State of Health on PEI

The Chief Health Officer for Prince Edward Island, Dr Heather Morrison, has published the first public report of health on the island.  It is a good read, and well worth the trouble.  I have excerpted a section of the executive summary for a quick overview.

Health Trends

The Health Trends section is presented in four sub-sections: demographics, health status and determinants, common & chronic conditions, and communicable diseases. In this document, Islanders are commonly compared with the entire Canadian population as an assessment of how different or how similar PEI rates are with the national rates.

Below is a summary of the key findings within each sub-section.

Demographics

• PEI, similar with Canada and many other countries worldwide, has an aging population- Based on current projections by the year 2020, 1 in 5 Islanders will be over the age of 65. By 2040, 1 in 3 Islanders will be over the age of 65.
• Male Islanders born in 2007 are expected to live for 78 years and female Islanders for 83 years, both are similar to Canadian expectancies. Life expectancies have been slowly increasing over time and Canada boasts one of the highest life expectancies in the world.
• Cancer, heart disease and stroke are the leading causes of death in both PEI and Canada.
• Fewer low birth weight babies are born in PEI compared to Canada and this rate has remained stable over time.
• PEI's education levels, similar to Canada's, are improving.
• PEI's average annual income per person has risen over the past ten years but still remains lower than Canada's.
• The unemployment rate in PEI has decreased since the early 1990's but remains consistently higher than the Canadian rate.

Health Status & Determinants

• Almost two-thirds of Islanders and 60% of Canadians report their health as very good or excellent.
• The majority of Islanders and Canadians report their mental health as very good or excellent.
• Islanders are less likely than Canadians to consume 5 or more fruits and vegetables per day.
• Breastfeeding initiation rates have steadily increased over time, but still have room for improvement.
• More Islanders are likely to be obese than Canadian counterparts.
• PEI and Canada have similar rates of children and young adults who report being either overweight or obese.
• Islanders are less likely to be physically active than Canadians.
• More Islanders report heavy drinking than Canadians and this has not changed over time.
• The same proportion of Islanders report daily smoking as Canadians. This rate declined between 1995 and 2005 and has remained stable since that time.
• Fewer Islanders are exposed to second hand tobacco smoke in public places compared to Canadians.
• Over half of all Islanders intend to do something to improve their health in the next year. The overwhelming majority intend to get more exercise.
• More Islanders report a strong sense of belonging to their community compared with other Canadians.

Common & Chronic Conditions

• Islanders are more likely to suffer from "any chronic condition" (arthritis, asthma, heart and stroke, diabetes or cancer) than Canadians overall.
• Prostate (males), breast (females), lung and colorectal cancer are the most common cancers diagnosed in both PEI and Canada.
• Islanders (aged 50 to 74) are less likely than their Canadian counterparts to be screened for colorectal cancer by either FOBT or colonoscopy/sigmoidoscopy. In 2011, the FOBT screening program was expanded Island-wide for all Islanders 50-75 years of age.
• A similar proportion of Islanders and Canadians are living with Type II diabetes which is more likely to occur in males and rises considerably after age 45.
• One in every 5 Islanders has been diagnosed with hypertension. Hypertension is more likely to occur in females.
• One in every 10 Islanders has been diagnosed with asthma which is more prevalent in our younger population.
• The proportion of Islanders being diagnosed with COPD has been increasing since 2000.

Communicable Diseases

• The most common sexually transmitted infection in 2010 in PEI was Chlamydia which accounted for over 75% of all sexually transmitted and bloodborne infections. Over two thirds of reported chlamydia cases occurred in people aged 20-29 years.
• Influenza was the most common vaccine preventable disease in PEI during the 2010-2011 influenza season. Age and sex were evenly distributed. Almost 50% of individuals who had lab-confirmed influenza were hospitalized. It is well established that the number of lab-confirmed cases greatly underestimates the actual number of influenza cases.
• Among enteric, foodborne and waterborne illnesses, Campylobacteriosis accounted for 39% of all reported cases, followed closely by Salmonellosis (37%) and parasitic infections (17%). Over 60% of the Salmonellosis cases were S. enteritidis which was the first time this serotype was that predominant in PEI.
• The number of new Hepatitis C cases in PEI increased between 2009 and 2010. This increase was paralleled with an increase in Hepatitis C testing.
• In total 5 cases of Pertussis were reported in 2010. This increasing trend has been seen in all parts of North America. To enhance efforts to protect Island infants from pertussis, a Cocooning Strategy has commenced across the province that provides Pertussis (dTAP) vaccination for new mothers post-delivery in the hospitals, and additional close contacts (e.g. father, grandparent, nanny etc) through Public Health Nursing. This strategy aims to prevent adults from transmitting pertussis to their infants.

Conclusions

Over the past century, improvements in health and quality of life have made Canada one of the healthiest nations in the world. This report provides comparisons with the rest of Canada and comparisons over time on a number and range of indicators. In many areas PEI is similar to the rest of Canada and has shown improvement over time. Islanders enjoy a similar life expectancy to the rest of Canada and the majority of us report our overall health as very good or excellent.

However, there are some areas which are concerning and require attention. It is no surprise that we are an ageing population and as we age our risk of having one or more chronic diseases increases. Having a chronic disease can interfere with lifestyle, sense of wellbeing, and limit opportunity for independence. While some risk factors like ageing and genetics are inevitable, many risk factors can be modified or changed. Such modifiable risk factors include being overweight or obese, being physically inactive, and smoking. While smoking rates have remained stable since 2005, Islanders are more likely to be obese or overweight, than the rest of Canada. As well Islanders are less likely to be physically active than the rest of Canadians. It is daunting to think that children today may be the first generation to see a declining life expectancy due to increasing risk factors such as obesity and lack of physical activity, which inevitably contributes to the earlier onset of chronic diseases such as Type II Diabetes and high blood pressure. In addition to concerns about increasing chronic diseases is the challenge faced by well established public health programs. Declining immunizations rates in a population can lead to resurgence of diseases such as mumps, measles, and pertussis which have previously been controlled.

The good news is that more than half of Islanders indicated they plan to do something to improve their health in the next year, with the majority indicating they plan to become more physically active. As well, Islanders report a strong sense of belonging to their community which is an important aspect of mental health and social wellbeing. Both of these factors may have a protective affect against life's stressors. Individuals taking action at any time to improve health, whether it is to stop smoking, increase physical activity, or having a child immunized, will contribute to healthier communities over time.

Moving Forward

The role of public health includes developing and influencing public policy to ensure the population is as healthy as possible as well as preventing injury, illness, and premature death. This is accomplished through education and awareness, public health programs such as immunization and food protection, and gathering and reporting accurate and timely information to support program and policy decisions.

Priorities for the CPHO going forward include:

1)    Maintaining a strong focus on Health Protection programs which are legislated under the Public Health Act, including Food Protection, Immunization and Communicable Disease surveillance and follow up.

2)    Improving immunization rates of children to ensure better protection against vaccine preventable diseases. It is also a priority to increase awareness regarding adult immunization.

3)    Maintaining a robust surveillance system in order to appropriately inform program and public health policy development.

4)    Working with partners within the Department of Health and Wellness, other government departments and all Islanders towards attaining healthy weights. This includes working to improve breastfeeding rates and developing a provincial breastfeeding policy.

5)    Working with Islanders in collaboration with our partners, particularly health promotion, to address the significant burden that high rates of chronic diseases such as heart disease, cancer and diabetes place on our society. Our primary focus must be to prevent and reduce the rates of chronic diseases.

Again, this is just a summary of the entire report, and I would encourage you to take the time and review it.

For a review of this report from the island newspaper, see the Guardian.

Doctor Grimes, I am just too old to exercise.....

Exercise has no age limitsOne of the things I love the most about my practice in rural Prince Edward Island is that I have the pleasure of taking care a a large number of independent folks in the 80+ age bracket (and not a few in the 90+ age bracket).  These are folks living on their own, keeping themselves active, and having a wonderful life.  I think about these patients often, they are an inspiration, and they remind me that you are never ‘too old’.  In fact, it has me thinking about how effective exercise is in patients that are older, and the truth of the mater is, you are never to old to exercise (an excellent review of the subject Clin Geriatr Med. 2011 February).

What good could exercise possibly do for me now that I am 90?  A key to living on your own as you age is to avoid ‘frailty’.  Believe it or not, there is a medical definition of frailty.  Dr Buchner ( Clin Geriatr Med. 1992 Feb) proposed the definition and Dr Fried further defined the elements(J Gerontol A Biol Sci Med Sci. 2001 Mar.). In short it s the combination of at least three of the following: exercise intolerance or easy fatigue, weakness, slowed motor performance, loss of physical activity, and unintentional weight loss.  If you meet this definition you are more likely to die, to fall and break a hip, have heart disease, and be hospitalized (Am J Med. 2005 Nov).  Exercise has shown the ability to reverse almost all of these elements of frailty (it does not help with the weight loss).  In two studies looking at frail patients, exercise at least twice a week seemed to reverse the components of frailty (J Am Geriatr Soc. 1999 Sep and J Am Geriatr Soc. 2000 Oct).

Ok, exercise might be good, but it can’t possibly work all that fast.....So, let’s take a look at a couple of studies to see how quickly things seemed to work.  In the first study it took place over 9 months and involved strength training and walking with the goal of having frail men reach 78% of their peak heart rate.  There was a 14% increase in their endurance over the course of the study (J Appl Physiol. 2003 Nov).  A second study looked at frail women and had them exercise using an stationary bike for 12 weeks.  These women improved their aerobic capacity by 30%  and increased their quadriceps (thigh muscles) mass by 12% (Am J Physiol Regul Integr Comp Physiol Epub 2009 Aug 19).

Well it might improve my endurance but I am still afraid of falling...  Thankfully, exercise also seems to help with this most dreaded fiend.  Ask anyone who is older and fear of falls will be in their top ten worries of life, and with good reason.  Falling has a definite impact on quality of life and longevity of life (Annu Rev Public Health. 1992;13 and MMWR March 31, 2000/49(RR02);1-2).  Improving muscle strength can be accomplished through resistance training (JAMA. 1990 Jun 13;263(22):3029-34, Med Sci Sports Exerc. 2001 Sep, J Gerontol A Biol Sci Med Sci. 2004 Jan, and Cochrane Database Syst Rev. 2009 Jul 8;(3):CD002759).  Even if you have declined so much that you are in a nursing home, strength training can improve your health (N Engl J Med. 1994 Jun and Arch Phys Med Rehabil. 1998 Jan).  It is the improvement in strength which is the bedrock for improved balance and fewer falls.  

So how much do I need to do?  There are various guidelines available, but the fundamental guide of 150 minutes a week is the one that is most recommended that is 20 minutes a day (Am Fam Physician 2010 Jan).  By performing 20 minutes of exercise daily you can decrease the risk of early death, heart disease, stroke, diabetes, elevated cholesterol, and some cancers.  Additionally, exercise has been shown to decrease the likelihood of dementia (Ann of Internal Med 2006 Jan).  

Where can I learn more about starting to exercise more?

The Centers for Disease Control and Prevention has an excellent resource on Physical Activity for Health Aging.

Here are two goog handouts form the American Family Physician (here and here).

My toe hurts so bad it must be gout!

Devilish Gout

I clearly remember this photo from the medical school lecture on gout.  The image a a demon chewing on the toe of the suffering patient was lasting.  In my clinic, often times, this picture is unfortunately only too true.  Many people come in with this demon chewing away.  Often it is not just the one toe, and in some cases, it is lots of joints.

It hurts like the devil, so what causes it? The short answer is urate crystals in excessive amounts (for the long answer look here Ann Intern Med 2005 Oct 4;143(7):499). Urate is common in the body, and as long as there is not too much of it, things go on pretty smoothly.  However, when there is too much, then it can start to form crystals and these are very irritating.  These crystals tend to form on locations that are a little cooler (such as toes and fingers) and under greater pressure (such as the big toe).   An individual may either make to much urate or get rid of it too slowly, either way it leads to excess. 

It never happened before, why did it happen now?  There are several ‘risk factors‘ associated with the development of gout.    Like many other diseases, gout is linked to obesity, weight gain, and over consumption (especially alcohol, sugary soft drinks, seafood, meat) as well as high blood pressure and some of the medications we use to treat high blood pressure (Arch Intern Med 2005 Apr 11;165(7):742 , BMJ 2008 Feb 9;336(7639):309 , N Engl J Med 2004 Mar 11;350(11):1093 and Lancet 2004 Apr 17;363(9417):1277).  The blood pressure medications that are the most likely contributors include diuretics (the water pills), beta-blockers (like metoprolol or carvedolol), ACE inhibitors (rampart, lisinopril, fosinopril) and some angiotensin II receptor blockers (except losartan).  This is a shame since these are all really good medications for treating high bold pressure, but there it is (BMJ 2012 Jan 12;344:d8190).

Besides hurtin’ is there anything else ‘gout’ can do?  By far the most debilitating aspect of gout is the pain.  However, when folks with gout are observed over time, it seems to be associated with reduced life expectancy (J Epidemiol 2000 Nov;10(6):403).  It is not clear if this is due to the complicating conditions that give rise to increased risks of gout, or gout itself.   

Ok, so how do I know if it is gout?  Usually, the sudden onset of extreme pain in a single joint without any recent trauma is all the history that is needed to make gout the number one item on your diagnostic list. The pain usually begans and peaks in 24-48 hours and if we don’t do anything else, it will resolve in 3-14 days (Rheumatology (Oxford). 2007 Aug;46(8):1372-4. Cleve Clin J Med. 2008 Jul;75 Suppl 5:S22-5. .and Cleve Clin J Med. 2008 Jul;75 Suppl 5:S5-8.).  The pain may be so intense that you cannot tolerate putting anything (even bed linen) on the affect part.  It is classically the big toe, but can affect any joint.  The gold standard for diagnosis remain examination of some joint fluid under a microscope and finding the little gout crystals (and also rule out infection as the cause).  It is also helpful to take a blood sample and see if the urate is elevated.

If it goes on long enough then a build up of urate in the joint may cause it to bulge and potentially leak out (warning images may be a bit graphic fingers with tophi and surgical removal of thophi).  As things settle down and we look back on the history, often a precipitating event may be identified (such as new medication, recent infection, change in diet, or such).

So how do we treat it? Treatment falls into two camps, acute and prevention.  Treating the acute attack is really important (especially if you are the one with gout), and it consists of reducing the inflammation.  So, the steps to reduce inflammation include anti-inflammatory medications such as NSAIDs (like indomethacid) or steroids.  The traditional treatment has been colchicine but data indicates that it works slower than NSAIDs (Rheumatology (Oxford) 2007 Aug;46(8):1372).  The treatment usual needs to run for about two weeks.  The second phase of treatment is prevention.  This includes weight loss, improving your diet, and possibly medication to lower the urate levels.  All of this should be started about two weeks after the attack has settled down.  There is some question as to whether or not the medication really decreases the frequency of the attacks.  The medications work by increasing the the amount of urate that is filtered out through the kidney.  

Here is where you can get more information

American College of Rheumatology 

Patient UK 

National Institute of Arthritis and Musculoskeletal and Skin Diseases 

American Family Physician

Arthritis Foundation

Doc, why do my hands and feet tingle so much? Doc, why do my hands and feet tingle so much?

Foot with pins and needlse from http://neuropathy911.com/

Doc, you know my hands seem to tingle an awful lot.  And you know, so do my feet.  It is like they are asleep or something.  Any idea what that is?

So, the sense of tingling is called parasthesia, and might represent any number of things.  It usually represents an irritation or inflammation of a nerve, such as when your legs fall asleep while sitting cross legged.  Sometimes it feels like tingling, and sometimes it feels like a burning.  The pattern or the tingling, the characteristics of the tingling and the presence or absence of weakness help us figure out the cause.  

What kind of things may make this happen?  There are lots of causes of peripheral neuropathy.  This can range from trauma, infection, or endocrine problems.  Trauma (chronic or acute) can lead to trapping of nerves that causes chronic irritation, inflammation and may lead to neuropathy.  Carpal tunnel syndrome is the classic example of this kind of problem. This could also be due to problems with diabetes or thyroid dysfunction.  Nutritional deficiencies also account for some of the cases, usually due to problems with B12 absorption as seen in patients with celiac disease, renal disease, or liver disease (Lancet 2004 Jun 26;363(9427):2151).  In these instances, the irritation/inflammation of the nerves is as a consequence of the disease progress.  There are also other causes (such as infections), from medications (alcohol, chemotherapy drugs, and others), or from toxins (arsenic, mercury, cyanide and such).  

Ok, so how do I figure out if I have this problem or not?  This is pretty straight forward for us.  The first step is a good history and a thorough physical examination.  Often these two steps will do a great deal to help figure out what is going on.  The history and physical will help us narrow down the likelihood of peripheral neuropathy and point us in the direction of the tests that will need to be considered to determine the cause.  The American Academy of Neurology has laid out a straight forward stepwise evaluation of peripheral neuropathy (Neurology 2009 Jan 13;72(2):185).  The basic screening tests include a test for diabetes, B12 deficiency and serum protein immunofixation electrophoresis.  Additionally, testing the nerves themselves using a nerve conduction test is usually performed (Neurology 2003 Mar 25;60(6):898).

OK so if I have this, what do I need to do to treat it?  Well, this is a case of prevention being far better than treatment.  First off, activity is not likely to make things worse and helps people maintain strength (Cochrane Database 2004 Oct 18;(4):CD003904).  For patients who have pain as the main symptom of their unhappy nerves, then there are several medications that have been shown to help with the control of the pain.  Narcotics (such as morphine and such) have been shown to decrease the pain from neuropathy (Cochrane Database Systemic Review 2006 Jul 19;3:CD006146). Additionally, there are some older antidepressant medications are helpful in decreasing the pain from neuropathy (Neurology 2003 Apr 22;60(8):1284).  Of course, if the cause is vitamin deficiency then treating that deficiency will help correct the neuropathy.  

Where can I get some more information?

The National Institute of Neurological Disorders and Stroke has lots of information here.

MedlinePlus also has a lot of good information.

Hey Doc…..Is it alright if I run while I am pregnant?

You would be surprised at the number of answers that are given to this question.  The traditional thought was a categorical NO, but in the past several years views have begun to change.  The American College of Obstetricians and Gynecologists has changed their tune with regard to exercise during pregnancy as of 2002. So let’s take a look at the question a little closer.

Will it do me any good to exercise when I am pregnant?  The short answer is yes.  It appears that regular exercise improves fitness (Cochrane review 2010) and it decreases the risk of having an overly large baby (Obstetrics and Gynecology 2009).  Additionally it decreases the likelihood of gestational diabetes (Diabetes Care 2011) and for women who have gestational diabetes is appears to improve their diabetes control (Diabetes 1991 and American Journal of Obstetrics and Gynecology 1989).  It appears that exercising regularly may decrease some of the third trimester discomforts (Medical Science of Sports Exercise 1995) and daily yoga decreases labor discomfort (Complimentary Therapies in Clinical Practices 2008) and reduces stress (International Journal of Gynaecology and Obstetrics 2009).

Are there any problems with exercising while pregnant?  There are some theoretical concerns regarding the potential to decrease the blood supply to the placenta and baby, preterm labor and potential trauma.  Studies looking into this have yielded varying results.  Here are several studies that look at the effects of exercise and possible effect of low birth weight (here, here, here, here, and here).  Some studies show that exercise does not change birth weight (here, here, here, here, and here).  And yet another shows that it might increase birth weight (here).  In a large study that reviewed 18 prior studies it did not appear that exercise had a significant effect on maternal weight gain, birth weight, length of pregnancy, length of labor, or scoring of the infant at birth (Medicine and Science in Sports and Exercise 1991).

What do I need to know to exercise safely?  There are some very clear reasons NOT TO exercise and these are absolute:  Pregnancy induced hypertension, Premature rupture of membranes, Incompetent cervix (or having had the surgery to keep the cervix closed), persistent second or third trimester bleeding, a baby that is not growing very well, preterm labor in this or a prior pregnancy (ACOG 2002).  Additionally, if you have heart disease, uncontrolled high blood pressure, uncontrolled kidney disease, profound anemia, or uncontrolled diabetes you are probably better off without the exercise while you are pregnant.   Generally the exercise you were doing prior to pregnancy can be continued.  Here are some specific guidelines from DynaMed:

• sedentary women - walking, bicycling, stair climbing, aerobic dance, water aerobics or swimming for 65-75% of maximum heart rate for 30 minutes 3 times/week
• recreational athletes/regular fitness exercisers - same as above plus running/jogging, dance, tennis at 65-85% of maximum heart rate for 30-60 minutes 3-5 times/week
• elite athletes - same as above plus some competitive activities depending on gestational age at 75-85% of maximum heart rate for 60-90 minutes 4-6 times/week

And of course, it goes without saying that you should probably avoid certain high risk activities such as contact sports (boxing, field hockey, football, rugby, ice hockey, martial arts, rodeo, soccer, wrestling), high risk sports (scuba diving, hang-gliding, parachuting, rock climbing, power lifting) and overly strenuous exercise that might lead to dehydration or hyperthermia.

For more information look to the American Academy of Family Physicians here and here.