called the FRAX score.

        You should be prepared to answer at the least the following questions:
        • Your age
        • Any family history of fracture
        • The number of alcoholic drinks you consume per day
        • Your smoking status
        • Personal history of rheumatoid arthritis

        DEXA scan results and interpretation

        The DEXA (DXA) scan is the only test that can diagnose osteoporosis before a broken bone occurs. Typically, a radiologist—a doctor who specializes in reading imaging studies—will interpret the results of your bone density. Rarely, an endocrinologist (gland doctor) or rheumatologist (joint specialist) will be reviewing your test. With newer software, the results are automated by the computer after the technician takes the pictures at very specific levels or areas within your bones.

        The test results provide four important pieces of information:

        1. Your bone mineral density (g/cm2)
        2. Your T-score. A T-score shows how much higher or lower your bone density is compared to a healthy, 30-year-old adult of your sex. 
        3. Your Z-score. A Z-score compares your bone density to someone of your sex, age, size, and ethnicity. This score is considered useful for patients under the age of 50.
        4. Any change from an earlier study, if one was previously done at that center.
        A T-score of -1.0 or above is considered normal bone density.
        A T-score between -1.0 and -2.5 is called low bone density or osteopenia.
        A T-score of -2.5 or below is called osteoporosis.

        If you are planning to repeat your bone density test, it is important to use the same scanner each time. If this is not possible, try to use a machine made by the same company. There can be very large errors when trying to compare the measurements from studies done on different machines.

        What about a DEXA scan for body fat?

        A DEXA (DXA) scan can also be performed to determine body fat percentage. The DEXA scan is considered the gold standard to examine what doctors call body composition, or how much fat your body contains (% body fat).

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        Last Modified: Feb 21, 2018 @ 5:26 pm
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        Chris Palmeiro D.O. M.Sc.

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        Dr. Palmeiro is Chairman of Endocrinology at the HealthAlliance of the Hudson Valley, he also serves patients with intellectual and developmental disabilities at the Westchester Institute of Human Development in Valhalla, New York. He has a Masters of Science degree in clinical nutrition and is a diplomate of the American Board of Internal Medicine. His interests within the realm of endocrinology include nutrition support, obesity counseling and the progressive management of diabetes.

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        The Complete Guide to Atrial Fibrillation

        Atrial Fibrillation: The Complete Guide [In 3 Lessons]

        and

        Afib

        Lesson 1: What is atrial fibrillation?

        Atrial fibrillation is an abnormal heart rhythm that causes a fast and irregular pulse. In atrial fibrillation, parts of the atria send disorganized electrical impulses into the top of the heart. These abnormal discharges cause the atria to shake like jelly. This activity takes over the heart’s normal beats, and the body is not able to control how fast the heart is beating. This causes the most common symptom of atrial fibrillation: fatigue.

        The most common symptom of afib is fatigue

        What is afib? : an abnormal heart rhythm

        Atrial fibrillation is the most common type of abnormal heart rhythm. An estimated three to six million Americans have it.  In fact, it happens so commonly, doctors have a nickname for it — “a fib.” Most often, the risk of a fib increases as we get older. As people age, so does their heart, and age is the biggest risk factor for developing a fib.  Just 2% of people under the age of 65 have atrial fibrillation, but as high as 9% of those over the age of 65 have it.

        2% of people under the age of 65 have a fib, but as high as 9% of those over the age of 65 have it

        What causes afib?


        • Advanced age

          This is the most important risk factor.

        • Obesity

        • Thyroid problems

        • Too much alcohol, caffeine or energy drinks

        • Lung problems like COPD

        • Sleep apnea

        • Severe illness


        Afib causes two main problems:

        afib causes symptoms and possibly a stroke
        Afib can cause symptoms
        Afib increases your chances of having a stroke

        Lesson 2: Atrial Fibrillation and the Risk of Stroke

        Strokes caused by afib

        To understand how are strokes caused by afib, we need to look at a part of the heart called the left atrial appendage. This part of the heart is kind of like the heart’s tail.  When afib starts, the atria shakes like jelly. This type of movement does a bad job at pushing blood out of the top part of the heart and into the bottom. Because of this, some of the blood pools inside the heart’s little tail, where it settles and can form blood clots.

        blood clot in heart are responsible for strokes caused by afib
        The left atrial appendage can squeeze the clots out into the body. The most common place a blood clot goes after it leaves the heart is the brain.
        the left atrial appendage cause strokes in afib

        In afib, some of these formed clots inside the left atrial appendage can detach. If the heart breaks out of afib and starts squeezing normally again, the tail appendage can squeeze the clots out. The clots can then be launched into the body. The most common place a blood clot goes after it leaves the heart is the brain. If a clot lands in your brain, it can obstruct the blood flow and cause a stroke. A stroke can have a huge impact on a person’s life, even taking away their ability to talk and move independently. 

        Calculating Your Stroke Risk

        If you have afib, it is important to find out your stroke risk so you can decide if you need to protect yourself from one. Fortunately there is a tool that can help you and your doctor quickly determine your risk. This tool is called the CHADS VASc score. This score looks at all the factors that increase stroke risk in people with afib.


        The CHADS VASc score looks at all the factors that increase your stroke risk if you have afib.
        If your score adds up to 0 or 1, then your stroke risk is low.
        For any score over 2, protection with a blood thinner or what is called an occlusion device is recommended.

        Calculate your CHADS VASc Score here by adding all the conditions that apply to you:


        Stroke Prevention in Atrial Fibrillation

        Warfarin can prevent strokes in patients with afib.

        Until recently, Coumadin, also known as Warfarin, was the only choice of blood thinner available for patients with afib. Coumadin can protect from a stroke but it is a very difficult drug to take as it requires frequent testing. Fortunately, there are now four new oral blood thinners that do not need regular blood draws for monitoring and have minor interactions with food and other medications. 

        If a patient is bleeding or is at high risk of bleeding because of frequent falls, job activities or sports, or has had head trauma, an occluding device for the left atrial appendage is recommended. An occluding device may also be used if the patient has a history of not taking their prescribed medications.

        Doctors in the US offer two occlusion devices that can protect you permanently from a stroke:

        The Watchman Device: Plugs the atrial appendage.
        The Watchman® Device:

        A plug is placed inside the left atrial appendage so clots cannot settle inside of it.

        The Lariat Device ties off the left atrial appendage
        The Lariat® Device:

        Ties off the left atrial appendage altogether so it can no longer cause the problem.

        Lesson 3: Atrial Fibrillation and its Symptoms

        What are afib symptoms?

        Afib can feel like

        Symptoms of atrial fibrillation (afib) can be different for everyone. The same irregular heart rhythm can cause severe symptoms in one person and literally nothing in others. The most common symptom of afib is fatigue, but people with afib can also feel their heart racing (palpitations), shortness of breath, chest pain, and even anxiety.


        Symptoms of afib can be fatigue, shortness of breath and palpitations.
        The most common symptom of atrial fibrillation is fatigue.

        Afib treatments

        There are medications available that can help treat the heart so that afib happens much less often; this can lead to an improvement in symptoms. These medications are called “antiarrythmics”, and as a group have only a modest ability to help and several potential side effect. The most common and powerful of these medications is called Amiodarone.

        Amiodarone side effects: thyroid problems, skin color changes, and lung scaring

        Although amiodarone is very effective at controlling atrial fibrillation, its down side is that it can potentially cause serious side effects. Amidorone can affect the thyroid gland, making it either over-or underactive. Also, taking amiodarone for a long time can lead to changes in skin coloration and lead to an untreatable condition that scars the lungs permanently.

        Over the last two decades, atrial fibrillation has also been treated with a procedure called an ablation. The ablation procedure was invented in the 1990s and has been dramatically improved over time. It can offer patients improvement in symptoms and mortality while reducing the need for medications and their side effects. 

        Atrial fibrillation ablations can improve symptoms and reduce mortality while at the same time reducing the need for medications and their side effects.

        With an ablation, doctors can precisely target the root of the problem that causes afib. Using space age technology, doctors trace the abnormal electrical discharges that provoke the irregular heart beat and locate the parts of the heart where they occur. Up to 85% of these happen in the part of the heart that receives blood from the lungs: the pulmonary veins . Once they locate these trigger areas, doctors then enter the heart using a minimally invasive approach. Inside the atrium they target and zap or “ablate” these abnormal trigger areas while leaving the normal parts alone.

        How afib ablations are done: the pulmonary veins.

        How effective are atrial fibrillation ablations?

        The earlier the problem is treated the more effective an ablation will be.

        90% effective at treating afib that comes and goes, called “paroxysmal”.
        70-80% effective at treating “persistent” afib that has been occurring for less than one year.
        60% effective at treating afib that has been happening for over a year.

        Since 2016, the procedure of afib ablation has begun to expand to include the left atrial appendage. When the left atrial appendage is ablated in addition to the ablation around the pulmonary veins, the procedure’s effectiveness improves by approximately 20%. Many studies have shown that this updated ablation procedure is safe and does not increase the risks related to ablation.

        afib ablations can be effective up to 90%

        Regardless of how long afib has been going on, it is never too late for treatment. Even in those who have had it for a long time, reducing the amount of time the heart stays in afib can lead to an improvement in symptoms.  

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        Last Modified: May 26, 2018 @ 1:04 am
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        Jorge Romero M.D. F.A.C.C. F.H.R.S.

        Twitter

        Jorge Romero, MD, is an Attending Physician and Assistant Professor of Medicine in the Arrhythmia Service of the Cardiology Division at the MontefioreEinstein Center for Vascular Care. He specializes in the treatment of complex arrhythmias, particularly in catheter ablation of ventricular tachycardia and atrial fibrillation using cutting-edge technology. Dr. Romero is a member of the American Heart Association (AHA), and a fellow of the Heart Rhythm Society (FHRS) and the American College of Cardiology (FACC).

        And
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        Jose Taveras M.D. F.A.C.C.

        Twitter

        Dr. Taveras is a non-invasive cardiologist in the Montefiore-Einstein Center for Heart and Vascular Care in Bronx, New York. He trained in both internal medicine and pediatrics and is currently an assistant professor of medicine at Albert Einstein College of Medicine. Dr. Taveras is a fellow of the American College of Cardiology. He is the co-creator of Doctablet.

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        Fiasp Insulin, Insulin Aspart, Fiasp vs Novolog - Doctablet®

        Fiasp Insulin, Insulin Aspart, Fiasp vs Novolog

        Doctablet Diabetes, Endocrinology, Everything About Insulin

        Fast Acting Insulin: Fiasp is Faster than Novolog

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        It’s understandable if you are wondering what Fiasp insulin is. The truth is, we were wondering the same thing when the FDA announced its approval of Novo Nordisk’s new, first in class, injectable, “faster-acting” insulin. What do we mean by faster-acting insulin? Well, now there are two levels of fast when it comes to mealtime (rapid-acting) insulin: Fast and Faster.

        Fast vs Faster-acting insulin injections


        Fast Acting Insulins

        Faster Acting Insulin

        Insulin Name

        Humalog® (insulin lispro)

        Novolog® (insulin aspart)

        Apidra® (insulin glulisine)

        Fiasp® (insulin aspart)

        Timing of Dose

        Within 15 minutes before meal

        (Within 20 minutes after starting a meal for Apidra® only)

        Up to 2 minutes before a meal

        Up to 20 minutes after starting a meal

        Onset of action

        10 to 20 minutes

        2.5 to 4 minutes

        Duration of action

        3 to 5 hours

        3 to 5 hours


        Insulin aspart is a powerhouse in the world of diabetes. It was introduced under the brand name Novolog in June of 2000. For over 15 years, Novolog has been a staple of insulin regimens for many patients. Novolog and Humalog are the two most commonly prescribed fast-acting insulins that patients take within 15 minutes of mealtime. For this article, we will be paying closer attention to insulin aspart (more commonly called Novolog or Novorapid® in Europe and Canada). Novolog itself is an insulin analogue. This means it has been modified from regular insulin to change its structure and how quickly it is absorbed from under the skin.

        Novo Nordisk teamed up their workhorse Novolog insulin with a B3 vitamin (nicotinamide) to make it absorb more quickly and the amino acid arginine to stabilize it. That’s right! Fiasp insulin is simply Novolog with two small additions: Vitamin B3 and naturally occurring arginine. Researchers discovered that adding nicotinamide to the insulin aspart molecule causes its initial absorption to happen more quickly. This means it acts more like the insulin normally made by your pancreas. Fiasp insulin can even be taken up to 20 minutes AFTER starting the meal! So if Fiasp were racing Novolog, it could give Novolog a 15-minute head start and still catch up! Not only that, but twice as much insulin is available within 30 minutes of injecting Fiasp as compared to Novolog. More insulin available earlier means more insulin is in the body to handle the sugar entering your blood stream after eating. So what are the key differences between Novolog and Fiasp? Here is a quick summary:


        Novolog vs Fiasp: Same insulin aspart plus Vitamin D

        Novolog vs. Fiasp


        Novolog® (insulin aspart)

        Fiasp® (insulin aspart)

        Year released

        2000
        2017

        Class

        Fast-acting mealtime insulin
        Faster-acting mealtime insulin

        Onset of action

        10-20 minutes
        4 minutes

        Injection frequency

        Within 15 minutes of the meal
        Beginning of meal, up to 20 minutes after

        Duration of action

        3 to 5 hours
        3 to 5 hours

        Differences vs. regular insulin

        Amino acid substitution
        Amino acid substitution

        Added nicotinamide for faster absorption and L-arginine for stability

        Cost

        $564 per month
        (0.38 cents per unit)
        Pricing has not been finalized in the USA

        Common questions about Fiasp® Insulin

        Insulin Apart is present in both Fiasp and Novolog
        How long does Fiasp last in the body?

        Fiasp is in a class of insulin called “faster-acting” insulin. Fiasp’s onset to action is approximately 4 minutes. The half-life of Fiasp is 1 hour, and it lasts about 4 hours in the body. By adding a vitamin B3 to insulin aspart (Novolog), the initial absorption is quicker and the amount of insulin available doubles in the half hour after the injection. This allows Fiasp to be used even after you start eating.

        Should I lower my insulin dose when I change from Novolog to Fiasp?

        Despite the fact that Fiasp has a faster action than Novolog, it is converted on a 1:1 basis. Meaning if you are on 5 units of Novolog and your doctor changes you to Fiasp, your dose will likely still be 5 units.  Close fingerstick glucose monitoring is always recommended when changing between mealtime insulins. While you might start at the same dose, studies suggest improved after-meal blood sugars in those with Type 1 diabetes, in those with Type 1 diabetes on insulin pumps, and improved blood sugars 1 hour after eating in those with type 2 diabetes when patients take Fiasp as compared to Novolog.

        What will happen to my HgbA1c if I change to Fiasp?

        Studies show that the hemoglobin A1c (HgbA1c, A1c) drop on Fiasp is similar to Novolog both for patients with Type 1 diabetes as well as in those with Type 2 diabetes.

        How much insulin does the Fiasp FlexTouch® Pen contain? (vs. Novolog)

        The Fiasp FlexTouch pen contains 300 units of insulin, the same amount as the Novolog FlexPen

        How many pens are in a box of Fiasp? (vs. Novolog)

        The Fiasp FlexTouch pens come 5 in a carton (the same as the Novolog FlexPen).

        How should the Fiasp pen be stored?

        Both Fiasp and Novolog pens contain the same insulin (aspart) and are stored in a similar way. Insulin pens that have not been used should be kept in the refrigerator. After the first use, both Fiasp and Novolog can be kept at room temperature. Both the Fiasp FlexTouch and Novolog FlexPen should be discarded 28 days after the first injection.

        Can Fiasp be used in pregnancy?

        Fiasp is insulin aspart, and therefore has the same indication as Novolog in pregnancy. There is no known risk of fetal harm associated with insulin aspart in human studies.

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        Last Modified: Dec 27, 2017 @ 11:24 am
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        Chris Palmeiro D.O. M.Sc.

        Twitter

        Dr. Palmeiro is Chairman of Endocrinology at the HealthAlliance of the Hudson Valley, he also serves patients with intellectual and developmental disabilities at the Westchester Institute of Human Development in Valhalla, New York. He has a Masters of Science degree in clinical nutrition and is a diplomate of the American Board of Internal Medicine. His interests within the realm of endocrinology include nutrition support, obesity counseling and the progressive management of diabetes.

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        Toujeo vs Lantus, Toujeo Costs, Insulin Glargine - Doctablet®

        Toujeo vs Lantus, Toujeo Costs, Insulin Glargine

        Doctablet Diabetes, Endocrinology, Everything About Insulin, Medicine

        toujeo vs lantus: They are both insulin glargine

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        It’s understandable if you are wondering about the difference between Lantus® and Toujeo®. After all, both Lantus and Toujeo contain the same insulin, called insulin glargine. Insulin glargine was introduced in the year 2000. This was a huge advancement because it was the first long-acting basal insulin. Before the development of insulin glargine, doctors did not have many types of insulins to choose from.

        Insulin Glargine: Toujeo vs Lantus

        Glargine (the insulin in both Lantus and Toujeo) is an insulin analogue—meaning it has been modified from regular insulin to change its structure and the way it is absorbed. Insulin glargine is still available in its original formulation as Lantus, most commonly prescribed as the Lantus Solostar® pen. Insulin is classically prescribed at a very specific concentration called U-100. The U stands for units. The 100 stands for the number of units present in the liquid (1 milliliter). U-100 insulin has 100 units in 1 milliliter. U-100 is also referred to as “regular” insulin, but this can be confusing since many different types of insulin come in this concentration.

        Fast forward a decade and a half later, and insulin glargine (originally Lantus) has reinvented itself. Toujeo (U-300) insulin glargine was approved by the FDA in late February of 2015, making it the first long-acting concentrated insulin available on the market.  It is available in insulin pen form only as the Toujeo SoloStar. What researchers discovered was that if they made glargine more concentrated, it lasts slightly longer in the body. That’s right, Toujeo IS GLARGINE, just in the concentrated form of U-300. This means Toujeo is three times more concentrated than Lantus.  Some people think Toujeo is stronger than Lantus, but this not true.  Toujeo is more concentrated than Lantus, but this does not make it a stronger insulin (learn more about concentrated insulin here). Three times higher concentration means that the same amount of liquid (one milliliter) contains three times the amount of insulin. Toujeo is more concentrated, so the amount (or volume) of the injected medicine is three times less than that of Lantus, but the strength of the medication is the same.

        Toujeo IS GLARGINE, just in the concentrated form of U-300. This means Toujeo is three times more concentrated than Lantus. The amount (or volume) of the injected medicine is three times less than that of Lantus, but the strength of the medication is the same.

        What are the key differences between Lantus vs Toujeo?

        • Lantus is available in both a vial and the pen form, while Toujeo is only available in the SoloStar pen.

        • Toujeo is three times the concentration as compared to Lantus.

        • The changes in the concentration of Toujeo (as compared to Lantus) have prolonged its absorption, and it therefore lasts slightly longer in the body.

        • Some studies suggest that the changes in the concentration of Toujeo have led to a decrease in the amount of hypoglycemia that occurs as compared to Lantus (approx. 30% less).

        • Studies show that the dose of Toujeo may need to be 10-15% higher to get the same fasting sugar control as compared to Lantus.

        Toujeo: Common Questions

        How long does Toujeo last in the body?

        Toujeo is in a class of insulin called long-acting basal insulin. Toujeo’s onset to action is 5 hours or longer. The half-life of Toujeo is 19 hours, and it lasts for a little longer than 24 hours in the body. It seems that by increasing the concentration of glargine, the absorption is prolonged, allowing Toujeo to last a little longer under the skin. The change in the concentration also causes Toujeo to need more time to build up in the body. It takes at least 5 days to reach a steady state. This means that the original starting dose really should not be increased until the medication has had time to reach its full effect.

        Should I lower my insulin dose when I change from Lantus to Toujeo?

        No. Despite the fact that Toujeo is three times more concentrated than Lantus, it is converted on a 1:1 basis. Meaning if you are on 22 units of Lantus and your doctor changes you to Toujeo, your dose will likely be 22 units. In fact, you might start at the same dose, but the studies show you are likely to need 10-15% more Toujeo to achieve the same blood sugar control.  In studies, patients who were changed from another long-acting insulin to Toujeo required (as compared to Lantus) higher doses to get the same early morning sugar levels.

        The dose for Toujeo is the same you use for Lantus.

        What will happen to my HgbA1c if I change to Toujeo?

        Studies suggest that the hemoglobin A1c (HgbA1c, A1c) drop on Toujeo is similar to other basal insulins. In a series of studies called EDITION that compared Toujeo to Lantus , the average three-month blood sugar drop was similar to Lantus.

        How much insulin does the Toujeo SoloStar Pen contain? (vs. Lantus)

        The Toujeo SoloStar pen contains 450 units of insulin, while Lantus has 300 units in a single pen.  There is no need to do any fancy calculations while using the Toujeo Solostar pen, as the pen was designed to take into account that the insulin concentration is higher and does the math by giving smaller volumes per click.

        How many pens are in a box of Toujeo? (vs. Lantus)

        The Toujeo SoloStar pens come three in a carton.  Lantus comes as five pens per carton.

        How much does Toujeo cost? (vs. Lantus)

        Three pens of Toujeo costs approximately $358.24, or 0.27 cents per unit. Five pens of Lantus costs approximately $397.16, which breaks down to 0.26 cents per unit.

        How should the Toujeo pen be stored?

        Both Toujeo and Lantus SoloStar pens contain the same insulin glargine and are stored in a similar way. Pens that have not been used should be kept in the refrigerator. After the first use, both Toujeo and Lantus can be kept at room temperature. Both Toujeo and Lantus Solostar pens should be discarded 28 days after the first injection.


        Toujeo cost, onset of action and injection frequency vs Lantus


        Lantus®
        (insulin glargine U-100)
        Lantus Solostar: Insulin Glargine U100
        Toujeo®
        (insulin glargine U-300)
        Toujeo Solostar : Insulin Glargine U300
        Year Released
        2000
        2015
        Class
        Long-acting basal insulin
        Long-acting basal insulin
        Onset of action
        1-3 Hours
        6 Hours
        Half-life
        12 hours
        19 hours
        Steady-State
        2 – 4 days
        ≥ 5 days
        Injection Frequency

        Daily
        Daily
        Duration of action
        Hypoglycemia
        Can Occur
        Cost
        397.16 dollars
        (5 pens)
        358.24 dollars
        (3 pens)
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        Last Modified: Apr 7, 2018 @ 11:55 pm
        About the Author
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        Chris Palmeiro D.O. M.Sc.

        Twitter

        Dr. Palmeiro is Chairman of Endocrinology at the HealthAlliance of the Hudson Valley, he also serves patients with intellectual and developmental disabilities at the Westchester Institute of Human Development in Valhalla, New York. He has a Masters of Science degree in clinical nutrition and is a diplomate of the American Board of Internal Medicine. His interests within the realm of endocrinology include nutrition support, obesity counseling and the progressive management of diabetes.

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        What is a Stress Test, Heart stress test - Doctablet®

        What is a Stress Test, Heart stress test

        Cardiology, Coronary Disease

        What is a stress test?: a test that takes a picture of your heart while its running

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        When doctors want to study the heart in detail, they often start with a type of test called a “stress test.” Stress tests examine the heart in different ways while the heart is beating. Performing a stress test on the heart is like examining a runner while they are in a race—doctors want to see the heart muscle in action.

        A heart stress test gives different types of information about the heart.

        • They can find blockages in the arteries that send blood to your heart. This known as coronary artery disease.

        • They can be used to examine tight valves. This helps doctors to decide if valve replacement surgery is necessary.

        • Stress test overall results are “prognostic.” This means they can help peek into the future and predict your long-term health.

        The “stress” in a heart stress test has nothing to do with the emotional stress we all feel from time to time. This type of stress is a medical term used to describe something you put the heart through to see how well it handles it. There are three ways we can stress the heart when we want to test it.

        Types of “stress” in stress tests

        Exercise

        Considered the best and most complete type of stress. This can be done by walking on a treadmill or riding a stationary bike. The exercise starts off slowly and gets harder over time until you cannot do it anymore because you either get tired or develop symptoms. This is the type of “stress” used in a treadmill stress test and stress echocardiogram. 

        Medication that speeds up your heart

        For those who cannot exercise because they have a physical disability, this type of medication makes the heart behave as if it were exercising. The medication’s dose is slowly increased until the heart is beating fast enough to be examined. This type of “stress” can be used in stress echocardiogram and in nuclear stress tests.

        Medication that opens up all the blood vessels that give blood to your heart

        This is usually given as a single dose or through an infusion that runs for one or two minutes. This type of stress can only be used in nuclear stress tests.


        The “test” part of heart stress test is more than just a single test. During the stress test, the heart and your body are monitored and examined in several ways. All stress tests monitor your blood pressure, heart rate and electrocardiogram. This is done for safety, and also because these measurements will provide important information. There may also be a second part to the stress test that takes images of the heart. This can be done with a nuclear camera or an ultrasound.

        What are the different types of stress tests available?

        How are stress tests done?

        The way stress tests are done is by comparing the heart at rest with the heart at stress.

        Heart at Rest:

        Heart at rest in a stress echocardiogram
        Heart at rest in a stress echocardigram

        Heart at Stress:

        Heart at stress in a stress echocardiogram
        Heart at rest in a stress echocardiogram

        What are the different types of stress tests available?

        Your doctor will decide the best way to study your heart. Doctors consider your age, other medical conditions and your chances of having a heart attack when deciding what type of stress test is right for you. For this post, we will cover the types of stress tests that DO NOT use radiation to look at the heart. Because they are different in very specific ways, we will discuss those tests in another tablet. Let’s look at the different types of stress tests available today.

        • ECG Exercise Stress Test

          Also known as a treadmill stress test. This is the simplest type of stress test available. It uses the electrocardiogram and exercise to test the heart. Most stress tests of this type are completed using the Bruce Protocol of exercise on a treadmill, but can also use a stationary bicycle. An ECG stress test takes about 20 minutes to complete.

        • Exercise Stress Echo

          Also known as a stress echocardiogram. The exercise stress echo is very similar to the ECG Exercise Stress Test. It uses the same parts, but adds an echocardiogram either during the exercise if you are using the bicycle, or immediately after if the exercise is done on a treadmill.

        • Pharmacological Stress Echo

          This is another type of stress echocardiogram. This test replaces the exercise with a medication called Dobutamine. Dobutamine is a synthetic form of a substance the body uses to make your heart rate go up. Your electrocardiogram and vital signs are monitored while you get a continuous intravenous dose of this drug. Usually, an echocardiogram is done while you are getting the drug. The drug is stopped once a certain heart rate has been reached.

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        Last Modified: Feb 20, 2018 @ 1:07 am
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        Jose Taveras M.D. F.A.C.C.

        Twitter

        Dr. Taveras is a non-invasive cardiologist in the Montefiore-Einstein Center for Heart and Vascular Care in Bronx, New York. He trained in both internal medicine and pediatrics and is currently an assistant professor of medicine at Albert Einstein College of Medicine. Dr. Taveras is a fellow of the American College of Cardiology. He is the co-creator of Doctablet.

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        Why is my sugar high in the morning? - Doctablet®

        Why is my sugar high in the morning?

        Checking Blood Sugar, Doctablet Diabetes, Endocrinology

        It can be very frustrating to check your blood sugar and find it is always high in the morning. Diabetes is a complicated condition. There are many different factors that contribute to worsening blood sugars, including diet, hormones, exercise and genetics. A high blood sugar in the early morning can be caused by several things. The common ones will be covered below.

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        Causes of high blood sugar in the morning:

        Insulin resistance in the liver:

        The two main hormones involved in blood sugar control and regulation are Insulin and Glucagon. Insulin pushes sugar into the cell, so it can be used or stored. Glucagon does the opposite of insulin. It frees sugar from storage in the liver, so the body can use it while you are fasting.

        A high blood sugar in the morning is one of the earliest changes people with diabetes experience. This is due to insulin resistance in the liver and high glucagon levels, which often occur in people with diabetes. The insulin the pancreas produces does not work well anymore, even though the pancreas is working overtime to produce more of it. Insulin resistance in the liver and elevated glucagon levels causes the liver to spill out extra sugar into the bloodstream while you are sleeping and fasting overnight. This raises your blood sugar levels.

        The Dawn Phenomenon:

        In the early morning, it is normal to have higher levels of cortisol  and growth hormone. Both of these hormones help prepare you to wake up and start the day. Doctors often call this hormone increase the ‘Dawn phenomenon.’ Dawn phenomenon happens between 2 AM and 8 AM, and it also occurs in patients without diabetes. This natural hormone change helps to keep sugar in the blood while a person is fasting. In patients with diabetes, the Dawn phenomenon is more noticeable because of both insulin resistance and decreased levels of insulin.


        Both Dawn and Somogyi affect morning blood sugar
        High blood sugar the night before

        A high blood sugar in the morning can often be from high blood sugars left over from the night before. If the pancreas cannot secrete enough insulin after a large dinner or snack, you can have high blood sugars during the night and into the following morning. Many people with diabetes cannot recover to a normal blood sugar by the early morning, especially after a large carbohydrate filled meal.

        The Somoygi Effect—a low blood sugar overnight:

        Some medications for diabetes, such as insulin, can make your blood sugar go too low. When this happens, the body will rebound with stress hormones like glucagon and epinephrine that raise the blood sugar. This is called the Somoygi effect – named after the researcher who first described it.

        Dawn phenomenon vs Somogyi Effect

        Tricks to help lower your blood sugar in the early morning:

        • Skip the bedtime snack and limit carbohydrates (sugars, pasta, bread, rice) with dinner.

          Having a bigger lunch and a smaller dinner can often lower the morning blood sugar level. This is because there is less sugar available to the body overnight.

        • Try changing the time you take your prescribed medications.

          Metformin, the first-line medication for diabetes, is the best oral medication for reducing insulin resistance in the liver. Sometimes moving the evening metformin dose from suppertime to bedtime can help lower early morning glucose levels.

        • Exercise

          Exercise increases sugar uptake by the muscle. This increased sugar uptake lowers the amount of sugar in the blood for many hours after the activity. A safe exercise plan can greatly lower all of your blood sugars.

        • Stay hydrated

          Drinking plenty of water—not flavored or diet drinks—keeps you well hydrated. Sugar always travels with water, so it is important to keep up with the body’s need for fresh water to balance the blood sugar.

        • If you are on insulin, there might be a problem with your insulin dose.

          The first step is to find out if your blood sugar is running high or low in the middle of the night. If you have low blood sugars overnight, this needs to be corrected first in order to prevent the subsequent “rebound” effect.

        How can I help my doctor figure out why my blood glucose is high in the AM?

        Your doctor will likely recommend checking your blood sugar at bedtime and at 2 AM, in addition to the morning time. For patients on  complicated insulin regimens, a newer technology called continuous glucose monitoring might be used to trace the sugar levels over a longer period of time.

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        Last Modified: Oct 2, 2017 @ 1:50 pm
        About the Author
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        Chris Palmeiro D.O. M.Sc.

        Twitter

        Dr. Palmeiro is Chairman of Endocrinology at the HealthAlliance of the Hudson Valley, he also serves patients with intellectual and developmental disabilities at the Westchester Institute of Human Development in Valhalla, New York. He has a Masters of Science degree in clinical nutrition and is a diplomate of the American Board of Internal Medicine. His interests within the realm of endocrinology include nutrition support, obesity counseling and the progressive management of diabetes.

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        What is a Clear Liquid Diet for Diabetics? - Doctablet®

        What is a Clear Liquid Diet for Diabetics

        Diabetic Diet, Doctablet Diabetes, Endocrinology, Medicine

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        Patients with diabetes often have to take tests that require they eat a clear liquid diet the day before. Some tests that need this special diet include a colonoscopy, capsular endoscopy, and certain surgeries. Doctors recommend the clear liquid diet before a procedure because this type of food is very easy to digest. This means the food will not block the doctor’s view of the important parts of the body. For people with diabetes, eating a clear liquid diet can be hard, because many of the allowed foods and drinks contain high amounts of sugar. It is important for someone with diabetes to have other choices besides the high-sugar foods usually recommended on a clear liquid diet.

        Sugar-free foods that can be eaten on a clear liquid diet:

        • Water and flavored waters (carbonated waters are also okay)

        • Diet drinks like Diet Snapple™, Crystal Light™, PowerAde ZERO™, Skinny Water™, and Gatorade G2™ - Avoid red and purple colors

        • Coffee and teas without milk or creamer ; Can be iced or hot, unsweetened or artificially sweetened.

        • Sugar-free popsicles – Choose lighter colors like lemon

        • Sugar-free gelatin (Jell-O™) – Avoid flavors that are red or purple

        • Soup broths (must be low- or non-fat broth, bouillon and consommé are okay)

        No matter what type of clear liquid diet you choose, make sure you check in with your doctor first. When diets change in a big way, anti-diabetic medications have to be adjusted, too. For instance, medications like insulin and pills called sulfonylureas can become very dangerous when a person is eating much less than normal. Also, for surgeries that may require hospitalizations, other diabetic medications like metformin and SGLT-2 inhibitors are not to be taken for at least 24 hours before the procedure.

        A colonoscopy is probably the most common reason for a clear liquid diet. That test also includes a preparation to help wash out the system so the doctor can view the colon better. Before the procedure, be sure to tell the doctor about medical problems, including diabetes. It is important for those with diabetes to know that the commonly used preparations GoLYTELY™, NuLYTELY™, and HalfLYTELY™ contain no added sugars.

        For some procedures, the patient is usually NPO (nothing to eat at all). This will affect medications doses as well. Be aware that patients do not usually eat after they wake up from sedation until much later in the day. Again, having a plan from your doctor ahead of time can help avoid problems like low blood sugars.

        Because a clear liquid diet of sugar-free foods contains little to no calories, be sure to get your doctor’s okay before starting the diet. Not only will medications need adjusting, but these types of foods are only safe for very short periods of time. Clear liquids, especially those that are sugar-free, do not have enough nutrition to provide the energy needed for daily life.

        A clear liquid diet for diabetics.
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        Last Modified: Oct 9, 2017 @ 12:48 am
        About the Author
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        Chris Palmeiro D.O. M.Sc.

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        Dr. Palmeiro is Chairman of Endocrinology at the HealthAlliance of the Hudson Valley, he also serves patients with intellectual and developmental disabilities at the Westchester Institute of Human Development in Valhalla, New York. He has a Masters of Science degree in clinical nutrition and is a diplomate of the American Board of Internal Medicine. His interests within the realm of endocrinology include nutrition support, obesity counseling and the progressive management of diabetes.

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