Protecting your Hearing

According to the CDC, hearing loss is one of the most prominent debilitating health conditions in the U.S., with almost two times as many reportings as diabetes or cancer. While hearing loss has traditionally been a concern in older individuals, this issue has begun to cross all age groups. This is due to the increasing rates of hearing loss observed in young adults.

So how is sound measured? Sound is measured in decibels (dB) indicative of sound intensity or loudness. To give you a standard of comparison, an individual with normal hearing can typically hear sounds ranging from 0-140 dB. While normal conversation usually meets a level of 50-65 dB, sounds above 85 dB can be detrimental, depending on the length and intensity of sound exposure.

What causes hearing loss? [Read more…]

Diabetic retinopathy

Diabetic retinopathy is the result of damage to the blood vessels in the eye due to chronic elevations in blood sugar, or diabetes.  The retina is responsible for detecting light and visual cues and sending them via your optic nerve into your brain to tell you what you just saw. 

Uncontrolled sugar levels leads to damage to the small blood vessels in the eye, allowing them to leak.  Over time, this leaking leads to swelling in the eye.  The end effect is a lack of blood flow and nutrients to the retina, resulting in loss of vision.  The body attempts to repair this damage by building new blood vessels, which are even more fragile and likely to leak.  All of this bleeding and blood vessel growth causes scar tissue to form, and as scars tend to do, they contract away from the surrounding tissue.  This pulling away can actually pull the retina off, leading to permanent visual loss. 

Unfortunately, there are often no symptoms of diabetic retinopathy.  Later symptoms may include visual floaters, increased visual difficulty, dark spots or difficulty with night vision.

This is why it is vital that people with diabetes get annual eye exams by an optometrist or ophthalmologist.  Since there are usually no symptoms, it is important to get a visual of your retina and its blood vessels to ensure there are no abnormal blood vessels. 

The best way to prevent diabetic retinopathy is to control your blood sugar.  Long term sugar control is measured via hemoglobin A1C, which can tell you how your sugar has been over the last 3 months.  An A1C of less than 8.0 can reduce your risk of developing diabetic retinopathy by more than 75%.  Don’t be discouraged if your A1C is not at that goal yet – studies show that for every 1 point reduction in A1C, there is a 35% reduction in retinopathy development.  So, small improvements can help while you are working toward your diabetic control goals. 

There are some treatment options for diabetic retinopathy, depending on the severity of the disease. 

An ophthalmologist may inject a medication directly into the eye.  One type of medication is to block a protein that stimulates blood vessel growth and leakage, vascular endothelial growth factor (VEGF).   Another is a steroid, which is used to reduce inflammation and can be an injection or implant. 

There are two different types of laser eye treatments used for treatment: focal laser surgery and panretinal photocoagulation.  Focal laser surgery uses a spot laser to concentrate in an area that is already leaking fluid into the macula, the central area of the retina.  Panretinal photocoagulation utilizes multiple laser spots to diminish current blood vessels and prevent new blood vessels from forming, thus preventing leaking in the future.

If there is severe bleeding, a vitrectomy may be needed.  This is removal of the gel in the center of the eye.  It is replaced with a salt solution.  Or a terminator eye, if you have a billion dollars to spare. 

We are fortunate to have these treatments available, but they usually don’t return vision after it’s been compromised by diabetes.  Our best hope is to slow the progression of further retinopathy once it has started.  If you do have diabetes, make sure you follow up with your ophthalmologist or optometrist for regular exam.  And, even more importantly, make sure you follow up with your health care provider to ensure you have optimal sugar control!

Adult Pneumonia Vaccination

What is Pneumonia?

Pneumonia is an acute infection of the lungs, most often caused by a virus or bacteria.

As it turns out, breathing is not optional. And fortunately, our lungs are awesome. We are constantly bombarded with microbes that manage to get into our lungs via our upper respiratory tract. But our body’s own defense mechanisms usually fight them off and maintain the sterile environment needed in the lungs so that we can preserve air exchange. Sometimes we are not able to fight off the infection, because the microbe is too strong, because our own body has a weakened defense, because our lungs are compromised, or because the amount of exposure was particularly impressive.

Of the 4 million cases of pneumonia annually in the U.S., the most common bacterial agent is Streptococcus pneumoniae. Symptoms usually start with sudden fever, cough, shortness of breath and possibly wheezing or pain in the side or chest. Some people will also have their shortness of breath progress to a faster breathing rate and lower oxygen level. While many people have mild disease and will recover without damage to their lung function, some patients will have complications. The infection can take over an area of the lung, leading to a big ol’ ball of pus where the lung should be, or travel to the heart, brain or joints. In severe illness where the infection from the lung gets into the blood stream, the mortality rate is over 25%.


How can you protect yourself?

Once again, you could live in a bubble. But that could be a general solution for just about all contagious problems. Keep it in mind, as I may forget to mention it in future posts.

As always, wash your hands, don’t put things in your mouth, don’t plant a big kiss on the coughing guy on the subway (unless it is John Travolta and this may be your only chance; some things are worth risking) – common sense, people!


A more realistic approach is vaccination. We used to recommend a single dose of pneumonia vaccine for adults aged 65 and older. This recommendation changed in 2014, and in order to improve immunity we recommend that adults get two different pneumonia vaccines: PCV13 (pneumococcal conjugate vaccine – Prevnar ®) and PPSV23 (pneumococcal polysaccharide vaccine – Pneumovax ®). These vaccines are given one year apart. If you haven’t started the series yet, start with the PCV13, followed by the PPSV23. But if you already received the previously recommended single dose of the PPSV23 (the recommendation before 2014), we can just update you with the PCV13 one year later.

Of course there are others besides those over age 65 who are at risk for pneumonia and its complications. People with medical conditions that put them at risk may need to be vaccinated sooner than age 65. Adults with the following medical conditions should speak with their provider regarding vaccination as they are at risk due to immune suppression: cancers, any immunosuppressive medical treatments (steroids, chemotherapy), organ transplant recipients, kidney failure/disease, HIV/AIDS, loss of spleen, sickle cell, cochlear implant, cerebrospinal leaks, immunodeficiencies. You’ll need additional an additional dose of PPSV23 when you reach age 65, as long as it has been 5 years since your previous PPSV23. You may need an extra dose of PPSV23 before age 65 but after 5 years anyway, depending on your medical condition and level of immune suppression, so make sure you and your provider review the immunization schedule. It’s can be a bit complicated, so consider politely asking them to bring out their copy of the immunization schedule to show you the footnotes (they are tiny and detailed and definitely worth reviewing to protect yourself) – it is available online if your provider doesn’t have one accessible in the office (

Adults with the following medical conditions should consider vaccination with PPSV23 before age 65: heart disease, asthma, COPD/emphysema, diabetes, alcoholism, cirrhosis, smoking.


I’m always disappointed with the number of people who have declined these vaccines in the past, thinking doctors are trying to trick them into something. No trickery here – intact safety data and lives saved. I’m just trying to keep you out of the hospital. I’d much rather spend my time being healthy than being hooked up to the IVs on the medical floor at the hospital. What about you?


“The flu” is an acute respiratory infection actually caused by the influenza virus. It is not the same as the common cold. While many of us are familiar with the symptoms of the flu, there are still too many people who confuse an actual influenza with an unfortunate viral cold.

People with the flu usually have a sudden onset of fever, headache, muscle aches and general fatigue and may also have the usual cold symptoms of cough, sore throat and runny nose. Gastrointestinal symptoms (sometimes called “stomach flu”) are actually not usually part of influenza symptoms in adults, but are more common in children.


How do you get influenza?

You can catch the flu from exposure to an infected person and their respiratory secretions – particles emitted when someone coughs, sneezes, etc. Ew. You can actually shed the virus for 24-48 hours before you feel sick, so if you know you’ve been exposed you’re really doing us all a kindness by being even more cautious than usual with your infectious respiratory secretions. You can actually have 1-4 days between exposure and symptoms (called the incubation period), so you can’t just blame the lady coughing next to you at church, although we’d all like to. And even after you feel better, you can still shed the virus for a total of 7-10 days in otherwise healthy adults.


What are the complications of influenza?

Pneumonia – You can actually have an influenza pneumonia or a secondary bacterial pneumonia infection while your immune system was distracted fighting the flu itself. The bacterial infection is often the cause of severe illness and/or death in people over age 65.  

Myositis – Inflammation of the muscles, sometimes severe enough to lead to breakdown of the muscles can be a severe but rare complication of influenza. This can lead to muscle proteins in the urine and kidney failure in severe cases.

Central nervous system involvement – Although it is unclear exactly how, the influenza virus can also attack the brain and surrounding tissues. This can lead to several severe brain pathologies, such as meningitis (inflammation of the tissue surrounding the brain), encephalitis (inflammation of the brain), or transverse myelitis (inflammation of the spinal cord). The actual influenza infection has also been associated with Guillain-Barre syndrome, in which the peripheral nervous system shuts down, likely due to the body’s own immune system getting confused and attacking it. In Guillain-Barre syndrome, people first notice weakness of their legs, which then spreads upward, hopefully stopping before it reaches muscles that control breathing. Guillain-Barre syndrome is always listed as a potential consequence of the flu vaccine, but it can be a result of getting the natural virus as well.

Cardiac – Several studies have linked influenza infection and hospitalization for poor blood flow to the heart and heart attack.  

Death – In the U.S, there’s around (an average) of 30,000 deaths annually, with influenza as a contributing factor.


High risk persons

People who have medical conditions that affect their lungs or immune systems put them at increased risk for the flu: diabetes, asthma, pregnancy, HIV/AIDS, cancer. In addition, children less than 5 years old, and adults greater than 65 years old are also at greater risk.


How can you prevent influenza?

Clearly, getting the flu sucks. Well, getting a cold sucks; getting the flu really sucks. There are several ways to prevent catching the flu.

Move to Alaska to live in a bubble – It’s happened before (

Good hygiene – Wash your hands often and definitely before you touch your face, eyes, mouth or nose. You can’t make others cover their mouths and nose when they cough or sneeze (so gross!), but you can make sure you do cover your own. Always cough or sneeze into your elbow so you don’t get germs on your hands and mush them around all over the place.

Encourage sick family/friends to stay home – Sick contacts in public spread germs. We all know you’re tough; I’ll even write it on a prescription pad for you to show all your friends. Even if you’re the toughest one around, please stay home when you are sick so your whole office doesn’t get sick too. Your boss won’t be happy about you missing some work days, but will be even less happy about the entire office being out for a week because you sneezed.

Clean surfaces – Clean areas that are highly trafficked by dirty hands, such as doorknobs, light switches, keyboards, phones, desks, water faucet handles. Don’t let germs move in without paying rent.

Vaccine – The flu vaccine reduces both your risk of catching the flu and having complications if you do catch the flu. Studies show a reduction in hospitalizations of infants when pregnant women are given the vaccine (92% reduction!), of diabetics given the vaccine (79% reduction!), and of patients with chronic lung disease given the vaccine (52% reduction).

The vaccine causes your body to develop its own antibody response in the event you are exposed to the flu in the future. Because your body is mounting an immune response and generating antibodies, you can have those unpleasant side effects of mild fever, body aches or fatigue. Fortunately, it is not the flu itself and is much less severe than the actual flu. Think you don’t like feeling like that? Try getting an influenza infection. Most of the vaccines are injected via needle, but there is even a nasal spray available for you needle-phobic people out there (ages 2-50 only). The nasal spray does contain a live virus, and is not appropriate for people with poor immune systems or people who will be around those with poor immune systems. The standard flu vaccine is manufactured via virus grown in eggs, which can be a problem for people with an allergy to eggs. There is an egg-free vaccine approved for adults, so if you have an egg allergy, discuss this option with your provider.


Flu season is here. You have tools to keep yourself and those around you healthy. Set up an appointment with your provider to get your vaccine today!

Sun Protection


Beach attire, indeed!

Beach attire, indeed!

The sun is wonderful – it promotes life, improves our mood and allows us to make vitamin D. But this comes at a cost. Sunlight contains ultraviolet radiation, which results in damage to the skin and DNA leading to burns, color changes and cancer.

There are two types of UV radiation from the sun – UVA and UVB. Nearly 95% of the radiation reaching the earth is UVA (UVA1 + UVA2), which causes increased pigmentation (sun spots) and aging (wrinkles) in skin as well as may be involved in the processes leading to skin cancers. UVB radiation, while less of the overall radiation, has been found to be responsible for burning, inflammation and cancers of the skin.

Protecting your skin from sun now can prevent cancerous changes in the future. In addition, you can keep your skin smoother and reduce sun-related dark spots by being diligent with the protection now.

Fortunately, you don’t have to cover up every bit of skin to protect it from the sun.

Fortunately, you don’t have to cover up every bit of skin to protect it from the sun.


SPF (Sun Protection Factor) – This measures the sunblock’s effectiveness in protection against UVB only when compared to not wearing sunblock. Theoretically, the SPF is a measure of how much longer you can stay in the sun before burning. But, people in real life don’t apply the sunblock in the same way it was applied in the actual studies – real people actually use approximately 1/3 the amount expected. Also, real people sweat, and go in the ocean / pool or wipe the water off their face taking some of the sunblock with it. And, remember the SPF only measures the protection against UVB.

So, while the SPF does matter, it also is important to pick out the right sunblock and apply it correctly. An SPF of 15 will protect against 93% of UVB radiation, SPF of 30 against 97%, SPF of 50 against 98%. So that SPF of 100, which sticks to your skin for days is not really getting you any more protection than the SPF 50, and providing much more irritation to your skin than likely necessary.

Spectrum – This tells whether the sunblock protects against UVA and/or UVB radiation. Remember that the SPF already tells you that there is UVB protection. Now, you need to make sure there is UVA protection as well. Only three ingredients will protect against UVA1: avobenzone, zinc oxide, titanium dioxide. Avobenzo will come combined with other ingredients to ensure entire UV spectrum protection, as it does not provide full coverage alone. Zinc and titanium are mineral compounds that reflect a wide range of UV wavelengths and are considered broad spectrum independently, however they are often combined with other ingredients, both for efficacy and cosmetic reasons (remember the lifeguards with white noses?). But if you tend to sensitive skin, limiting the chemical components can be helpful and a sunblock containing just zinc oxide or titanium dioxide would be a good choice for broad spectrum coverage with a single ingredient.

Form – If you wear it, it will work. It doesn’t work sitting in your beach bag. Spray, cream, lotion, stick, whatever. Put it on.

Application – Apply 20 minutes prior to the sun exposure and every two hours thereafter. Also reapply if you’ve been in water or wiped off water or sweat. The SPF is tested at 2 mg/sq cm, but no reasonable person knows how much that is when applying sunblock.   An adult should use approximately a fully a shot glass full to cover his/her body (more relatable?).

Water-resistant – In order to be labeled as “water-resistant” the sunblock has to stay strong for 40 minutes in the water. That’s it. How many of you go to the beach and spend 40 minutes in the water? Make sure you reapply! The “very water-resistant” sunblock gets 80 minutes.


Is sunblock safe?

Sunblocks have an excellent safety profile. Most of the issues related to sunblock are skin irritation and / or allergic reactions. Fortunately, since there are so many formulations available, a person with sensitive skin can find a manufacturer they can handle.

More recent concerns have been raised with the use of titanium dioxide and zinc oxide nanoparticles (for cosmetic reasons) in sunblock and the possible absorption through the skin.   Studies show that use of these components do not cause toxicity and the nanoparticles do not penetrate the outer layer of skin, which is composed of dead cells.

With sunblock use, your body will be unable to synthesize its own vitamin D. Fortunately, vitamin D is readily available as a supplement at your local pharmacy, grocery store, big box store and likely gas station these days.


Other measures

Protective clothing

Ultraviolet protection factor (UPF) – This is an international classification system to identify how well a fabric blocks out ultraviolet radiation.   The UPF depends on several factors: type of material, tightness of weave (most important), color, stretch, moisture, conditions, additional treatments. Garments marked with UPF have built in photo-protection.

Laundry additive – Make your own UPF clothing by adding a package of sun blocking agent such as “SunGuard®” to your washer. 

The Skin Cancer Foundation has a seal of recommendation on products they have reviewed and tested for sun protection.

Shade – Shade is better than direct sunlight, but remember that UV radiation can reach the skin indirectly as well. UV radiation can scatter and bounce through clouds, off sand, off concrete, etc.

Hats – Stylish and protective.

Sunglasses – Don’t forget sun can damage your eyes too.


We live on a beautiful island. With occasional beautiful weather. Enjoy the sun safely now and avoid skin biopsies later!


Screening for Cervical Cancer

The cervix is the lowest part of the uterus, opening into the vagina. Fortunately, cervical cancer incidence has decreased by 75% in the last 50 year in developed countries due to screening programs and HPV vaccination. Of women diagnosed with cervical cancer, more than half have not had appropriate pap smear screening, including 25% who never had a pap and 10% who didn’t have a pap in the last 5 years. Cervical cancer usually doesn’t have any symptoms and early cancers definitely don’t have any symptoms, leaving screening to be an important factor in preventing this type of cancer from progressing.

A pap– Papanicolaou (pap is way easier to say) – smear is when the doctor takes a small scraping of the cervix to test for cancerous or precancerous cells. Most people use the term pap smear to include the whole exam, which is often called a “well woman exam” or previously an “annual exam.” This includes a reproductive history, breast exam, pap smear and internal vaginal exam.

Every woman should start getting pap smears at age 21. Most women should have a pap smear every 3 years. This has changed from what many women were used to having as an annual exam, but who can object to spacing these out! Some insurances have started to pay for human papillomavirus (HPV) cotesting with the pap smear in women over age 30, which extends the need for a pap smear to every 5 years. Not all insurers are paying for this yet, and some insurers are actually requiring pap smears for screening more frequently than that, so don’t be surprised if your physician asks you to come in for your screening.

We don’t routinely test for HPV in women under age 30 because there are a higher number of HPV infections in this age group that the body can clear on its own, and testing can lead to unnecessary cervical biopsies. However, if a pap smear comes back abnormal, an HPV test is also run. We just don’t test for HPV independent of an abnormal pap smear.

If a pap smear comes back abnormal, you may require additional testing with colposcopy. Some primary care physicians do this procedure, but not all and a referral to a gynecologist may be required. A colposcope is used to magnify the cervix to look for abnormal areas and biopsies are taken of any concerning spots. In addition, the inside of the cervix, the endocervical canal, is usually scraped to obtain samples to test for abnormal cells as well.

Pap smears have greatly reduced mortality from cervical cancer and can detect early changes before they turn into cancer. This ten minute exam could save your life. You can spare 10 minutes every 3 years. Make sure your pap smear is up to date.  

Screening for colorectal cancer

Colorectal cancer is the third most common type of cancer in the U.S. It is the second leading cause of cancer related deaths within the U.S and the world.

Colon cancer is rare before age 40 and 90% of cases occur after age 50, which is why we start recommending screening for all adults at age 50. Your doctor may recommend earlier screening if you have significant risk factors, so always review your medical and family history with your doctor.

Risks for developing colon cancer include a family history, prior colon cancer, prior colon polyps, inflammatory bowel disease (not irritable bowel disease), high fat and low fiber diet, lack of physical activity, smoking, diabetes, radiation exposure, certain genetic syndromes.

Now that you’ve been appropriately warned or perhaps worried, let’s talk about ways of detecting colorectal cancer early, when it is easiest to treat.

Fecal Occult Blood Test (FOBT)
This test requires you to collect 3 separate small poop samples at home and provide them to the lab on a card, which the lab will then test for blood. This test will not be able to see the inside of your colon or detect any polyps unless they are bleeding. Because this test detects a component of blood, you do need to avoid certain foods, such as red meat prior to collecting the samples. This routine screening test is valid for 1 year only and any findings of blood will require a colonoscopy.

A colonoscopy is a medical procedure done by a trained doctor who specializes in the colon. He inserts a colonoscope, which is a long thin tube with a camera on the end, into the rectum and through the colon to visualize the tissue of your colon. Calm down, you get some medication to help you relax for this procedure and you definitely need a chauffeur as a result. Fortunately, during this procedure, if there are any polyps or areas of concern, the gastroenterologist can remove the polyp or take a biopsy immediately. Unfortunately, in order for the gastroenterologist to have a good look around, we need to give you diarrhea the day before the procedure. While it is unlikely, colonoscopy does have the risk of perforation and bleeding (when they remove the polyp).
Interestingly, the biggest complaint I get isn’t about the procedure, or even the diarrhea – it’s that the liquid to induce diarrhea tastes pretty darn icky. Even with today’s technology, the best we can do is watered down Crystal Light apparently. Sorry. For most people, this routine screening test is valid for 10 years.

Flexible Sigmoidoscopy
A flexible sigmoidoscopy is an outpatient procedure similar to a colonoscopy that can be done by a trained doctor who doesn’t have to specialize in gastroenterology, which can increase its availability. You will still need to have bowel prep with diarrhea the day prior to get a good exam. The sigmoidoscopy does not usually use sedation and it doesn’t reach as far within the colon as the colonoscopy, which are the main differences between the two exams. A normal routine screening is valid for 5 years. If there are concerning findings on this exam, a colonoscopy will need to be completed.

Here are some possible other methods that may available, depending on your location, medical needs or the timing of your reading of this.

Double Contrast Barium Enema
A barium enema also requires the bowel prep with diarrhea. You are given a dose of barium solution rectally to outline the colon during a radiologic exam. It is less sensitive than a colonoscopy for smaller polyps and cancers. A normal routine screening is valid for 5 years. If there are concerning findings on this exam, a colonoscopy will need to be completed. We don’t usually recommend this as a routine screening for colorectal cancer.

CT Colonography
This is a CT scan that visualizes your colon in order to look for abnormal findings. A CT scan also requires the bowel prep with diarrhea, so you still haven’t found a way to avoid that portion of the pain and suffering of maintaining your health. This screening does expose you to radiation, and the accumulation of repeated radiation may increase cancer risk in the future. A normal routine screening is valid for 5 years. If there are concerning findings on this exam, a colonoscopy will need to be completed. So far studies haven’t been conclusive on whether this screening reduces the deaths from cancer, so many insurance companies will not pay for the procedure and the USPSTF does not recommend this as a routine screening for colorectal cancer.

Immunochemical-based Fecal Occult Blood Test (iFOBT or FIT)
This newer test is more expensive than the regular FOBT. This routine screening test is valid for 1 year only and any abnormal findings will require a colonoscopy. This test is not considered effective if it is completed one time only. I haven’t known our local insurers to cover this testing, so if you find out differently, let me know.

This is a poop test which can detect both blood and DNA biomarkers that have been linked with cancerous growths. It is more expensive and new to the market so not quite ready for prime time yet. Stay tuned for more information on when this one may be incorporated into the guidelines.

The incidence of colorectal cancer in Hawaii is 43-49/100,000.
This incidence of colorectal cancer death in Hawaii is 11-14/100,000.
(source: CDC)

Let’s lower these numbers!


Fluoride is a naturally occurring mineral that protects the teeth from decay. It stops the demineralization of the good enamel and helps enhance the remineralization of bad enamel on the teeth.

It seems that there is a complex relationship between systemic (body concentration) and topical (on the surface of the teeth) fluoride, as the concentration of fluoride in the enamel does not completely explain how we achieved such a marked reduction in cavities by adding fluoride to water. There seems to be at least some level of topical protection from the systemic fluoride from salivary secretion of fluoride as well. And, who’s to say that some of the topically applied fluoride doesn’t get into our system as we swallow a small amount?

Here in Hawaii, we do not add fluoride to the water. So, the fluoride needs to come from either your doctor or your dentist. According to the American Academy of Pediatric Dentistry 2014 update, there are three recommended ways to provide fluoride to your child:
1. Oral supplementation – This dose is based on the age (and on the amount of fluoride in your water) and can be combined with a multiple vitamin. I’ve been advised by several experts in the area (taste-testers under the age of 6) that the fluoride only is palatable, but the multiple vitamin combination is quite “icky.”
2. Professionally applied treatments – These are usually done by a dentist in his office every 3-6 months.
3. Fluoridated toothpaste – This is my least favorite of the options as a stand-alone source of fluoride. It is the most cumbersome for parents as it does require ensuring the correct amount of fluoride – in the toothpaste, the amount of toothpaste used, the frequency of the brushing, and avoiding rinsing after brushing. And all of these factors need to change with age.

As with everything, there is always a risk. Excessive fluoride can cause dental fluorosis, which can cause irregular coloration of the teeth. This usually presents as white lacey spots on the surface of the tooth, but a stronger form can appear as an opaque white area. A very severe, very rare form can cause some brownish discoloration or pitting of the teeth. This is why it is important to get the correct dosing; as the severe form usually occurs when the community has water fluoride levels greater than 2 mg/L (current recommendations are 0.7 mg/L).

Babies will get some fluoride via breast milk if mom is drinking fluorinated water. Bottle fed babies will get fluoride from two separate sources – a small amount from the formula and from the water used for preparing a concentrate. Most of the fluoride found in infant formula will come from the water, as the amount in the formula itself is quite small. To avoid giving the baby too much fluoride, a low-fluoride bottled water can be used to mix the formula; these are labeled as purified or demineralized and can be purchased at most stores.

I like my teeth. I like my teeth intact. I have paid extra, even when I was living on noodles and butter in medical school, just to have a cavity filled with tooth-colored filling instead of the silver. My waistline may have paid the ultimate price, but I’d be certain my smile wouldn’t.
We’ve seen more studies linking periodontal disease and systemic diseases (cardiovascular, infection, diabetic, etc). Perhaps we’ll see studies linking fluoride into the picture as our knowledge continues to grow. For now, I’ll continue to request tooth-colored fillings on the rare occasion they are needed. But I’ll do everything in my power to prevent cavities from appearing in the first place, for both me and your child.

Screening for breast cancer

Breast cancer is the second most common cancer in women and the leading cause of cancer death in women in the U.S. Those are scary statistics. But you can do something about it. Breast cancer can be caught early and early detection gives you the best opportunity to have treatment that is less invasive and more effective.

Screening for breast cancer is important and you may have heard some mixed messages about it recently. It can get pretty confusing when there are differing opinions.

What we all agree on:
Mammograms save lives. A mammogram is an X-ray of your breasts and is the best way to detect breast cancer in the early stages, when it is easily treatable. These can often be found before you can feel a lump or have any other symptoms.
Getting my boobs squished sucks. Yep, no argument there. If it is severely painful, some women may benefit from topical lidocaine prior to the procedure to make it more tolerable.
Mammograms sometimes detect false positives. Sometimes, in our concern to avoid missing any potential cancerous lesion, we (meaning the computer programs and radiologist) will look at the mammogram and see an area that will look concerning on the first pass. This will result in you returning for further mammogram or ultrasound images and possibly even a biopsy to see if the area is cancerous in nature. Fortunately, often these will be totally normal tests. Unfortunately, these will result in more tests and extra worry on your part until the results come in.

What we still can’t agree on:
When to start mammograms and how often to complete them. Depending on which governing body you ask (USPSTF, NCI, ACOG, AMA, AAFP, ACS, ACR, etc), it can get overwhelmingly confusing to try to figure out when you are supposed to get a mammogram! Some say you should start at age 40, some say age 50, some say stop at age 70, some say age 75. Then they all differ on how often you should get that stressful mashing of the breasts – every year, every 2, every 3 years – what’s a woman to do!
Please talk to your doctor. He may have updated information, will be able to review your personal health risks (see some of them below), and will review the risks and benefits of completing mammography in the different time frames. You don’t have to make the decision alone.

There are some factors that increase your risk for breast cancer. A first degree relative with breast cancer and the age at which that relative was diagnosed can increase your risk, particularly if that relative had a gene that you could have inherited as well (BRCA). While only 5-6% of breast cancers are associated with this genetic mutation, BRCA testing is available if you have a relative who tested positive for this mutation. Even if your relative didn’t have a BRCA gene, it is important to let your doctor know who in your family had breast cancer and at what age.
You may also have a small increased risk of breast cancer through exposure to estrogen. This can be from birth control pills, never having been pregnant, or having your first child after age 30.

Breast thermography
Breast thermal imaging maps the surface heat of the breast using a heat sensitive camera. Unfortunately, breast thermography has not been shown to be an effective screening tool for breast cancer and should not replace mammography. Thermal imaging was first suggested as an alternative based on the observations that breast cancer patients had elevated skin temperatures over their cancers. In the original investigations, thermography was found to have a false negative rate of greater than 60% and a 2012 review showed that it missed 75% of the cancers seen on mammogram. Although the U.S. FDA did approve infrared imaging technology (based on safety data, not efficacy), it did issue a safety communication stating “the FDS is unaware of any valid scientific evidence showing that thermography, when used alone, is effective in screening for breast cancer.” The American Cancer Society recommends “thermography should not be used as a substitute for mammograms.”

Breast cancer is detectable early and treatable early. Please contact your doctor and arrange for a mammogram!