Coronavirus Takeout vs Delivery Food
20 Mar

Take-Out or Delivery of Food during Coronavirus: Is one safer than the other? Four recommendations to keep you safe.

The Coronavirus pandemic has turned our world upside down.

Schools are closed.  Travel has come to an abrupt halt. Many employees are working remotely.

Our conversations are peppered with new terms like social distancing and flattening the curve.

According to the Center for Disease Control (CDC), it is socially irresponsible to eat in a restaurant. Luckily for us and the restaurants, they are sanctioning delivery and takeout since there is currently no evidence the virus can be transmitted via food.

But is take-out and delivery from your local restaurant risk-free?

Here are my top four recommendations to lower risks and flatten the curve while mindfully practicing social distancing… (amazing how I incorporated all of that in one sentence.)

Let’s start with takeout:

Recommendation #1: Always order from a place you trust, a place in which you have eaten and have used their bathroom.

  • While the bathroom piece may sound strange, it is a logical metric. After all, if the bathroom isn’t clean, can you imagine what is going on in the kitchen?
  • Ordering takeout from a new restaurant without accessing the bathroom? Check the local health report before placing your order. If the report was good prior to the pre-coronavirusoutbreak, you can probably trust them.

Recommendation #2: Minimize human contact when picking up your order.

  • Try not to go to the restaurant for pickup during the most crowded time of day and practice social distancing when in the restaurant.
  • While you are picking up your order, assess the precautions taken by the staff. Gloves? Anyone sneezing or coughing? No precautions? Cancel your order.
  • Packaged cutlery? Probably perfectly safe. If they offer you loose cutlery, either toss it and use your own or sanitize it the way you would sanitize your hands.
  • To be extra cautious, wear disposable gloves to carry the order home and dispose of any of the takeout containers or any packaging materials along with the gloves.

 Here’s my take (out) on delivery:

Recommendation #3: Schedule delivery directly from the restaurant itself if possible.

  • If your favorite restaurants, which you know and trust, have in-house delivery options, consider ordering through them directly instead of going through third-party apps. The apps take a commission fee which cuts into the profits of the restaurant.

Why not support the restaurant directly during these tough times?

Recommendation #4: Avoid direct contact with the delivery person.

  • Short of spraying down the delivery person with Lysol, there is no way to 100% protect yourself. But you do not need to take your order from the delivery person directly. Instead, you can ask the delivery person to place your order outside your door and avoid personal contact. Then dispose the packaging (using gloves if you prefer), the containers and disinfect the area where the delivery was placed.

Then follow proper hand hygiene before eating.

I was recently featured on Channel 10 and took questions from consumers about whether I am personally ordering take-out and having any food delivered.

The answer is yes. While my refrigerator and freezer are stocked with essentials, I have to be realistic. I have limited interest in cooking and I need something more substantial than a Greek yogurt or a protein bar for dinner.

Is take-out and delivery risky? Of course, it is. But so is crossing the street, driving a car or boarding a plane.

We take calculated risks every day.

Is one riskier than the other?

If you pick up your food, you can assess the measures the restaurant is taking to prevent contamination.

However, at the same time, you may be exposing yourself to the plague. It’s a toss-up.

The important takeaway message is to keep-up-to-date with the news, think logically, avoid going out unless necessary, practice social distancing and most importantly, wash your hands.

If we all took the rules seriously and vigilantly stayed at home or at least practiced social distancing, we could flatten the curve.

That could save lives and help turn our world right side up.

20 Tips for Heart Health
30 Jan

20 Tips for Heart Health: A Cardiologist’s Guide to Making Healthy Choices (and Bypassing Your Genes)

It’s February, time for a heart-to-heart talk.

Here’s the irony: heart disease is the leading cause of death for men and women in the United States. Every year, 1 in 4 deaths are caused by heart disease

So we should be having this conversation during the course of the year as well.

Heads up. That is part of my 2020 plan.

While the death rate from heart disease is scary, there is good news. While genetics do play a role, making healthy choices can promote longevity. Maybe bypassing your genes is a stretch, but I just loved the pun and I hope you will take heart and give these a try.

20 Tips for Heart Health:

  1. Eat something green. To age well, we must eat well. There has been a lot of evidence that heart-healthy diets help protect your brain and slow down the rate of cognitive decline.
  2. Moooo-ve and move regularly. Anything is better than nothing as long as you have the permission of your physician. While exercise is no longer optional, the type of exercise you choose is.
  3. Go for a blood pressure check, a traditional silent risk factor for cardiovascular disease. You can only control your blood pressure if you know your baseline.
  4. Get at least seven hours of sleep. Sleepdeficiency is associated with many chronic health problems, including heart disease, high blood pressure, diabetes, kidney disease, stroke, obesity, and even depression.
  5. Avoid eating simple sugars like cake, cookies and candy. Processed foods such as cakes, cookies and refined sugars, including high-fructose corn syrup and all-purpose flour, all contribute to the obesity epidemic in the United States. Obesity has been closely linked to diabetes, cardiovascular disease, stroke and even cancer.
  6. Exercises such as mediation, breath work, yoga and tai chi are great tools to improve the function of our autonomic nervous system which is responsible for heart rate, blood pressure, digestion as well as hormonal regulation. And the health and regulatory function of our autonomic nervous system is a known predictor of overall longevity and quality of life.
  7. Limit your alcohol intake. Yes, we know there are studies promoting red wine as being good for your heart. But alcohol is empty calories and heart health can be achieved in other ways.
  8. Hold off on bad fats. While fat adds flavor and is a major source of energy, foods rich in trans-fat increases harmful cholesterol and creates inflammation which is linked to heart disease.
  9. Add good fats to your diet such as those found in avocados, coconut oil and nuts. By adding good fats to your diet, you will enjoy the benefits of taste and energy while feeling fuller longer.
  1. Take your medications as prescribed. There is no place for creativity in medication management. Always consult your physician before stopping or starting a medication.
  2. Optimize your Vitamin D. Supplements, vitamins such as Vitamin D, mindfulness, sleep, exercise and proper nutrition have all have been shown to augment the body’s natural ability to maintain balance.
  3. Ask about the benefits of fish oil. Fish oil has omega-3 which fights inflammation and may prevent heart disease and cognitive decline.
  4. Have your hormones checked. When hormones are out of balance, that machine called the body, will not operate at peak performance.
  5. Consider getting a coronary calcium score. The score is determined after a scan which detects deposits in your arteries. The presence of calcium deposits can indicate you are at risk for a heart attack. And knowing your risks may save your life.
  1. Brush your teeth and take care of your gums. Research shows a high correlation between gum disease and heart disease.
  2. Spend time outdoors. Enjoying the great outdoors, particularly while exercising, has been known to lower blood pressure and improve mood and overall oxygenation. Walking with friends who are as committed to their health and wellness as you are, adds a social benefit and promotes accountability and good habits.
  3. Join an exercise class. Exercise is an investment with excellent return on investment (ROI). It may be a long-term investment, but the results will surely pay off.
  1. Avoid sitting for long periods of time. Too much sitting and extended sitting behind a desk or on the couch can increase your risk for cardiovascular disease and even cancer. Taking regular breaks and rotating between standing and sitting can stave off the harmful effects of being sedentary.
  2. Be mindful of what you eat. Your body is a temple. Ask yourself, “Is this something I want to incorporate in my body?”
  3. Explore your inner child and be playful. Exploring new places and learning new things cause a release of endorphins which can reduce blood pressure and improve vasoreactivity.

If you slip up, get back up!

It’s ok to have our cake and eat it too. Just don’t make it a daily habit in February or any other day of the year.

Five tips to avoid holiday weight gain
18 Dec

Five Tips To Avoid Holiday Weight Gain

Some call the six-week holiday season, “the most wonderful time of the year.” I call it binge fest. While I am not referring to the extreme behaviors cited in the Urban Dictionary definition of the word, those six weeks are often marked by a serious of regretful behaviors. We eat too much, drink too much, party too often and forget to exercise. That combination of factors can be a disaster.

But there are ways to make that extended time period less intoxicating but equally full of joy and holiday goodies. Here are my top five tips to keep regret in check:

1) Not all calories are created equal

The concept of counting calories began in the early 1900s. According to the laws of thermodynamics, all calories are created equal. But how our body breaks down each food group and the effect each food group has on our body is incredibly different. 1,000 calories of jelly donuts do not equal 1000 calories of veggies. And focusing on the calories instead of the quality and quantity of food you choose to consume during the holiday can be deleterious to your waistline. Eating is an essential part of our celebrations.

2) Pregame before family dinners or office parties

We often starve ourselves before attending an event, thinking we are saving up the calories to enjoy later. But going to a party hungry often leads to overeating. The best way to prevent overeating is to eat a light meal and drink lots of water before you head out the door. This will allow you to eat with your stomach and not your eyes and select those food items which you really want to eat…in moderation of course.

3) Size Matters

When it comes to plates, size does matter.

Studies have shown that our dinner plates have grown in size over the last century and our waistlines have grown proportionately. Big plates with a small amount of food can make you feel hungry. Instead, grab a smaller plate and fill it up proportionately, balancing the food groups. It may sound like a mind game but it can effectively help you eat 20% less during a meal. And don’t forget to eat mindfully, savoring the different textures and flavors in each mouthful. This process allows you to focus on your body and the signals it sends you during the eating process. While changing the size of the plate cannot guarantee weight loss, it will generally prevent weight gain.

4) Make way for veggies

One of the simplest ways to feel full and stay healthy is to fill half your plate with vegetables, either raw or cooked. Non-starchy colorful veggies like broccoli, cauliflower, beets and salad stuff are the best way to feast, both for your eyes and your belly. And they are a great way to fill you up. Blame it on the fiber which can help slow digestion, regulate your appetite and control your blood sugar levels.

5) Limit your empty calories

Alcohol is pure sugar which means it has no nutritional value. Same for most desserts. The more decadently elaborate, the higher the sugar content. I would never recommend to totally pass up the alcohol or the dessert table. My suggestion is to limit your quantity. Have a glass of wine and if you are still craving alcohol, try a glass of seltzer with a twist and see if that helps. Take bites rather than slices of cake or pie. You never want to feel deprived but at the same time, why leave yourself open to temptation?

6) Bonus Tip: Maintain your schedule

It’s a busy time of the year. While immersing ourselves in the joy of gift giving and spending time with family and friends, we often forget the importance of taking care of ourselves. Regular exercise is an important part of your schedule and it is in your best interest to keep it up. We look better, feel better, and have more energy and less cravings when we work out…the perfect excuse to enjoy a glass of wine and a small slice of dessert.

Looking to save these tips in an eBook? Click HERE to download. Or watch this WSFL TV segment for the full visual impact!

Testosterone Supplements
21 Nov

Why I Wouldn’t Take OTC Testosterone Supplements and Why You Shouldn’t Either: A Cardiologist’s Perspective

I recently had a 49-year old male walk into my office to help control his elevated cholesterol.

As part of my normal protocol, I do a hormone ​workup.

His testosterone was low. His prolactin was super high. Normal is ​18. His was 300.

I sent him for an MRI and the diagnosis was not surprising: a pituitary gland tumor, also called a pituitary adenoma.

Treated surgically by a neurosurgeon, he has an excellent prognosis.

Is Low T Age-Related?

But he is not the first patient to come into my office and walk out with a low testosterone diagnosis that was indicative that something else is happening in the body.

In fact, I had a 35-year-old who was experiencing low libido and came for a blood test to determine his testosterone level.

What prompted him to come in? The proliferation of OTC testosterone ads on TV.

Are Over-the-Counter Testosterone Supplements Effective?

Here’s my problem with those commercials: there is little evidence to demonstrate their effectiveness.

The second problem is low libido, which could be a sign of low testosterone, is not a reason to start taking OTC supplements. It’s a sign to have your level professionally tested through a blood or saliva test.

Low testosterone could be a symptom of something bigger, like a pituitary gland tumor, which was the diagnosis for the 35-year-old as well.

That particular diagnosis was not what the 35-year-old had in mind. But thankfully the commercial gave him the impetus to seek medical advice.


Here are five take away messages about testosterone:

    1. Testosterone, a hormone produced mainly in men, gradually diminishes with age. This is normal. But ​Low T is also linked to pituitary gland problems, HIV, obesity, diabetes, sleep apnea and more.
    2. Low testosterone affects more than six million men in the US alone. Signs of low testosterone or low T are often subtle and may include not only low sex drive but also depression, fatigue, osteoporosis, loss of muscle and bone mass, increase in abdominal fat, development of breast tissue, body and facial hair loss and infertility.
    3. Low testosterone level is a red flag ​only and should not be treated symptomatically.​It is simply a sign we need to dig deeper and once we dig, we can come up with the proper treatment.
    4. ​Avoid taking a supplement unless you have been tested. Testosterone testing involves a simple blood test, aka serum testosterone test, or saliva test but it is an important ​diagnostic procedure.
    5. In fact, it is preferable not to take an OTC supplement at all until you have discussed treatment protocols with your treating physician. Low testosterone is best treated (after ruling out a bunch of stuff) by injection or cream/gel.​​ Typically ​there is ​little evidence to demonstrate the effectiveness​ of most testosterone OTC supplements and research has indicated there may be negative consequences from the over-the- counter version.

The Bottom Line on Testosterone Supplements:

I personally would not take OTC Testosterone supplements and I do not suggest you do either. Before you head over to your local pharmacy to buy an OTC supplement to enhance your bedroom experience, make an appointment with your healthcare professional to enhance your overall health experience.

Your every body part will thank you.

07 Oct

A Cardiologist’s Exclusive Guide to 5 Favorite Vitamins and Supplements

The demands of the modern world take a heavy toll on our body.

Lack of sleep, stress as well as a diet filled with processed foods wreak havoc on our internal machinery. Our body may suffer not only from lack of vitamins and minerals, but also coenzymes which are metabolic buddies needed to produce energy, promote bodily functions and cell growth and prevent aches and pains from which we often suffer.

Food is an excellent source of vitamins and minerals. But those rich in particular nutrients are not always our favorites. And we tend not to eat enough of them to get the results our body needs for a healthy lifestyle.

Coenzyme Q10 (CoQ10): The Energizer Vitamin

A good example is Coenzyme Q10 (CoQ10). Our body normally produces a small amount of CoQ10 but our lifestyle and certain medications may decrease our natural supply. CoQ10 is abundant in organ meats, which we may not normally include in our diet. It is also found in beef, mackerel, and sardines.

How often are you willing to eat liver and sardines?

When Coq10 is lacking, we may feel a lack of energy as well as muscle aches and pains.

And if we are on statins for cholesterol, beta blockers for blood pressure, diuretics such as furosemide, antibiotics or hormones, these deficiencies are often more pronounced and supplementation is essential.

Vitamin CoQ10 or its biologically active form, Ubiquinol, can easily be found in the vitamin section of the pharmacy or supermarket.

Top Five Favorite Vitamins and Supplements

A top vitamin on my list of favorites is Vitamin K2 which helps prevent chronic disease and maintain your cardiovascular health, strengthen your bones, promote cognitive health and even improve your skin. By the way, there is actually a Vitamin K1, which we learned about by accident. For years, people who took coumadin (warfarin) were advised to limit their vitamin K intake as it potentially counteracts the anticoagulant properties of warfarin. Unbeknownst to researchers, Vitamin K comes in two varieties. Vitamin K1 counteracts the effects of warfarin. But Vitamin K2 pulls calcium out of arteries and puts it back in your bones and has nothing to do with coagulation. So we were advising patients to avoid foods like green leafy vegetables, dark chicken meat and egg yolks which are excellent sources of Vitamin K2.

Magnesium is another underrated mineral which has been known to prevent cramps in your legs, calm your nerves and lower your blood pressure. Avocados, dark chocolate, nuts, seeds, tofu, legumes and bananas are tasty sources of magnesium. But you may not be getting enough of it even with a healthy diet. A simple blood test can determine if you need more or less of this simple nutrient.

As a cardiologist, I am also a fan of the more well-known supplement Omega-3 fatty acids which lowers triglycerides and helps with sugar breakdown. Don’t let the word fat in the name be a deterrent since this is one fat you absolutely want to include in your diet. Found in fish such as mackerel, herring, oysters, sardines, salmon as well as nuts, flaxseeds and cod liver oil, omega-3 fatty acids may curb stiffness and joint pain and is important for visual and neurological development in babies and dry eyes in adults. When possible, try to get omega-3 fatty acids from foods rather than supplements. But if fish is not your favorite, then a supplement may be a consideration. A word of caution: make sure you buy this supplement from a reliable source as some brands may not be free of heavy metal impurities.

Equally well known is Vitamin D3 which we believe is essential for calcium balance and strong bones. Less well known but equally as important is the role Vitamin D plays in reducing cardio-vascular disease as well as stroke and peripheral vascular disease. Vitamin D sources include sun exposure and your diet. Cheese, egg yolks, sardines, fortified orange juice, milk and yogurt as well as canned tuna are excellent sources of Vitamin D. But getting enough Vitamin D through your diet alone is challenging. Most adults should have their levels checked with their physician before starting any supplement.

Let’s end with Vitamin B complex, nutritional supplements which have all eight B vitamins which are essential in producing energy and lower levels of inflammatory markers.

Good new. B vitamins are found in many foods like meat, dairy, eggs and seafood.

If you are eating well, you are probably covered except during pregnancy where your body demands more B12 and folate to support fetal development. Some medications do interfere with the absorption of Vitamin B and some of us with certain medical conditions are susceptible to nutrient deficiencies.

When it comes to your health, there is no one size fits all. Multivitamins may seem like a quick and easy answer. But research shows that men who take a daily multivitamin have an increased risk of developing prostate cancer. While causality has not been established, I personally am not a fan of the shotgun approach. Take the time to talk to your physician and create a targeted therapeutic plan to balance the heavy toll life takes on our body.

Together we can balance all our individual health needs and wants and create a comprehensive strategy to a perfect “Vitamin You.”

Types of Headaches
02 Aug

Not Tonight Dear: Common Types, Causes and Treatment of Headaches

America’s got headaches.

It’s a well-documented fact. Just look at the statistics.

It is estimated half of the adult population suffers from run of the mill headaches at least once a year. According to a population-based US government survey, 1 out of 6 Americans and 1 out of 5 women suffer from severe headaches and migraines. This statistic has not changed for the past 20 years.

Interestingly, headaches are more prevalent in younger adults than in seniors than and twice as high in women as in men.

Who knew there were so many different types of headaches?

According to The International Classification of Headache Disorders (ICHD) there are more than 150 different types of headaches which are divided into two main categories: primary and secondary.

Primary Headaches

Migraines and tension headaches are considered primary headaches since they are conditions in themselves. Tension headaches are fairly common and usually resolve fairly quickly with the passage of time and over-the-counter pain killers.

A migraine is a more severe kind of headache that occurs when there is vascular instability. Patients with migraines report having an aura before suffering this malady, which means they may see flashing light, experience nausea or sensitivity to bright light. The pain or symptoms can last anywhere from a few hours to a few days.

Cluster headaches are recurrent, severe headaches which are six times more likely to develop in men than women. Often characterized by a burning pain behind the eye, they often occur without warning and usually take place at the same time of day and are induced by stress.

Other primary headaches include exertional headaches brought on by strenuous exercise and hypnic headaches which is also known as an “alarm headaches” since it wakes you up in the middle of the night.

Secondary Headaches

As for secondary headaches, those are related to a head injury, caffeine withdrawal, medication overuse, sinus, menstrual and hangover headaches.


There are many factors which can trigger a headache or a migraine. External factors such as weather conditions, persistent loud noises or music, fragrances or carbon monoxide poisoning are possible contributors. Stress, sleep apnea, alcohol, vision problems or eye strain and dehydration are also known contributing factors.

The Food Factor

Food or lack of it can be a trigger for a headache or migraine.

Food triggers are often specific to individuals. What triggers a migraine in one person may not do the same to others.  In my experience, foods containing Monosodium glutamate (MSG) or nitrates since they are vaso-active substances are very common triggers. Other foods which commonly cause migraines include caffeine, spicy foods, aged cheese and even chocolate.

I have a patient who had consistent headaches after seeing a movie in a movie theatre. The trigger: movie-theater popcorn, a bummer since that was her favorite part of the movie experience.

Treatment Options

The most common treatment for a headache is over-the-counter medications such as ibuprofen (Advil, Motrin IB, others), acetaminophen (Tylenol, others) and aspirin. For migraines or any severe repetitive headache, it is best to schedule an appointment with a neurologist or migraine specialist. There are a variety of prescription medications to both treat and prevent migraines including sumatriptan (Imitrex) and zolmitriptan (Zomig). Some of my patients have found success with Botox, stress reduction, yoga and massage.

So next time your wife says, “Not tonight dear, I have a headache,” you can take comfort in the fact you are not alone. It’s part of being an American.

02 Jul

3 Reasons Binge Watching is Bad for Your Health

You wake up in the middle of the night and cannot go back to sleep. Tossing and turning is making you anxious. So you turn on the TV and catch up on the latest Netflix series.

Here’s another typical scenario. You have FOMO (Fear Of Missing Out) because everyone at your office was watching Game of Thrones and you never did. Now you are trying to figure out what all the hoopla was about by watching four episodes a night.

Just FYI, it’s going to take you a while. There are eight seasons.

Binge watching occasionally? No problem. Like everything else in life, moderation is key. But regular binge watching is a poor lifestyle choice with at least three major health consequences.

Consequence #1: A sedentary lifestyle is deleterious to your overall health.

Multi-episodic TV watching means you are sitting for long periods of time. And being sedentary is a significant public health issue.

According to the Center for Disease Control (CDC), “Only 21% of adults are meeting the physical activity guidelines of 150 minutes of moderate-intensity physical activity each week and less than five percent perform 30 minutes of physical activity per day.”

Recent research confirms how a sedentary life can lead to obesity, type 2 diabetes, stroke, cardiovascular and metabolic disease and even an increased risk of death.

If that is not enough to get you to turn off the TV and leap out of your recliner, couch potatoes have a high incidence of depression and other mental health disorders.

Consequence #2:Your TV emits blue light which may negatively impact your eye health and sleep cycle.

Binge watching can lead to poor sleep quality, increased fatigue, eye strain and insomnia. Blame it on the blue light. According to Hollywood Ophthalmologist Inna Ozerov MD, “Blue light is part of the visible light spectrum, with wavelengths of about 415 nm to 495 nm. Blue light can be divided into two bands: blue-violet light (415-455 nm) and blue-turquoise light (465-495 nm).  The largest source of blue light is the sunlight but computer monitors, cell phones, tablets, TV screens all emit blue light.  Recent studies have found that Blue-violet light may cause harm to the delicate cells that make up the retina and may be implicated in the development of age-related macular degeneration or AMD.”

It can also delay the release of melatonin, the hormone which regulates sleep and reset your circadian rhythm. The result is sleep deprivation which can lead to fatigue, depression, memory issues and even heart problems.

Consequence #3: Binge watching can lead to binge eating.

Binge watching and binge eating often go hand in hand. From personal experience, binge watching is often associated with poor snack choices.A reasonable portion of anything on an occasional basis is not a cause for concern. However, most of us are not preparing stacks of celery sticks to munch on as we get cozy comfy on the couch. And while air-popped popcorn with no added sugar or salt is low in calories and high in fiber, oil-popped, flavored popcorn can be a slippery slope. Mindless snacking, even on so called “healthy choices” can lead to obesity and the related medical consequences.

In the mood to mindlessly binge watch or have a chunk of time on your hands? Break it up. Watch an episode and then throw in a load of laundry, grab your mat and do some sit-ups or run an errand. If the binge takes place at night, limit yourself to one episode before disconnecting and trying to fall asleep.

Finally, if you must binge watch, invite others to join you and make it a social occasion. Just don’t forget to serve the celery sticks.

13 Jun

How to Lose Your Veins in Ten Days

You’re so “vein,” I bet you think this blog is about you… and it is.

For many, varicose veins are an issue of cosmetics. Most are not aware these prominent sinewy (a favorite word of mine) vessels can cause pain, swelling and ultimately skin breakdown and ulceration. Many may experience leg heaviness and tightness.

And by the way, it is not just women. Men are equally as affected.

The Cause of Varicose Veins:

So how does one end up with this vascular problem? For one, blame your genes. You are more likely to develop varicose veins if your parents had them…and we are not just talking about mom. Another risk factor is trauma which destroys the native valves which live in your veins which are responsible for moving blood back to your heart. When they malfunction, blood moves in the wrong direction, causing the veins to dilate and become snakelike.

Obesity is another cause. Excess weight caused by the pressure of your belly pushes blood flow backwards and blows out those necessary valves.

The Old Guard Treatment for Varicose Veins:

Conservative measures such as compression stockings have been the mainstay of treatment for decades. Although these elastic hosiery may take care of the symptoms of varicose veins, improve circulation, prevent them from getting worse and even hide them, their constricting existence during the hot months makes them an unwelcome and annoying presence.

There is a supplement which may help improve your venous tone, horse chestnut extract, while use may be helpful, it is not curative. In days of yore, surgical options such as vein stripping were used to remove them. The treatment, albeit effective, was quite barbaric as it required a number of incisions along the length of the vein and after it was tied off, the vein would be removed segment by segment, pulling it out of the leg. Recovery was brutal.

The New Guard Treatment for Varicose Veins:

More recently advances in catheter technology have allowed doctors to laser, burn out or glue these veins shut. Such procedures are less invasive, less painful, and allow for a quicker recovery time. One or two veins at a time in 30-45 minutes session and most people go back to their normal activities thereafter. Most patients do fine long term so if you are plagued by varicose veins, see a specialized health care provider trained to identify and treat these conditions which are diagnosed by a non-invasive ultrasound.

“My legs have always been unsightly and having babies made the veins even more pronounced. I hesitated to do the surgery but I after my last baby, I opted for this newer treatment and I am thrilled. I even started wearing shorts.”

Christina R, Age 35, Davie Florida

To schedule a vein consultation, please call 954-980-0361. Your legs will thank you!

20 May

Is Using A CPAP Machine On Shabbos Permissible?

In recent years an increased number of people have been diagnosed with sleep apnea. Indeed, experts estimate that three to nine percent of the general population suffers from its most common form, Obstructive Sleep Apnea (OSA).

A person with OSA stops breathing periodically during sleep, which causes deep (and loud) snoring and deprives the brain of oxygen. Untreated sleep apnea puts a person at greater risk of high blood pressure, stroke, heart failure, diabetes, obesity, and depression. It may also severely impact one’s executive function and ability to stay awake during daily activities such as driving.

Dr. Adam Splaver, a clinical cardiologist in Miami, FL, describes the risks of sleep apnea as follows: “When you have obstructive sleep apnea, you are becoming hypoxic for extended periods of time. This causes rise in blood pressure [and] irritates the electrical system of the heart, causing atrial fibrillation and starving your other vital organs of life-nourishing oxygen, including your brain. Patients can wake up foggy with a headache and, in some circumstances, cause irreparable damage if a stroke or heart attacks occur.”

Numerous factors determine whether a person will get OSA, including age, neck size, the shape of one’s septum, allergies, sinus problems, obesity, and family history. Men get it more than women.

Those who suffer from sleep apnea are often encouraged to change their behavior or life-style; take medication to clear the nasal passages; or even have surgery. The “gold standard” treatment, however, is sleeping with a CPAP machine.

A CPAP (continuous positive airway pressure) machine is a ventilator device attached to a mask worn over the nose which provides mild air pressure to keep one’s airways open. Some machines have a humidifier as well, used to lessen nasal congestion, dryness, and rainout. The continuous flow of air prevents the throat and nasal passages from closing and allows a person to sleep without risk of repeatedly waking up during the night.

Potential Halachic Problems

Doctors insist that OSA patients should use their CPAP every night, including Shabbos and Yom Tov.

Rabbi Dr. Mordechai Halperin, chief officer of medical ethics for the Israeli Ministry of Health and director of the Falk Schlesinger Institute for Medical-Halachic Research in Jerusalem, told this author that a person who needs a CPAP should be treated like one whose life may be in danger if he doesn’t follow medical instructions. Therefore, he argues, using a CPAP is allowed on Shabbos.

If one can, one should turn the machine on before Shabbos or set a Shabbos timer for it to turn on when it’s needed. The problem is that some models only start working once a person places the mask on his face. Furthermore, breathing into a CPAP machine causes a screen to display numbers, and some machines record details on an installed chip. Finally, the machine increases and decreases air pressure in response to the person’s breathing.

To address all these potential halachic problems, we need to first, briefly, summarize the laws of electrically-operated machines and ill individuals on Shabbos.

Cholim on Shabbos

In general, one is permitted to perform any melacha normally forbidden on Shabbos to save of the life of a person whose life is in danger (i.e., a choleh she’yesh bo sakanah). We violate Shabbos for such an individual even if we’re not sure that his life is truly in danger and even if it’s possible that treatment can be delayed until after Shabbos (Mishnah Berurah 328:16). The Rema (Orach Chayim 328:12) rules that, if possible, one should try to perform the prohibited melacha in an unconventional manner (i.e., with a shinui).

If the person is sick but his life is not in danger (choleh she’ein bo sakanah), we may ask a non-Jew to perform a biblically-prohibited act or do a rabbinically-prohibited act ourselves in an unconventional manner (Rema, ibid. 17).

Some Acharonim (see Chayei Adam 69:12) rule that if one is unable to perform the necessary task in an unconventional manner, one can do so in a conventional manner. In addition, some Acharonim, including the Baal HaTanya (Shulchan Aruch HaRav 328:19; see also R. Shlomo Zalman Auerbach, cited by Shemiras Shabbos KeHilchasa, 3rd edition, 33:3 footnote 18) permit performing even a biblical prohibition in an unconventional manner to aid a choleh she’ein bo sakanah.

Finally, Acharonim explain that these principles apply also when trying to prevent future illness (see below).

Electricity on Shabbos

Acharonim have debated the halachic status of using electricity on Shabbos for over 100 years. The most significant debate relates to turning on and off an electric machine. The Chazon Ish (Orach Chayim 50:9) insists that completing a circuit constitutes the biblically forbidden melacha of boneh (building), and R. Asher Weiss (Minchas Asher 1:32) offers other reasons why using certain electric appliances may violate a biblical prohibition.

Most poskim, however, rule that using electricity is only rabbinically prohibited (see, for example, R. Shlomo Zalman Auerbach, Minchas Shlomo 74, 84).

What about increasing or decreasing a machine’s electric current once it’s already on? R. Shlomo Zalman Auerbach (Shmiras Shabbos Kehilchasa 1:23 n. 137) rules that “shinuy zerem” – i.e., changing the degree of electric current – is permitted. Thus, Shemiras Shabbos KeHilchasa (4:28) permits increasing or decreasing the volume of a hearing aid, for example.

Using a CPAP on Shabbos

Obviously a person who is dangerously ill may – indeed, must – violate Shabbos. But someone suffering from OSA may only be at risk of being seriously ill months or even years from now if he doesn’t use a CPAP. Can such a person violate Shabbos?

Most poskim (see R. Asher Weiss, Minchas Asher 1:30) maintain that breathing into a CPAP is fine as long as the machine is turned on before Shabbos or via a Shabbos timer. It’s true that breathing into it also alters the digital display, and data is often recorded onto a chip, but there are numerous reasons to be lenient on this question.

First, the patient does not intend to, and is not particularly interested in (lo neicha lei), affecting the display and the information recorded, which are, in any event, rabbinic prohibitions. (While most agree that turning on an incandescent light, which heats a metal filament until it glows, is biblically prohibited [see Rambam, Hilchos Shabbos 2:1], turning on a fluorescent or neon light, which do not use heat, is generally regarded as a rabbinic prohibition.)

Second, R. Asher Weiss (ibid.) argues that none of the normal reasons to prohibit electricity apply in this case. (He also permits prisoners to wear ankle bracelets, which record their movements on Shabbos.)

May a CPAP be activated on Shabbos? Rabbi Dr. Avraham Sofer Abraham (Nishmas Avraham, Orach Chayim 328) asserts that a person who may face medical harm in the future is considered to be a choleh she’yesh bo sakana and therefore rules that the patient should, if necessary, “turn on the machine in an unusual way, such as with the back of his hand, and when he rises he should leave the machine on until after Shabbos.”

The Star K (Kashrus Currents, winter 2010) records that R. Heineman also permits using a CPAP on Shabbos, although based on a slightly different reasoning. R. Heinemann insists that a person with a condition that is cumulatively life-threatening is in no less danger than a choleh she’ein bo sakanah, and therefore a person with sleep apnea can activate a CPAP with a shinui.

As for machines that are activated by breathing into them (and for which it is difficult to find an appropriate shinui), R. Heineman invokes the Chayei Adam (cited above) and rules that one may violate a rabbinic prohibition in a normal manner when doing so with a shinui is not possible.

R. Yitzchak Rubin (from Har Nof) and R. Yitzchak Ziberstein, posek of Maayanei HaYeshua Hospital in Bene Berak (Heichala v. 4, 5774) debated using CPAPs on Shabbos. R. Rubin writes that it is difficult to offer a general ruling and concludes that one should consult one’s doctor and posek. R. Zilberstein, however, views OSA as a condition that is safek pikuach nefesh and therefore rules that a patient suffering from it may turn on a CPAP in an unconventional manner. If his doctor tells him the machine must be activated normally, he can turn it on in a normal manner, writes R. Zilberstein.

As mentioned earlier, some machines use a humidifier. Heating water to a temperature above yad soledes bo violates the biblical prohibition of bishul (cooking) and, therefore, the CPAP’s temperature setting should be lowered before Shabbos so that the water won’t be heated above yad soledes (110 degrees Fahrenheit according to R. Moshe Feinstein – see Igros Moshe, Orach Chayim 4:74).

In conclusion, while it is preferable to turn on a CPAP before Shabbos, or set a timer to turn it on when needed, many poskim maintain that one may turn it on in an unusual manner on Shabbos and, if necessary, even place the CPAP mask over one’s face, which turns on the machine. Those seeking practical guidance should discuss this matter with a doctor and halachic authority.

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12 Apr

Will an Aspirin a Day Keep the Doctor Away?

For many years it was common to advise seniors to take a daily dose of aspirin to prevent a heart attack, stroke, and other cardiovascular complications.

It seemed to be working. Not any more. As more data has accumulated, the old adage, Take two and call me in the morning,” has come into question.

Based on the latest research, the American College of Cardiology and the American Heart Association is advising against daily aspirin use for prevention because, “It may actually cause more harm than good.”

For decades, we prescribed aspirin to preclude clot formation, a forerunner to a heart attack or stroke, and based on the then “current studies,” we thought a low dose of aspirin was a perfect preventative measure. But as time passed and more data was accumulated, it became noteworthy that more people were having bleeding complications. It seems we were creating more health havoc through a simple prevention tactic. While the benefits of this wonder drug were pushed, many suffered the consequences of having thin blood, internal bleeding, strokes and other manifestations of blood loss.

The daily dose of aspirin is no longer recommended for older adults who don’t have a high risk or existing heart disease. Instead, the focus is on promoting a healthy life style and reducing those lifestyle factors which can be modified such as smoking, diet and exercise.

It has also proven beneficial for any individual of any age who has already had a heart attack, stroke, or vascular intervention like stents or angioplasty. The benefits far outweigh the risks.

Though currently out of vogue, the history of aspirin is still fascinating. Aspirin comes from the bark of the willow tree and has been known for centuries for its healing properties. Records dating as far back as 3000 BC corroborate the medicinal properties of the willow as a pain reliever used by ancient civilizations like the Sumerians and Egyptians. The Greeks administered it in tea form to help relieve the pain of childbirth in the year 300.

Fast forward to 1828 when a pharmacy professor in Germany extracted the active ingredient, salicin, from the willow tree. In a clinical trial in the late 1800s, salicin was found to reduce fever and joint inflammation in patients with rheumatism. About the same time German Pharmaceutical Company Bayer figured out how to purify the salicylic acid with acetic acid, aka vinegar. They patented ‘acetylsalicylic acid’ as ‘aspirin’, a brand name which became generic like Kleenex, Xerox and Scotch tape.

This brings us back to modern times where aspirin is still one of the most researched drugs in the world, with more than 700 clinical trials conducted each year. 

Back to the new guidelines for aspirin. Here’s a word of advice: People who were taking the aspirin proactively should not stop it cold turkey but speak to their medical professional.

Case in Point: I have a patient in his 50s who read the news and stopped taking the aspirin despite his history of stents and angioplasty. Several weeks later he was rushed to the emergency room with a heart attack as a clot had formed in one of his coronary arteries. He lived to tell his story and be a warning to all considering taking their health into their own hands.

But for anyone who has had a heart attack, stroke or any cardiovascular-related disease, the standard dose of aspirin taken proactively can be a lifesaver.

And you don’t need to wait until the morning to call me.