B&T105

2 Brown & Toland’s HealthLink, Winter 2005 www.brownandtoland.com

HealthLinkWinter 2005

Brown & Toland’s HealthLink editor: RichardAngeloni, Corporate Director, Communications andPublic Relations, Brown & Toland Medical Group,415.972.4307. Brown & Toland’s HealthLink is pub-lished quarterly and printed in the United States.Copyright 2005 by Health Ink & VitalityCommunications, 780 Township Line Road, Yardley,PA 19067, 267.685.2800. Articles in this newsletterare written by professional journalists or physicianswho strive to present reliable, up-to-date healthinformation. Our articles are reviewed by medicalprofessionals for accuracy and appropriateness. Nomagazine, however, can replace the care and adviceof medical professionals, and readers are cautionedto seek such help for personal problems. Someimages in this publication were provided by ©2005PhotoDisc, Inc. PhotoDisc models used for illustra-tive purposes only. (105)

3 Diabetic CareWhy your checkup shouldbe head to toe.

4 Childhood ObesityHealthy habits help preventserious medical and emotional problems.

7 Effective Asthma ControlAn assertive approach tothis chronic disease canmake a difference.

8 Top PerformanceWe scored in the top 10 percent for qualityamong California medical groups.

10 Healthy SeniorsA food pyramid just foryou; plus new HMOoptions in 2005.

LEARNING

Communicating effec-tively with your physi-

cian plays an importantrole in the overall quality

of care you receive. Aspatients, we expect qualitycare. Your physician, how-ever, can deliver that care

only if you provide the cor-rect information.

Here are some simplesteps you can follow toensure that you and yourdoctor are communicatingcorrectly.

Start the conversationwith your physician byexplaining the reasons foryour visit. Are you visitingfor a regular checkup? Do you want to talk about

How to CommunicateBetter With YourPhysicianby Tammy Fisher, M.P.H.Manager of Health and Quality ImprovementBrown & Toland Medical Group

Antibiotics are medicinesthat kill bacteria. They dothis in a variety of ways,such as breaking down bacteria cell walls, shuttingdown protein synthesis andinterfering with bacterialDNA replication. As we allknow, when we have a bac-terial infection, antibioticsare essential weapons inyour doctor’s arsenal. Thewidespread use of antibi-otics after World War II hasled to significant improve-ments in our ability to treata wide range of infections.Common infections treatedby antibiotics are communi-ty-acquired pneumonia,skin infections and urinarytract infections. Why?Because these infections are caused by bacteria.

On the other hand,antibiotics are useless

against the other maincause of infections: viruses.Viruses are small bits of protein that are not quite“alive” and need to “live” in a host to survive. Thecommon cold and flu arecaused by viruses, as aremost sore throats and many sinus infections. Sinceantibiotics work by killingbacteria, they are ineffectiveagainst viruses. There areanti-viral medicines for cer-tain viral infections, but notfor common viral infections.

This is where we get intotrouble — we are a culturethat relies on pills. We wanta magic bullet to make ourcold go away yesterday,when, in fact, this is just notpossible. I know that manyof us have had a cold, goneto the doctor, taken antibi-otics, and then gotten better.

But many studies over thepast decade have shownthat antibiotics are of NObenefit in fighting viralinfections. How about inbronchitis — better knownas a chest cold? Nope. Mostacute bronchitis is viral.Bacteria can be culturedfrom the lungs, but it isn’tcausing the problem. Infact, a local University ofCalifornia–San Franciscoresearcher, Ralph Gonzales,

M.D., has shown that antibi-otics are of no benefit infighting this disease.

The bigger issue is thatoveruse of antibiotics hasmany negative implications.Overuse has led to rampantbacterial resistance, so manyof our once powerful anti-biotics no longer workwhen we — and at somepoint, you — really needthem. There is always a riskof an adverse reaction tomedication, and these reac-tions may be very serious.The cost to our medical sys-tem is staggering, resultingfrom wasted medicationsand needless doctor visits.

The main reason we feelbetter after we take anti-biotics for a viral cold isthat we were getting betteranyway. Most people wait afew days to go to the doc-tor. When they finally startthe medicine, they werealready on their way torecovery.

Remember what yourgrandmother said: “Here,dear, rest and have some ofmy chicken soup.” That, andtime, is all that works. Untilnext time, stay healthy. ■

During the winter season, fightinga cold the old-fashioned way — without

the use of antibiotics — can be unappealing.But the implications of improper antibiotic usecan affect all of us, clinically and financially.

by Peter Alperin, M.D., Medical DirectorBrown & Toland Medical Group

In addition to his role as

medical director of Brown &

Toland Medical Group, Peter

E. Alperin, M.D., is in active

practice at Mills-Peninsula

Hospital and teaches as an

assistant clinical professor of

medicine at the University of

California-San Francisco.

Why Don’t Antibiotics WorkAgainst the Common Cold?

Brown & Toland’s HealthLink, Winter 2005 3www.brownandtoland.com

M ost of us could use a head-to-toe

checkup now and then.But for people with dia-betes, it is important to geta head and toe checkupevery year.

In 2002, there were anestimated 18.2 millionpeople in this countrywith diabetes. For them,eyes and feet can bepotential trouble spots.The American DiabetesAssociation (ADA) recom-mends an eye exam and afoot exam by a medicalprofessional each year.

Why? Diabetes can causeeye problems that can leadto blindness if left untreat-ed. And when diabetescauses poor circulationand nerve problems in thefeet, sufferers can developwounds that are difficultto heal.

Eye to eyeDiabetes is the leading

cause of new cases of

blindness among adultsages 20 to 74 years. Loss ofvision can result from acondition known as dia-betic retinopathy, in whichthe delicate blood vesselsin the back of the eyeswell and bleed. Accordingto the National DiabetesInformation Clearinghouse,diabetic retinopathy causes12,000 to 24,000 new casesof blindness each year.

“There may be substantialdamage before a person isaware of visual problems,’’says Jeffrey Susman, M.D., ofthe University of NebraskaMedical Center. “So it isimportant to have regulareye exams whether you arehaving problems or not.’’

During the eye exam, anophthalmologist can lookinto each eye and checkalong the inner back wallfor damage. “It is some-thing that, if we can catchit early on, we can do agreat deal to help,’’ Dr.Susman says.

On your feetMore than 60 percent

of nontraumatic lower-limb amputations occuramong people with diabetes. According to the National DiabetesInformation Clearinghouse,in 2000–2001, about 82,000nontraumatic lower-limbamputations were per-formed annually amongpeople with diabetes.

Why? Diabetes can

decrease blood flow anddamage nerves in theextremities. Then commonscrapes and bumps ofeveryday life can end upcausing some seriousproblems.

“People can lose sensi-tivity so that they don’tknow if they step on aneedle or get a small stoneimbedded in their foot,’’says Christine Beebe, pres-ident of health care and

education for the ADA.The decrease in bloodflow also impairs the heal-ing process. This can leadto infection and, in theworst cases, amputation.

“Our feet are subjectedto a tremendous amountof pressure and wear,’’says Dr. Susman. “Footcare should be practicedeach day in addition tobeing part of an annualcheckup.” ■

DIABETES CARE

Check daily for calluses, cuts or cracks in the skin andlook for signs of infection.Use a mirror, if necessary, to look at the bottoms ofyour feet.Keep feet clean. Do not use alcohol or hydrogen peroxide. They dry out skin.Be careful when soaking feet in hot water. Nerve damage decreases sensitivity to temperature. You could burn yourself.Do not go barefoot outdoors. Indoors, wear slippers or sandals if you don’t want to wear shoes.Make sure all footwear fits properly.Do not cut calluses yourself. See your doctor, who also cancheck for ingrown toenails and other potential problems.

Follow These Healthy “Footsteps”

Diabetics Must TakeCare from Head to ToeGet your doctor to check your eyes and feet each year

some medication you’vebeen taking? Be as specificas possible.

Also remember to tellthe doctor if you havebeen taking over-the-counter medications orherbal remedies, or if youuse alternative therapies.

Here are some otherhelpful hints.

Ask questions. Everyquestion is important,

especially if your healthdepends on it.Make a list of yourconcerns and take itwith you on your visit. Take notes! You cannever remember every-thing your physiciantells you.If you have troublecommunicating withyour physician,take along a friend or

family member.Have any changesoccurred in yourhealth? If so, rememberto tell your doctor. Listen to your physician. Make sure you knowthe phone numbersand emergency contactsof your physician’soffice.Remember, effective

communication can go a

long way to ensuring thatyou are receiving a correctdiagnosis and quality care.Good communication willkeep you better informed,happier and healthier!

Your medical group,Brown & Toland, caresabout the care we provideto you. Each year, we sendsatisfaction surveys to a group of our patients to inquire about their

satisfaction with the carethey receive from their personal doctor and med-ical group. Should youreceive a survey from us,we strongly encourage youto complete it so that wecan continue to improvethe care we provide to you.Having satisfied patients ismost important to us. ■


Too little activityAnyone up for a breathlessgame of tag, kick-the-can,hopscotch? Childhoodshould be filled with hoursof energetic play, but chil-dren today are less activethan past generations. With more families living incities, fewer children walkto school, and parents may keep children indoorsmore often out of concernfor their safety. Adding tothe problem, many schoolshave cut back on physicaleducation programs. Anational survey found that20 percent of children ages8 to 16 in the United Statesare vigorously active onlytwice a week or less.Instead of getting the

recommended 60 minutesof moderate activity a day,many children spend hoursa day watching televisionor playing video and com-puter games.

Television troublesAlmost half of all 8- to16-year-olds watch three tofive hours of televisiondaily. Children who watchthe most television are alsothe most likely to be obese.A study published in themedical journal Pediatricsfound that the rate of obe-sity rose 2 percent among12- to 17-year-olds forevery additional hour spentwatching television. A studyby the Harvard School of

Public Health revealed that the risk of being over-weight is more than fourtimes greater in childrenwho watch more than fivehours of television dailycompared with those whowatch two hours or less.And having a television inthe bedroom is associatedwith being overweight, evenin very young children.

Food woesOur environment is loadedwith food temptations.High-calorie foods are avail-able everywhere a childturns: in school vendingmachines, at fast-foodrestaurants, at corner con-venience stores and even inkitchen cupboards at home.Fruits and vegetables areeasily ignored in favor ofhigh-calorie snacks such aspotato chips. Hectic sched-ules mean home-cookedfamily meals are oftenskipped and replaced withless nutritious grab-and-gofoods eaten on the run.Families eat more often atrestaurants, where portionsizes have ballooned, pro-viding too many caloriesand too much fat.

Why you shouldbe concernedBeing overweight or obeseplaces a child at risk formany health problems. Anobese child is more likelyto develop type 2 diabetes,a condition that used tooccur only in adults.According to the NationalInstitutes of Health, therehas been an alarmingincrease in diabetes amongobese children and adoles-cents recently.

Obese children often havehigh cholesterol and highblood pressure, increasingtheir risk for heart disease.Children who are obese are more likely to haveasthma and sleep apnea, a breathing problem thatinterrupts sleep, as well asbone and joint disorders.And overweight childrenare more likely to becomeoverweight adults.

The psychological stressthat overweight childrenexperience can be as

devastating as the medicalproblems. They are oftenteased by other childrenand as a result suffer poorself-image, low self-esteemand depression.

If you’re concernedIf you’re concerned aboutyour child’s weight, firsttalk to your pediatrician orfamily doctor. The doctorcan determine whetheryour child is at a healthyweight by calculating bodymass index (BMI). BMI, aratio of weight to height, isconsidered the bestmethod for evaluatingweight in children. (To findan online BMI calculator,you can go to www.cdc.gov/nccdphp/dnpa/bmi.) Yourpediatrician will comparethis number with a growthchart for children of yourchild’s same age and sex.

Your pediatrician canhelp you identify appropri-ate weight managementgoals for your child. Often,

Baby fat is something children are supposed to out-grow, not grow into. According to the American Academy of

Pediatrics, one in five children in the United States is overweight or obese.That’s twice as many overweight children as 20 years ago. Extra pounds andtoo-big waistlines have serious consequences for children, including lowself-esteem, social problems and increased risk for chronic diseases.

Why are so many children too heavy? Experts say there is no singlecause of childhood obesity. Genetics plays a role, but too little physicalactivity and poor food choices are more often the culprits.

How to Prevent

Childhood Obesity

HEALTHY DIET


the goal isn’t to lose weight,but to change behavior.Restrictive diets are not rec-ommended for overweightchildren. Rather, the goal isto help them maintain theirweight as they grow taller.Another approach is to helpa child burn more caloriesby being more physicallyactive. A registered dietitiancan provide guidance oneating behaviors, mealplanning and shopping. If your child is at risk formedical problems, yourdoctor may recommend aformal weight managementprogram staffed by a teamof health professionals,such as a pediatrician,dietitian and psychologist.

Most important, let yourchildren know that youlove them, regardless oftheir weight. Give yourchildren plenty of supportand approval. Helping tobuild your children’s self-esteem is a great way tohelp them develop healthynew habits. ■

Helping your children to have a healthy body weightis a family affair. Instead of putting the focus on the overweight child, the whole family should getinvolved in making healthy changes in activity andeating habits, experts say. As a parent, you are themost significant role model for your children, so it’simportant that you set an example with healthy lifestyle habits.

Get up and movePhysical activity is a great way for you to spend quality time with your children. Emphasize the fun of an activity, rather than skill.

Build family activity into every day, perhaps tak-ing an after-dinner walk or bike ride or dancingto fast music in the living room.

Plan active family outings, such as hikes, ice-skating, swimming or Frisbee. Try a familyvacation that emphasizes canoeing, bicycling,camping or swimming.

On birthdays, give presents that encourageactivity, such as roller skates or a basketball.

Set guidelines for how long your children canwatch television or play computer or video games.

Choose healthy foodsUse the Food Guide Pyramid as a guide for food choices. Serve fruits,vegetables, whole grains, beans, and lean meatsand poultry. Use low-fat or nonfat milk products(except for children younger than 2 years old).

Keep healthy snack foods in the house, such asfresh fruit, raisins, pretzels, string cheese andpopcorn.

Have your children start the day with a goodbreakfast, such as whole-grain cereal with fruitand low-fat milk, whole-wheat toast withpeanut butter, a fruit smoothie made withyogurt, or even leftover vegetable pizza.

Involve kids in shopping for and preparing meals.Children like to eat what they’ve helped prepare.

Don’t forbid “bad” foods. Instead, teach yourchildren about foods that can be eaten every dayand those that should be eaten only now and then.

Foster self-esteemChildren are more likely to makehealthy changes when they feel good about themselves. Experts at the BaylorCollege of Medicine suggest that parents help theirchildren find things to do that make them feel valu-able. It might be community volunteer work, visit-ing the elderly neighbor down the street, helpingGrandma clean her yard, or pursuing a special interestsuch as art or music. Point out your children’s strengthsand help them develop their own interests and abilities.

What You Can Do to Control Obesity

Thanks to new technology, Brown & Tolandproviders are now able to make key decisions

about prescription medication at the point of careand with the click of a button.

Brown & Toland is offering physicians free onlineaccess to the ePocrates RxOnline® drug database, aclinical database that compares the co-pay levels ofprescription drugs and provides the most up-to-date clinical information, such as dosing and druginteractions.

The technology will help health care profession-als avoid medication errors and practice more effi-ciently. Physicians can access the popular databaseonline via the medicalgroup’s new Web site,www.brownandtoland.com.

Modeled after ePocrates’ widely used hand-heldprogram, RxOnline operates from PC desktops andprovides numerous advantages to physicians. Theseinclude the ability to look up dosing and prescrib-ing information, check for adverse reactions or con-traindications, and access drug pricing, clinical tables,and guidelines. In addition, RxOnline’s pill checkerallows doctors to identify drugs based on their color,size and shape. It also features custom patient druginformation sheets that physicians may print and giveto patients. Most importantly, using the “Multi-Check”feature allows physicians to check the drug inter-actions of up to 32 medications simultaneously.

“Brown & Toland is committed to bringing ourphysicians the latest in technology to improvepatient care,” says Peter Alperin, M.D., Brown &Toland medical director. “ePocrates is well-known inthe industry for its quality drug information, andusing ePocrates will improve patient safety.” ■

ePocratesProvides Brown & TolandDoctors With On-the-Spot Drug Information

TECHNOLOGY

www.brownandtoland.com


Yet statistics show noteveryone is taking the stepsnecessary to achieve goodhealth. A 2002 nationwidesurvey conducted by the American DieteticAssociation (ADA) indicatesthat although 38 percent

of Americans say they havemade significant changes intheir eating habits over thelast two years, 62 percentsay they either know theyshould make changes buthaven’t or simply don’twant to be bothered aboutgood nutrition.

“Nutrition is an importantissue for people of all ages,”says Polly A. Fitz, R.D., apast president of the ADA.“Eating for good healthshould start at an early age.The sooner you develophealthful eating and physicalactivity habits, the longer,healthier, and perhaps moreenjoyable your life may be.”

According to Ms. Fitz,everybody needs the samenutrients, just in differentamounts. Age, gender andbody size are among the

reasons people’s nutrientneeds differ.

According to Ms. Fitz, it’ssound advice for everyoneto enjoy an eating plan inaccordance with the FoodGuide Pyramid. It’s basedprimarily on grain products,followed by vegetables and fruits, with moderateamounts of dairy products,lean meats, fish, poultry andlegumes, and small amountsof fats, oils and sweets.

In addition to the FoodGuide Pyramid recommen-dations, ADA offers the fol-lowing advice:

ChildrenKids should get a healthy

start to the day. They needa good breakfast to get mov-ing in the morning and to dotheir best in school and play.

Increase daily intake of fiber. Eating a variety ofgrains, fruits and vegetablesis the best way to fill

children’s needs for com-plex carbohydrates, andsoluble and insoluble fiber.

Physical activity, whetherplaying hopscotch or bicy-cling, and good nutritionare key to developing ahealthful lifestyle.

WomenChoose iron-rich foods,

especially during childbear-ing years. Make daily selec-tions from lean red meat,liver, pinto and kidneybeans, spinach, enrichedand whole-grain breads,cereals, rice and pasta.

Select low-fat dairyfoods. Build and maintainstrong bones throughoutlife by getting enough cal-cium. Include three to fourdaily servings of calcium-rich foods such as nonfator low-fat milk, yogurt,cheese, broccoli, sardinesand collard greens to reducethe risk for osteoporosis.

Get enough folic acidbefore and during preg-nancy. Eat a variety of folate-rich foods to prevent neuraltube birth defects. Foodsrich in folate include citrusfruits and juices, dark green,leafy vegetables, whole-grain and fortified breadsand cereals, and legumes(beans, peas and peanuts).

Maintain a healthy bodyweight. “Energy in” mustbalance “energy out.” Makea commitment to the follow-ing lifestyle behaviors: Enjoya variety of foods in modera-tion, get regular physicalactivity, and personalizeefforts to match yourschedule, family situationand personal preferences.

Older adultsEnjoy plenty of calcium-

rich foods. Foods such asmilk, cheese and yogurtcan slow the progression of bone loss.

Keep moving. Moderatephysical activity helps keepblood pressure, cholesteroland blood sugar normal,strengthens muscles andbones, and helps digestion.

Keep drinking water.Consume lots of fluids toprevent dehydration.

Enjoy a variety of foods.Perk up the flavor of favor-ite foods by using herbs,spices and lemon juice to compensate for a dimin-ished sense of taste or smell.

People of all agesBe realistic. Gradually

make changes in lifestyleand eating habits. And,remember, nobody’s per-fect. Allow for an occasion-al slip-up, but get back ontrack as soon as possible.

Be adventurous. Try newfoods. By expanding choices,people are more likely toget sufficient quantities ofthe 40 essential nutrientsfound in foods, which mayincrease vitality and reducerisk for many diseases.

Be flexible. No need toworry about just one mealor one day. Balance mealsand physical activity overseveral days.

Be sensible. Enjoy allfoods; just don’t overdo it.Be active. Walk the dog,don’t just watch the dogwalk. ■

“Nutrition is an important issue forpeople of all ages.”

— Polly A. Fitz, R.D., former president, ADA

A Guide to

Eating Throughthe Ages

HEALTHY DIET

At every stage of life, healthful eating fuels fitness. We can benefit from a lifelong eating pattern

that promotes health by adapting food choices and physicalactivity to match our personal needs.


She also had trouble sleep-ing several times a month,and hesitated to go outwith friends, because laugh-ing caused her to have asthma. She ultimately sawa doctor who prescribed a steroid inhaler. She wasalso given a new inhaler for relief (albuterol).

Subsequently, Erin feltbetter. She had fewerattacks at night. She couldexercise, but frequentlyhad to stop because ofasthma. She used herinhaler one to three timesa day for symptom relief.As she felt better, she beganto decrease the use of hersteroid inhaler. She justdidn’t like the idea of tak-ing steroids. Overall, Erinwas content with her asthma control. It was,after all, much better thanwhen she was just takingthe Primatene® Mist.

What do you think ofErin’s treatment? Does herimprovement mean thattherapy was successful?

As an asthma specialist, Ihear stories similar to Erin’salmost daily. Most asthmat-ics believe that someimprovement with therapyis all they can expect, andtherefore are content.

I love seeing patients likeErin, because I know thatwithin a few weeks theirlives can be turned around.

Appropriate asthma ther-apy is extremely effective.Most people with asthmacan have near total resolu-tion, or at least dramaticimprovement in symptoms.As a result, their quality of life also improves. Thegood news is that therapy is relatively simple and safe.

There are two primarycomponents of asthma.The first is spasm of themuscles that surround theairway, resulting in nar-rowing of the airways, andleading to chest tightness,wheezing and shortness ofbreath. Short-term relief isaccomplished by taking aninhaler, usually albuterol.This class of drug, called ashort-acting beta agonist,results in relaxation of thebronchial muscles and

improvement in breathing. The second and more

important aspect of asthmais inflammation. You canthink of inflammation asbeing similar to a burn onyour skin. There is swelling,increased secretions andirritation, with the skinperhaps sloughing off. Asimilar reaction occurs inthe lung, and is present inasthmatics even when theyfeel well. Treatment ofinflammation includesremoval of environmentalallergens, and treatment ofsinus disease or gastro-esophageal reflux. The hall-mark of treatment, howev-er, is low-dose inhaledsteroids.

These steroids are notthe same as those you hearabout athletes using. Their

function is to decreaseinflammation and returnthe lung to a more normalstate. As a result, the airwaybecomes healthier and thetendency for muscle spasmdecreases. So a person withwell-controlled asthma canreturn to a more normallife. If a long-acting betaagonist (12 hours) is addedto the inhaled steroid,there is even better controland stability. This is calleddual therapy.

Erin saw an asthma specialist, who performedpulmonary function tests.Although she felt well thatday, her tests showed mod-erate obstruction. She wasprescribed dual therapyand entered the freeBrown & Toland AsthmaEducation program, where

asthma nurse practitionerVickie Thun, R.N., F.N.P.,spent time with her in one-on-one teaching sessions.Within a week, Erin wasback to bicycling, slept better, and in fact hadimproved overall energy(even mild active asthma is fatiguing). She used heralbuterol only before exer-cise and, in fact, forgot todo that much of the timebecause she was having nosignificant symptoms. ■

How Effective Is YourControl of Asthma?by Charles McDonald, M.D.

Erin is a 32-year-old who has a history of frequent asthma symptoms. She relied on

Primatene® mist for relief. Last year, Erin was seenin the emergency room once for uncontrolledasthma. She had stopped regular exercise, andhad missed work at least once every two months.

ASTHMA CARE

How about you? Is your asthma really well-controlled?

If you are experiencing asthma symptoms more than twice a week,waking up with asthma-like symptoms twice a month, or needingmore than two inhalers a year for relief, you should consider a re-evaluation of your treatment regimen. The same is true ifyou hesitate to engage in physical activity because of asthma,or miss school, work or social engagements.

What can you do? First, make sure your doctor knows howmuch your asthma affects your life. When your doctor asks,“How has your asthma been?” don’t downplay your symptoms. Focus on yourdegree of control. If you are not on dual therapy, ask your doctor if this is rightfor you. If you continue to have active symptoms, consider a specialist evalua-tion. The majority of attacks and emergency room visits can be prevented; ifyou have been to the emergency room for asthma, this usually represents afailure of your treatment regimen and you should seek a specialist evaluation.Be sure your sinus problems or reflux are well-controlled. Pay attention to environmental triggers. Is there a smoker in the house? Is there mold?

Finally, with active asthma, do not be content with your level of control. Be sure you are closely monitoring your asthma and changing your regimenaccordingly.

TAKING CARE OF YOUR ASTHMA

“I love seeingpatients like Erin,because I know thatwithin a few weekstheir lives can beturned around.”

— Charles McDonald, M.D.

Charles McDonald, M.D.,

has been specializing in

pulmonary medicine since

he graduated from medical

school at the University of

Utah in 1976. He practices

at the California Pacific

Medical Center.


Doctors break clinicaldepression into five cate-gories of mood disorder:major depression, chronicdepression, adjustment disorder with depressedmood, depression causedby a medical condition ormedication, and bipolardisorder.

Major depression is notcaused by a life event, suchas the death of a loved one.It carries a high risk for sui-cide. Up to 10 percent ofmen and up to 20 percentof women may developmajor depression at somepoint in life.

Chronic depression, also

called “dysthymia,” is amilder form of depression.Doctors diagnose chronicdepression when adepressed mood and atleast two other symptomsof depression have beenpresent nearly every dayfor two years.

Adjustment disorder withdepressed mood is diag-nosed when a stressful lifeevent such as divorce or theloss of a job affects a per-son more than would beexpected. It is diagnosedonly within the first sixmonths after the stressfulevent has occurred. A con-dition that lasts longer than

six months would be calleda depressive disorder.

A medical condition ormedication can cause adepressive mood disorder.Treating the medical condi-tion or stopping the med-ication eases the mood dis-order, but psychiatric treat-ment is usually also needed.

Bipolar disorder, whichonce was called manic-depression, is a severemental illness.

Getting helpIf you have thoughts of

suicide, get help immedi-ately.

Clinical depression may

Chlamydia is the mostfrequently reported

bacterial sexually transmit-ted disease (STD) in theUnited States, according tothe Centers for DiseaseControl and Prevention. Yetmany people don’t knowabout it. For public healthofficials, stopping its spreadis a priority. Fortunately,you can prevent this disease.

Many people with chlamy-dia don’t have symptoms.Women especially areunlikely to have symptoms.If you do, you may noticethem as soon as one weekafter you are exposed to thedisease. Symptoms includepain or burning when youurinate and a dischargefrom the vagina or penis.Women may have abnormal

vaginal bleeding, such asspotting between periods,or heavier periods.

Symptoms can be so mildthat you don’t notice them.Even so, the disease doesnot go away without treat-ment. If you don’t get treat-ment, you can have perma-nent damage, includingpelvic inflammatory disease.

Consider these facts:

About one-third ofwomen who get chla-mydia also get pelvicinflammatory disease(PID). PID is a seriousinfection of a woman’s

Are You Depressed,or Just Blue?

MENTAL HEALTH

Protect Yourself Against

Chlamydia

STAYING HEALTHY

Anyone can feel down from time to time. But a lingering sense of sadness or depressed mood could indicate a more serious

depression that won’t go away on its own, no matter how long you try towait it out or pull yourself together.

Brown & Toland Medical Group scored in the top 10 percent among California medical

groups in several categories for clinical care in 2003in the annual “Pay for Performance” (P4P) initiative.

Brown & Toland scored in the 90th percentile for providing preventive care, such as breast cancerscreening, cervical cancer screening, childhood immu-nizations, diabetes care and cholesterol management.Additionally, the group scored in the 85th percentilefor providing care for its asthma patients. The resultsfor the 2003 initiative were released in fall 2004.

“We are obviously very pleased with our clinicalresults,” says Stan Padilla, M.D., vice president of med-ical services and chief medical officer. “We have placedan emphasis on providing the correct preventivemeasures at the right time, both to keep our patientshealthy and reduce the overall cost of health care.”

P4P measures and rewards physician groups forchronic care management, investment and use of infor-mation technology, and the patient experience. Groupsthat score well on the initiative are awarded a bonus.The initiative was first established in California in 2001by the Integrated Healthcare Association (IHA) and sixparticipating health plans.

Fiona Wilson, M.D., vice president for quality atBrown & Toland, notes that the medical group has a

number of programs inplace to ensure that itspatients receive qualitycare. These include asthma and diabetesmanagement programs, asupport report programin which the medicalgroup sends reports to

primary care physicians to alert them that theirpatients are due for certain tests, and a $10 millioninformation technology investment that will bringelectronic medical record and practice managementtools to select Brown & Toland physician offices.

“Health care is light years behind other industriesin the application of technology,” says Dr. Wilson. “AtBrown & Toland, we are making a concerted effort toclose the gap and set the pace by using technology toimprove the quality of care we provide to our patients,reduce costs, and give our physicians practice manage-ment tools that improve quality and efficiency.” ■

Brown & TolandMedical Group EarnsTop Quality Scores“Pay for Performance” initiative gives top rating

CLINICAL CARE

P4P rewards physiciangroups for chroniccare management, useof technology, andpatient experience.


worsen over time if nottreated. Still, most peoplewith depression don’t gethelp, even though 80 per-cent of people who seekhelp do recover.

If your company offersan employee assistanceprogram (EAP), you maywant to go there first forhelp. Often, the EAP has anetwork of mental health

specialists to whom theycan refer you. You alsoshould see your primarycare physician to make sureno underlying medical con-dition or medication sideeffect is causing yourdepression.

“If it’s determined youare depressed, your treat-ment plan is likely toinclude talk therapy and/or

a prescription for anti-depressants,” says MelodieMorgan-Minott, M.D., apsychiatrist in private prac-tice in Kent, Ohio, and adistinguished fellow of theAmerican PsychiatricAssociation.

When discussing yourtreatment plan with yourmental health practitioner,ask about its risks and bene-fits, how you’ll know it’sworking, how long it shouldtake for your mood tochange and the options andalternatives if your symp-toms persist or worsen.

Minding your meds

If you are prescribedmedication, be sure to takeit as directed. Most peoplesee an improvement inthree to four weeks.

Don’t take other med-ications, especially over-the-counter or herbal medications, without firstchecking with your healthcare provider to see if theywill interact with your anti-depressant medication. To

prevent relapse, don’t stoptaking your medicationwithout your doctor’sknowledge.

If you don’t want to takeantidepressants, clinicaldepression can be treatedwith talk therapy only.

“But because depressioninvolves changes in brain

chemistry, it’s very difficultto recover with talk therapyalone, and it can take years to see a result,” says Dr. Morgan-Minott.“Meanwhile, the qualityand productivity of yourlife can be severely com-promised while you’re wait-ing for therapy to kick in.” ■

reproductive organs.Each year, PID makes100,000 women infertile. Chlamydia can increasethe risk of tubal(ectopic) pregnancy. A baby born to a womanwho has chlamydia maydevelop pneumonia oran eye infection. Although it’s rare, mencan develop complica-tions. These includeswelling in the scrotumand infertility. You can get chlamydia by

having sex with someonewho has it. You increaseyour risk if you have sexwithout using a condom.

Your risk is also higher ifyou have more than onepartner. But you can pro-tect yourself. If you have

sex, the best protection is alatex condom. Use a con-dom correctly each timeyou have sex.

Having a screening testcan help prevent the spreadof chlamydia because itallows for prompt treat-ment. The CDC recom-mends a chlamydia test forany woman who answers“yes” to one of these questions:

Are you under age 20and sexually active? Have you had a new sexpartner within the past90 days? Have you had more thanone sex partner withinthe past 90 days? Have you not used acondom or diaphragmeach time you had sex?

If you are infected, tellyour partner. He or sheneeds a test, too.

Chlamydia is easy to treat.One dose of an antibioticcan kill the bacteria.

Tell your doctor if thereis any chance you could bepregnant. Only some medi-cines are safe for pregnantwomen. ■

Major depression is the most severe form ofdepression. Symptoms may vary from person toperson, but doctors diagnose major depression ifat least five of these symptoms are present for atleast two weeks:

Feeling depressed most of the day, every day

Loss of interest in daily activities

Weight loss or weight gain when not trying to lose or gain weight; increase or decrease in appetite

Difficulty sleeping or sleeping too much

Acting agitated or at a slowed pace

Fatigue

Feeling worthless or guilty

Difficulty concentrating or making decisions

Recurrent thoughts of death or suicide

Symptoms of Major Depression

Having a screening testcan help prevent thespread of chlamydiabecause it allows forprompt treatment.


But not everyone’s nutritional needs are identical. As weage, our bodies and metabolism change. Although olderadults still need plenty of fruits and vegetables, wholegrains and fiber, they need to add or subtract a few thingsfrom the food pyramid.

Older adults, says Althea Zanecosky, R.D., “havedecreased taste and decreased absorption.” They need to make sure they get enough water and nutrients, even if they must take supplements to get them.

Researchers at Tufts University developed a modifiedversion of the food pyramid (nutrition.tufts.edu/pdf/pyramid.pdf ) for adults 70 and older. One added sectionof the pyramid for older adults is water. Although we allshould drink eight glasses of water a day, it’s critical forolder adults to factor in water because they havedecreased kidney function and may not feel thirsty.

Yet they still need thesame amount of waterthat they did when theywere younger, Ms.Zanecosky says.Adequate water intakehelps avoid constipa-tion. Older adults’digestive tracts don’twork as effectively asthey once did, making constipation more likely. Also,many older adults have dental problems that keep themfrom eating as much fiber as they need. Fiber also helpsprevent constipation.

“This pyramid heightens people’s awareness to focusmore on fluids,” Ms. Zanecosky says.

Another addition to the pyramid is a flag at the top forvitamin and mineral supplements. The flag is a warningsign, not a mandate, about supplements. Older adultsoften don’t get enough calcium or vitamin D in theirdiets, and a lack of either of those can lead to bone lossand osteoporosis. Vitamin B12 is another nutrient that’soften found lacking in older adults. As the body ages, itbecomes less able to absorb B12, so a supplement can help provide enough of this important nutrient, which iscritical for nerve function.

Seniors should discuss the issue of supplements withtheir doctor. Older adults already purchase more supple-ments than other age groups. “They are led to believe thatmany of the conditions that come with aging can be fixed[with a supplement],” Ms. Zanecosky says. “That’s not true.”

But, she adds, recent research has shown that the agingprocess can be slowed with a good diet. “So we have a lotto benefit from eating well.”

Other aspects of nutrition for seniors

The other parts of the modified food pyramid forseniors aren’t that much different from the general foodpyramid. Older adults should consume a combined totalof at least five fruits and vegetables a day. (Most Americansdon’t even eat four servings of fruits and veggies a day.)

Fruits and vegetables are a real plus for seniors: Theyare lower in calories than other foods, yet high in nutri-ents, Ms. Zanecosky says. Fruit is much healthier fordessert than cookies or cake — yet many older adultsindulge their sweet tooth with sugary treats rather thanfresh fruit. Because the aging metabolism slows down asthe years pass, even a few extra calories can add up at thewaistline.

The dairy products section recommends that olderadults consume three servings of milk, yogurt or cheeseeach day. “Even three is low,” Ms. Zanecosky says, becauseof the risk for osteoporosis.

When eating is a problemSome older adults have trouble getting adequate nutri-

tion because of health problems or financial difficulties. Ifthese are problems that affect you, there are steps you cantake to ease them.

If you have trouble chewing, you might not be able toeat fresh fruits and vegetables, or meat. Instead, you mighttry the following ideas, from the Food and Drug Admini-stration (FDA):

Instead of fresh fruit, try fruit juices or canned fruitssuch as peaches or pears.Instead of raw vegetables, try vegetable juices or cookedand mashed vegetables.

Seniors’ Food PyramidStresses Vitamins

he food pyramid stands as the foundation of good eating. Designed by the U.S. Department of Agriculture more than a decade ago, the pyramidsuccinctly shows how much of each type of food we should eat to stay healthy

If money is a problem,here are some sugges-tions from the FDA:

Buy low-cost foods such asdried beans and peas, riceand pasta.

Use coupons to save moneyon food.

Look for sales and store-brandfoods, which often cost less.

Check with your religiouscommunity for free or low-cost meals.

Call a local senior citizenprogram about meal pro-grams. You may be able toeat there or have mealsbrought to your home.

Find out if there is a Mealson Wheels program nearyou. (www.mowaa.org)

Get food stamps. The foodstamp office is listed underyour county government inthe phone book.

HEALTHY SENIORS

“This pyramid heightenspeople’s awareness tofocus more on fluids.”

— Althea Zanecosky, R.D., nutritionist and spokesperson for the

American Dietetic Association

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www.brownandtoland.com

Instead of a chunk of meat, try ground meat, or proteinalternatives such as eggs, milk, cheese and yogurt.Instead of sliced bread, try cooked cereals, rice andbread pudding.If certain foods give you gas, making you uncomfortable,

try these alternatives:Cream soups, pudding, yogurt and cheese can take theplace of milk.Green beans, carrots and potatoes can take the place of broccoli and cabbage.

Fruit juices and canned fruits can take the place of fresh fruit.If you cannot shop for yourself or cook for yourself, you

can make other arrangements. Some groceries will deliverfood at no charge; others charge a fee. A family member,friend, or church or synagogue group may be able to helpwith shopping. A senior citizen program in your area maydeliver meals. You can use the microwave to cook already-prepared meals. You might consider moving to a placewhere meals are prepared for you — either with a familymember or a senior citizens’ community. Eating with otherpeople also is a good way to encourage your appetite; eat-ing alone can be lonely.

Food safetyNo matter what your age, it’s important to treat food

carefully to avoid foodborne illness. As you age, yoursense of taste or smell may not always be able to tell you when a food is no longer fit to eat — when milk hassoured or meat has spoiled. Your senses may be affectedby illness or by the medication that you take.

Your stomach also produces less acid. Stomach acid is a natural defense against bacteria you might have eaten.Your immune system also may not be as strong as it oncewas, making it more difficult to fight bacteria. ■

Refrigerate or freezeall perishable food.Your refrigeratorshould be kept at40 degrees, and your freezer atzero degrees.

Never thaw foods atroom temperature.Instead, thaw themin the refrigerator, incold water or in themicrowave, and cookthem immediately.

Wash your handswith soapy waterbefore preparingfood. Wash yourhands, utensils, cutting boards andother work surfacesafter they come incontact with rawmeat and poultry.

Never leave perish-able food out of therefrigerator for morethan two hours. Ifthe temperature inthe room is over 90 degrees, the foodshouldn’t be left outfor more than onehour.

Thoroughly cookraw meat, poultryand fish.

Food Safety TipsFrom the FDA

Brown & Toland’s HealthLink, Winter 2005 11

Tufts Food Guide Pyramid for Older Adults

The Doctors Behind Every Good Health Plan

P.O. Box 640469San Francisco, CA 94164-0469

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Permit No. 148

from in the Medicare arena in January, as Health Netrolls out lower premiums and lower co-pays andPacifiCare Health Systems enters the San Franciscosenior market for the first time since 2001.

Health Net’s filings for 2005, pending approval fromthe Centers for Medicare & Medicaid Services (CMS),indicate that the health plan will lower its premiumand lower its specialist co-pay. Primary office co-payswill remain unchanged.

“Health Net will be aggressively promoting thesechanges with a multi-tiered advertising campaignincluding newspaper and outdoor ads,” says JohnFisher, Brown & Toland marketing manager. “They areworking hard to educate the community about theproduct and all it has to offer.”

Meanwhile, PacifiCare will re-enter the Medicare arena in San Francisco in 2005, with a lower monthlypremium for its Secure Horizons product.

“This is yet another product that allows Medicare

beneficiaries to access Brown & Toland’s wide networkof physicians,” adds Mr. Fisher. “A beneficiary choosingeither Health Net or PacifiCare’s Medicare product willalso enjoy a long list of additional benefits and accessto a number of San Francisco’s finest hospitals.” ■

HMO Options Increase for MedicareBeneficiaries in 2005

rown & Toland members willhave more plans — with lowermonthly premiums — to choose

FOR MEDICARE BENEFICIARIES

BHealth Net rolls outlower premiums andlower co-pays andPacifiCare HealthSystems enters theSan Francisco market.

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