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COVID-19 is wreaking havoc!

I received my Ocrevus infusion last Tuesday. Am I setting myself up for serious illness with COVID-19?

Uncertainty.

 

Take a deep breath. And another.

 

Those of us with MS or another chronic disease are used to living with uncertainty. We don't know when another MS flare will sneak up on us, rob us of some vital function, make just a brief visit or stick around for a prolonged stay. That's the way it is with this bizarre disease, and in the weeks, months, and years after a MS diagnosis, we learn to cope.

 

But COVID-19 is a double whammy.  It is hitting hard on so many levels. First, of course, are the health concerns. While we know this new virus is bad, we don't know how bad, how long it will last, how far it will spread. We think it is worse for people with chronic diseases and/or suppressed immune systems, but we don't know how much additional risk we have, as people living with MS. (I had my Ocrevus infusion last week, potentially reducing my ability to fight infection. Bad idea? I don't know.)

 

We know COVID-19 is less contagious than influenza, but it is more deadly. How much more? Is the case fatality rate 2%? 4%? Much lower, because we aren't testing and counting those with mild or asymptomatic infection? Is it really 15% in people over 80, or even higher when factoring in preexisting conditions? How are survival rates impacted by having diabetes, heart disease, or multiple sclerosis?  We have so much to learn.

 

A second concern is the economic and societal impact. The huge music and film festival, South by Southwest (SXSW), was just cancelled in my hometown of Austin, causing some business owners to panic and creating widespread disappointment among musicians and would-be attendees. Events all over the country are being cancelled or postponed. Schools are closing. Vacation plans are being scrapped.

 

I've been reading about COVID-19 incessantly this week, and my initial sense that the hype and paranoia were unwarranted has shifted. I'm not stockpiling food, I'm not wearing a mask (it won't protect us from infection), and I'm not overly concerned about my own health. But I'm worried this virus is not going away soon. Spread of the infection is likely; containment is improbable. The ability to test more people for COVID-19 is a mixed blessing: Identifying people who are sick allows to us to take action to minimize spread, but it will also lead to a surge in confirmed new cases. Even if the situation isn't worse, new testing capabilities may make it look worse.  

 

How do we weigh the risks and benefits as we make decisions in the coming weeks?

 

My 12-year-old daughter, Clara, often asks questions like "Would you rather eat a cup of live cockroaches or spend the night in a cage with hungry lions?" In my case, the immediate choice is not quite as terrible: Would you rather give up a much-anticipated spring break trip to California or gamble in a game where the odds are unknown and the consequences could be quarantine, serious illness, or absolutely nothing?     

 

Uncertainty can be infuriating, even paralyzing, but as I have with MS, I will try to let it be a teacher and guide. I may not know what this week will hold, but I can be present in this moment. I can't control this virus, but I can try to meet each bit of news, each decision, with patience and grace.

 

Wash your hands – don't touch your face – cover your cough – don't go out if you're sick.  I will follow the guidelines. I'll keep up with the news and probably cancel that trip to California. But I will also look for silver linings, and practice gratitude, and take each day as it comes.

 

P.S. Don't spend all your time reading the news, but for regular, reliable information, here are my best references: https://www.cdc.gov/coronavirus/2019-ncov/index.html  and https://www.nytimes.com/2020/03/08/world/coronavirus-news.html

 

Please share your thoughts in the Comments below.

 

 

 
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Dizziness

Here's a ride I was happy to skip this summer when my family and I visited Tivoli Amusement Park in Copenhagen.

Dizziness is the bane of my existence. It's my most persistent and irritating MS symptom. It's led to a long list of restricted activities: amusement park rides, drinking caffeine or alcohol, cartwheels, reading on a road trip, certain yoga positions.

 

Obviously, none of these activities are essential. But even with strict adherence to my self-imposed "dizziness avoidance rules," I still have those days when I can't escape that woozy, cloudy feeling that I call "dizziness" (because nothing else describes it quite as well).

 

How do I cope? It's not always easy.

 

In the early years after my MS diagnosis, I felt dizzy every minute of every day. Nothing seemed to make it better or worse. I tried everything: medications, physical therapy, dietary changes, more sleep, less sleep, more exercise, less exercise. I was powerless.

 

But gradually, my symptoms lessened. I have relapsing remitting MS, so some improvement wasn't surprising. I also started to discover some ways to manage my dizziness, or even reduce the chance that it would happen at all.

 

For others struggling with dizziness—or any other frustrating symptom, for that matter—here are some suggestions that may help you take your life back:

 

Track your symptoms: For a long time, I didn't really know if my dizziness was tied to sleep, mood, stress or anything else. So, I started to track my symptoms on a scale of 1-10 and the quality of my sleep, level of stress and mood/overall wellbeing. Then I looked for correlations over several weeks. I was surprised that I didn't find much connection, but it was reassuring. If I couldn't sleep one night, I could remind myself that my insomnia didn't necessarily mean I would be dizzy the next day. If you have suspicions that certain foods, situations or activities are triggering (or improving) your symptoms, test out your theory and use that information to make some positive changes.

 

Rule out other causes: Dizziness is not a rare symptom of MS, but it is not the most common either. I have done hearing and visual tests, bloodwork, and have tried allergy medications to rule out other causes. I am now confident that my dizziness is due to MS. Unless your symptoms are an obvious consequence or your disease process, make sure you and your physician have investigated alternate explanations.

 

Trial and error: Although I never want my quest for a cure to take over my life, I have tried a range of treatments to see what might work. For me, acupuncture and restorative yoga provide brief relief. Visual therapy seemed to reduce my overall number of dizzy days. Although I sometimes cheat, avoiding caffeine helps. While I've opted for a mostly vegan diet for other reasons, I know that diet does not play much of a role in my dizziness. Trial and error helped me create the "avoidance rules" listed above, and it also allowed me to identify activities that are unlikely to cause dizziness.

 

Meditate: Nothing has helped me more than meditation to both reduce my dizziness and cope when I have it. I took a mindfulness-based stress reduction (MBSR) meditation class several years ago. I had hoped it might help with stress, but I had no expectation that it would give me a powerful tool to combat my most irritating MS symptom. By meditating for just a few minutes every morning and night, I reduce my odds of feeling dizzy. When I get dizzy, a 20-minute meditation session can sometimes stop my symptoms. Even when I have bad dizziness that won't go away, meditation helps. "This is the way it is right now," I remind myself. I acknowledge it, without judgement, and go on with my day.

 

Practice self-care: Regardless of your symptoms, you can feel better overall by prioritizing self-care. Follow a healthy diet, maintain nurturing friendships, reduce stress, exercise (find a way to get moving that you don't hate) and get enough sleep. If you are struggling with anxiety or depression (which are so common with MS and other chronic conditions), find a therapist who can provide guidance and support. Sometimes by focusing on self-care, you'll find that your prior symptoms will dissipate.

 

Please offer other suggestions in the comments below and let me know if any of my recommendations are helpful!

 

 

 
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The Importance of Preventive Care

Looking for a terrific New Year's resolution? Get caught up on preventive care!

MS had really taken a toll on my new patient. Or so I thought…

 

She came to see me one afternoon in my family medicine clinic. Her son pushed her into my exam room, and I moved my stool to make way for her wheelchair. One of her arms was rigid, useless. Her speech was slurred, and she reported terrible back pain. As an MS patient myself, I was disturbed to see her, knowing that my fate could be similar.

 

"How long have you had MS?" I asked.

 

"Oh, 20 years, at least," she said, pausing to clear her throat. "But I was doing OK until the stroke last year."

 

Stroke? What? It was a stroke that caused all these problems?

 

As I unraveled her story, I learned I was wrong about her MS. Before the stroke, she had been an active hiker and traveler. I don't think she had seen a doctor much either, except perhaps to treat her MS. And I don't think anyone had ever checked her cholesterol.

 

I was startled to see how high her cholesterol was, when I got her test results back a few days later. I immediately started her on medication. Now I had found a reason for her stroke... and a critical reminder to me, as an MS patient: Don't overlook preventive care!

Preventive care encompasses everything from screening for cancer, diabetes, and high cholesterol to getting immunizations, dietary guidance, and smoking cessation. It doesn't get the same attention, headlines, or research dollars as breakthrough medications for advanced cancer or complex new surgical techniques, but it is important.

 

Especially for those of us with MS, preventive care is often overshadowed by more urgent matters. MRIs

may be more critical than mammograms; seeing the neurologist may take precedence over seeing the family physician. I know when I was required recently to go in for a check-up with my primary care doctor, I complained, "I already see so many doctors! I don't want to go to another medical appointment!"

 

But preventive care should be a top priority for everyone with MS, adding quality and longevity to our lives. With preventive care, we can detect and remove colon polyps before they become cancer. We can identify osteoporosis (thinning of the bones) and treat it before a fracture occurs. We can and do prevent millions of infectious diseases every year through vaccinations. And perhaps my patient, had she been screened and treated for high cholesterol years before, could have prevented her stroke.

 

Those of us with MS may also be inclined to blame MS for every ailment, as I started to do when I assumed my patient's disability was due to MS. We shouldn't. For example, fatigue, though so common with MS, can also be due to a myriad of other conditions like anemia, underactive thyroid, depression or sleep apnea. Checking in regularly with a primary care doctor is an important way to ensure other symptoms and concerns are addressed.

 

If I'm stuck with MS, I'm going to make sure I do everything I can to prevent another chronic disease. That means getting up every morning to exercise, making sure I eat at least five servings of fruits and vegetables every day, and sleeping at least seven hours every night. That means seeing my primary care doctor for screening tests and reviewing new symptoms – that may or may not be due to MS.

 

Despite my best efforts to stay healthy, I still got MS at age 36. Illness can be random and mysterious, but I haven't let it stop me from seeking new challenges, prioritizing preventive care, and doing whatever I can to stay at healthy as possible.

  

 
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Self-Advocacy

As a doctor, I always advocate for my patients. As a person living with MS, now I have to advocate for myself too.

Are you kidding me? Another $749 out-of-pocket… just for lab tests?

 

It was another unexpected medical bill, even more irritating than usual because I had called the lab before the test was done to clarify the cost. The lab had assured me I would pay no more than $200, even if my insurance company failed to pick up the tab...

 

To keep reading, please go to Momentum Magazine's MS blog.

 

 
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Psst... It's a secret: I kind of like Infusion Day

My most recent Infusion Day earlier this month was a calm, relaxing experience. 

Needles, tubes, IV poles. A medicine dripping slowing into my veins.

 

And somehow, I find myself almost looking forward to Infusion Day. It feels almost like - dare I say? - a day at the spa!

 

OK, so I don't like the reason that I have to get the infusion. And getting an IV placed and being stuck in a chair for hours isn't usually part of the Deluxe Autumn Spa Package. I don't enjoy the prep involved either – getting labs drawn, sometimes an MRI, insurance company issues. But I'm fortunate that I don't have any side effects from my medicine. And I've realized the actual infusion day can be kind of great.

 

Getting my infusion every six months is nearly a full-day affair. From start to finish it's a pretty solid six hours. But I have learned to enjoy it (though I don't want to share that too widely, since I still like the sympathy from my family when reminding them, "I have to go in for ANOTHER infusion!").

 

On the day before my infusion (if I remember), I pack my special Infusion Day Kit:

-     Fluffy socks

-     A blanket or warm, cozy sweatshirt

-     Ear buds and music (I have Spotify on my phone, but any music-playing device will work)

-     Snacks/lunch

-     Travel mug (filled with warm herbal tea right before I leave for the clinic)

 

When I get there, I organize my space, placing everything I need within easy reach. Then I sink into the chair. I can relax. I have all day.

 

The room is peaceful. The enormous red chair is super comfy. I listen to spa music, usually acoustic guitar. The interruptions are few (if you don't count the inflation of the blood pressure cuff every 30 minutes).

 

I take a less sedating antihistamine [fexofenadine (Allegra) is best] beforehand rather than the usual Benadryl most people receive. My doctor has let me make that adjustment because I don't want to waste my time sleeping. I bring my laptop and get to work.

 

I work for a national care management company, and I am immensely grateful that I can work remotely, most of the time. I limit phone calls on infusion days, and I often find that my work is more productive than usual with no distractions.      

 

I get up to make tea – or sometimes the nurses get it for me. I take a short break for lunch, or I eat while watching a webinar.

 

I feel a quiet, unstated kinship with the other patients, the other MS Warriors. We are united by hope.

 

At the end of the day, I'm done. No more medicine to take for six months. I've done something important for my health, and now I can try to forget I have MS and move on.

 

 
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I'm on a podcast!

Hiking in Telluride, Colorado earlier this summer. Hiking in the mountains is as good as it gets for me!

A huge thanks to Dr. Errin Weisman for giving me an opportunity to share my story recently on her thought-provoking and informative podcast, Doctor Me First.

 

You can check out my episode, Role-Reversal, and also hear other fascinating interviews with women doctors on topics ranging from "Libido" to "Burn-out" to "Wisdom."

 

Get inspired, and share your comments or feedback below.

 

 
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Lessons from the Road

The morning of Day #2 was The Best! The "Challenge Route" through Buescher and Bastrop State Parks was the highlight of the MS150 ride for me. 

The MS150 pushed me to my limits, connected me with other MS Warriors and supporters, and brought intense highs and lows. I'm so glad it's over. And I'm so sorry it's over.  Here are some lessons from my weekend adventure, biking over 160 miles from Houston to Austin:

 

·         Pickle juice is really a thing. It is packaged and sold. It is a favorite drink along the MS150, available at every break point. It's supposed to help reduce cramps, and hey, it worked for me!

 

·         My mom is Super Woman. She is 26 years older than I am, and I yet I had to tell her – many times - to slow down so I could keep up during the ride. She never complained, never asked to rest, and never stopped inspiring me with her strength and perseverance. I need to buy her a cape!

 

·         I am not alone. Having MS can feel so isolating. Sometimes I feel like no one understands my struggle to live with my symptoms and the burden of uncertainty that MS has brought. But throughout the MS150 weekend, I met so many people who understood. Thank you, Michelle, Audrey, Reese, Mike, Lansing, Kristy, and everyone else who shared their stories or listened to mine and made me feel validated and valued.

 

·         I don't like a flat road. The first 40 miles of the route, through Houston and its suburbs, is devoid of even a slight incline. It's not hard, but it's boring. I prefer the ups and downs. Without riding uphill, you don't get to coast downhill. (I think there may be a metaphor here!)

 

·         Community is everything. The support from my Tacodeli teammates (especially team captain Lisa Steffek) and the MS150 community gave me hope and helped propel me forward. Bates, Cesar, and Luis drove from El Paso to ride with me. Along the route, I wore my "I Ride with MS" jersey like a badge of honor. Dozens of people offered encouragement, often as they whizzed past me on their bikes.

 

·         Setting and then accomplishing a goal feels great! I welcome the sore muscles and exhaustion because they remind me that I worked hard. For the rest of my life, I always want to be reaching towards a new goal, striving to do more. I encourage everyone to set a goal – something tough, but attainable - and Go For It!

 

Finally, I am overcome with gratitude. Thanks to everyone who donated to the National MS Society in support of my ride. (It's not too late to contribute if you still want to support their amazing work: http://main.nationalmssociety.org/goto/Lisa-and-Libby-Doggett.)

 

Thanks, also, for the encouraging texts, emails and well wishes from so many friends. Each one cheered me up - especially two-thirds of the way through Day #1 when I was ready to collapse.

 

I am so fortunate that I could do this ride, and I look forward to the next challenge.

 

Please share your most important goals below. Or if you rode the MS150 (or volunteered or cheered someone on), share your Lessons from the Road in the Comments below. 

 

 

 
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MS150 2019: I am really up for this?

My mom and I recently completed a 63-mile "training ride" during the LBJ 100 Bicycle Tour in the Texas Hill Country.

After months of training - 6 a.m. spin classes at the YMCA, long rides on the Southern Walnut Creek Trail, and the recent LBJ 100 ride in the Texas Hill Country - I am going to do it again: 168 miles from Houston to Austin during the last weekend of April. This will be my second time participating in the MS150, and for much of the time leading up to it, I've been feeling fine: I got this! But….

Now, as the weekend approaches, I am getting scared. Am I really up for this? I was in better shape last year. Even though I didn't decide to ride until five weeks before the race last time, I was running long distances and working out daily. Also, we had ideal weather on the ride last year - it can't possibly be that good again. And - dare I say it? - I'm sick of training! I've been struggling to get out on the trail. It's grueling and time-consuming. I can rattle off a long list of preferable activities.

But I have reason to hope I can do this again. My MS has been cooperating. I had some increased dizziness earlier this year, but it has dissipated. My recent MRI showed "no changes," indicating no disease progression. My cousin Bates, who helped me through every mile of the ride last year, is coming back again with two friends from El Paso to accompany me. And my mom, my most consistent support person throughout the course of my illness, is riding with me. Nine and a half years ago, she walked me up the stairs of my house, after the spinal tap that confirmed my diagnosis and then made me so sick I couldn't get out of bed. She was with me for my first ocrelizumab infusions. Next week, she will depart Houston with me and 9,000 more cyclists, as we head home on our bikes to Austin. She has trained so well that I will be struggling to keep up.

 

Last year, I was proud to join the ranks of the Top 300 Club of fundraisers, raising more than $7,500. This year, I've more than doubled my fundraising. All that financial support, which goes to the National MS Society's amazing research programs, advocacy efforts, and patient navigator programs, will also be a great motivation for me to finish this race. I am so grateful and humbled by the support from so many people who share my vision of a world free of MS. My trepidation will be my secret weapon: I'll finish this race and make you proud.

 

Thanks to all of you who have supported my race and have lifted me up in so many other ways during my difficult moments these last nine and a half years. If you want to learn more about the ride or make a contribution, please see my fundraising page: http://main.nationalmssociety.org/goto/Lisa-and-Libby-Doggett 

 

 

 

 

 
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Preventive Care, Part 3: Immunizations - Fact or Fiction?

 TRUE or FALSE?

·         Vaccines may cause autism – we don't know for sure.

·         Flu shots are overrated and sometimes actually cause people to get the flu.

·         Immunizations contain toxic chemicals that lead to brain damage in children.

·         Vaccines can trigger immune reactions that often cause autoimmune diseases like MS.

·         Vaccines are a government conspiracy to create profits for pharmaceutical companies.

 

FALSE, FALSE, FALSE!


Immunizations are one of the most important advances in public health of all time. Immunizations save lives, reduce hospitalizations and overall health care costs, and improve quality of life. With rare exceptions, they are safe and well-tolerated. The evidence is clear that they do NOT cause autism or brain damage. The risk – if any - of vaccines triggering an autoimmune disease such as MS is very low and outweighed, in almost every case, by the benefits of immunization. Making sure you stay up-to-date with your vaccines is one of the most important ways to stay healthy.

 

Of course, always consult with your doctor about which vaccines are indicated for you. Live vaccines are not recommended for people on certain MS medications, for example. The National MS Society also provides excellent guidance on their website.  Depending on your age and other risk factors, these are the most common immunizations that are recommended:

 

1) Influenza: Flu shots should be given to virtually everyone, at every age, every year. The flu shot takes about two weeks to kick in, and mild side effects can occur. But flu shots do not cause the flu, and only rarely are they contraindicated. Flu shots are safe, and they save lives and prevent hospitalizations. Did I mention flu shots do NOT cause the flu? The CDC is a great source of additional info

 

2) HPV: HPV vaccine helps reduce the risk of many types of human papilloma virus (HPV) infection, which is responsible for nearly all cases of cervical cancer and genital warts. HPV also can cause cancer of the throat, vagina, vulva, and anus.  HPV vaccination is recommended to all girls and boys beginning at 11-12 years old and to men to age 21 and women to age 26. It dramatically cuts the risk of HPV infection and, therefore, HPV-associated cancers. Last fall (Oct. 2018), the FDA approved use of the vaccine for both men and women up to age 45, though studies of effectiveness in this older age group are ongoing.  

 

3) Shingrix: Hurray for Shingrix! Shingrix is the new shingles vaccine, just released in 2017. It is far more effective than the previous vaccine (Zostavax) at preventing shingles and especially its dreaded and painful complication, post-herpetic neuralgia. The CDC estimates that about 1 million people get shingles each year, and about 15% of them continue to have pain two years later. The Shingrix vaccine, recommended for adults beginning at age 50, is a series of two vaccines, separated by two to six months. It is more than 90% effective at preventing shingles. 

 

4) Td and Tdap: Td is a tetanus booster shot, and Tdap is a combination vaccine designed to protect us against tetanus, diphtheria, and pertussis. Rates of tetanus (an often fatal infection caused by spores of bacteria in dirt and animal feces) have fallen >95% since the 1947, largely due to the success of the vaccine. However, sporadic cases still occur. Those who are not vaccinated or have failed to get the recommended booster shots have a higher risk of infection. Pertussis, or whooping cough, is generally more of an annoyance to older children and adults, but it is a particular concern for very young infants, who can die from pertussis. By vaccinating adults - especially those who have contact with infants - we help create herd immunity and protect infants from what can be a dangerous infection.    

 

5) Pneumonia: Pneumonia continues to be a leading cause of hospitalization and death among older adults. An estimated 900,000 people get pneumococcal pneumonia each year, resulting in as many as 400,000 hospitalizations and 19,000 deaths. For adults, two different pneumonia vaccines are available (PPSV23 and PCV13). Each protects recipients against different strains of pneumococcal bacterial infection. The vaccines are recommended for all adults at age 65, but may be given earlier depending on other risk factors (such as having diabetes, asthma, heart disease, cancer, or being a smoker). They cannot stop all forms of pneumonia, but they cut the risk significantly and save lives.    

 

The adult vaccine schedule has become more complicated over the years. (I think the two pneumonia shots are especially confusing!) But your doctor can help determine which immunizations you need. And you should keep track of your immunizations and help remind your friends and family members get their recommended vaccines as well.

 

 

 

 

 
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Preventive Care, Part 2: Isn't having one chronic disease enough?

I finally made it to the beach this week in Puerto Rico. I spent the week skipping out to explore San Juan in between meetings for work. What a beautiful place!

I have MS. Isn't that enough? Haven't I already received my allotted dose of bad luck regarding my health?

 

Unfortunately, those of us with MS are just as likely as anyone else to develop other chronic diseases. Some of us may even be at increased risk, due to adverse effects of certain medicines and the disabling effects of MS itself, making it hard to stay active.

 

Many chronic diseases – like MS - are beyond our control. We can't do anything to prevent them. The causes are unknown, and the course of the disease is uncertain.  

 

But other chronic diseases, including some of the most common and damaging, are often preventable. While other factors, such as genetics and the environment, play a role, in many cases, our lifestyle choices - especially diet and exercise - can doom us to diseases like diabetes and heart failure or significantly improve our odds of a healthy, long life.

 

(Warning: I'm jumping on my soapbox again.) There IS a magic formula to improve longevity and quality of life. It's not trendy or exciting, but I can't emphasize it enough: Find a way to exercise most – or all – days of the week. Eat a well-balanced, mostly plant-based diet. Don't smoke. Don't drink to excess.

 

AND get tested for chronic disease. As with screening tests for cancer, screening for chronic disease can help identify risk factors and detect disease early, when it is usually easier to manage.

 

Heart disease and stroke are still the #1 and #4 causes of death, respectively, in the U.S. High cholesterol, hypertension, and diabetes all significantly increase the risk for both. Diabetes, which now affects 9.4% of the U.S. population – also can cause chronic kidney disease, blindness, and nerve damage and pain.

 

Screening tests are easy to do, and a doctor can order the right tests and help interpret the results. Here are some of the most important tests that are widely recommended:

 

·         Blood pressure checks should be done routinely at each visit with the primary care physician. Nearly 30% of U.S. adults have hypertension, which increases the risk of heart attack, stroke, and chronic kidney disease. Hypertension is sometimes called the "silent killer" because it usually doesn't cause any symptoms, yet it can still lead to significant damage.

 

·         Cholesterol screening is recommended for most men starting at age 20-30 and women starting at age 30-35, though guidelines vary and other risk factors for heart disease and stroke should be considered.

 

·         Diabetes screening should be done, especially since almost a quarter of people with diabetes are unaware of their condition. The American Diabetes Association recommends screening for type 2 diabetes annually in everyone starting at age 45 and in those younger than 45 with major risk factors.

 

·         Bone density tests are used to screen for osteoporosis, a condition that can lead to hip, spine, and other fractures by causing weak bones. Usually bone density tests are recommended for women beginning at age 65, but they may be considered earlier depending on risk factors. Older men may also benefit from bone density testing, depending on age and risk factors.

 

A couple other screening tests to consider include testing for HIV and screening for mood disorders such as depression and anxiety.

 

I'm stuck with a life sentence of MS, and I can't do anything to change that. But I am doing everything I can to avoid additional disease. I hope you'll do the same. Check out this amazing myhealthfinder app to find out exactly what tests may be recommended for you. And please share your stay-healthy strategies in the comments below.

 

 

 

 

 
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Preventive Care, Part 1: What Is More Likely to Kill Me? Cancer or MS?

Cancer screening detects cancer early and saves lives!

MS may cripple or blind me. It may even cut a few years off my life. But odds are much higher that CANCER, rather than MS, will kill me. No question.

 

Most people with relapsing, remitting MS (the most common type) are in a similar position. Many people with other chronic diseases also have reason to fear cancer. It remains a threat to all of us.

 

According to the National Cancer Institute, nearly 40% of us will be diagnosed with cancer at some point during our lives. Cancer remains the second leading cause of death in the U.S. (only heart disease kills more people).

 

Those of us with chronic disease may be at even higher risk of cancer. My MS medication works, in part, by calming down my hyperactive immune system. Is the trade-off an increased risk of cancer? We don't know. My medicine is too new, and the studies just aren't available yet. But I'm a little bit paranoid.

 

So what can we do?

 

A lot, actually:

  • Don't smoke – SO important!
  • Eat fruits and veggies, 5+ servings a day – more is better. Avoid processed and "fast" foods.
  • Exercise most days of the week – more is better.
  • Don't drink excessively (no more than 1 drink a day for women, 2 for men).
  • Get vaccinated against HPV, the virus that causes cervical and other forms of cancer, if you're under 27 (and possibly even if you're 27-45).
  • Stay up-to-date with cancer screening. 

Cancer screening catches cancer early, and it can sometimes detect pre-cancer before it becomes a serious problem. Cancer screening saves lives! Make it a top priority for your health:

 

- For women: Cervical cancer is caused by the HPV virus and can occur even in young women. Pap smears, to screen for cervical cancer, are typically done every 3 years beginning at age 21. HPV testing may be substituted for or done in addition to a pap smear in women ages 30-65 every 5 years. Pap smears can detect cancer early and can save lives. (Cervical cancer screening can usually be stopped for women after age 65, assuming adequate prior screening.)

 

- For women: Mammograms, to screen for breast cancer, are recommended for all women. Guidelines vary and have changed in recent years, but mammograms are usually done every 1 to 2 years starting at age 45 or 50. The doctor can consider your specific risk factors for breast cancer and help make a decision about when to start screening, how often to screen, and when to stop.

 

- For men: Prostate cancer screening for men, usually ages 55-69, is controversial, but recent guidelines recommend weighing the risks and benefits with a physician.

 

- For everyone: Colon cancer screening - via colonoscopy, stool tests, or other methods - is important for everyone, usually beginning at age 50. There are several different options, though the "gold standard" is usually considered to be colonoscopy. Those with a family history of colon cancer should start screening earlier.

 

- For smokers or former smokers: Lung cancer screening – via low-dose CT scan – is an option for smokers or those who have quit in the last 15 years, who are 55-80 years old. Talk to your doctor to discuss the risks and benefits.

 

For more information, check out the U.S. Preventive Services Task Force, Centers for Disease Control, or the American Cancer Society.

 

And do NOT rely on supplements, vitamins, herbs, or magic beans to prevent or treat cancer.

 

Stay healthy and safe, my friends. What are some of your stay-healthy and cancer-free strategies?  Please add your comments below.

 

 

 

 
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Lessons Learned as a Doctor Turned Patient

 

As a family doctor and self-proclaimed health nut, I thought I'd never get sick. Although I saw patients every day with unexpected illness, with the right combination of a vegetarian diet + obsessive hand-washing + exercise + adequate sleep, I thought I would live to be 100. I knew the secret ingredients, the formula, for avoiding chronic disease.

And then, nine years ago, I woke up dizzy. I thought I was getting a cold that would pass in a few days. But instead of a sore throat and cough, I developed double vision and taste changes.

 

My MRI showed white spots; my spinal tap showed oligoclonal bands. I had MS.

Suddenly, I was no longer the physician, but the patient. I was the anxious woman sitting in waiting rooms, arguing with insurance companies, struggling to understand my doctor's instructions through a foggy, MS-induced haze. The tables were turned, and I hated it. MS, it seemed, was a thief; it had stolen my future, my certainty of health. I was angry. I still am angry.

 

(To keep reading, please go to the National MS Society's Momentum Blog.)

 

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A New Year's Resolution That Could Save Your Life

I try to practice what I preach: This is me yesterday on a morning bike ride in east Austin. Staying fit is one of the most important ways to prevent chronic disease.

RESOLVED: I will catch up on preventive care in 2019!

 

Ugh! Another doctor's visit? More stuff to worry about? More tests and blood work and exams? Groan…

 

Yes, indeed. But your health is worth it! Hear me out.

 

As we consider goals and resolutions for the new year, I want to urge everyone to prioritize health, and especially preventive care. For those of us with MS or other chronic disease, preventive care is often overshadowed by more pressing matters: MRIs, labs related to our medications or chronic condition, visits with specialists.   

 

But preventive care - from screenings for cancer, diabetes, and depression to immunizations, exercise, and even family planning - is important for all of us. While I don't believe a yearly head-to-toe physical exam is necessary for everyone, regular visits with a trusted primary care physician (usually every one to two years, depending on age, health status, and risk factors) is a good idea.  (See more of my thoughts here about the frequency of doctor's visits: https://www.rd.com/health/wellness/doctor-checkup-visits-guidelines/)

 

Over the next several weeks, I'll be writing additional blog posts with details about various aspects of preventive care. But to get started with a healthier new year, I recommend scheduling an appointment with your family doctor or internist to talk about your health-related goals, review recommended screening tests for cancer and chronic disease, and update your immunizations.

 

Here are some priorities for a healthier new year:

 

1)     Catch up on your health screenings: Staying up-to-date with screening tests for cancer and chronic diseases, like diabetes and hypertension, is very important and may even save your life. For all women, testing for cervical cancer (age 21 and up) and breast cancer (usually starting around age 45 or 50) is strongly recommended. All adults also should be screened for diabetes, HIV, high cholesterol, and other conditions, depending on your age and risk factors.

 

2)     Get immunized! Immunizations are not just for kids; they are important for adults of all ages. A flu shot is recommended for everyone, every year. Flu shots do not cause the flu, and there are few contraindications. Tetanus shots are given every 10 years. (One of those should be a TDaP). The new Shingrix vaccine is recommended at age 50 to prevent shingles. Two pneumonia vaccines, PPSV23 and PCV13, are recommended at age 65 (generally separated by a year) but may be given sooner depending on other health conditions and risk factors.

 

3)     Review your family planning/contraceptive choices: If you are of childbearing age, discuss family planning and contraception with your partner and physician. Ask yourself, do you want more children? Are you at risk of an unplanned pregnancy? Ask your doctor, "What are the different options for contraception, and what might make sense for me?" If you want to delay having more kids, ask, "At what point do I risk not being able to conceive? What are the other risks I might face by waiting?" (A huge issue today is that women are delaying having kids until it is often too late. Asking the right questions early may help avoid this problem).

 

4)     Exercise! Exercise has to make the list for anyone trying to lead a healthy life because it is SO important! Developing a daily (or almost daily) exercise routine can do more to improve health than any medication. Talk to your doctor, and set a goal: most authorities recommend at least 30 minutes of moderate-intensity exercise most days of the week. I like to exercise first thing in the morning before my kids get up and before another activity gets in the way. It's a great way to start the day, leaving me with more energy and a sense of accomplishment. Make exercise fun with a good workout mix, fun group class, an audiobook, or exercising with a friend.

 

Preventive care should be a top priority for everyone, adding quality and longevity to life.  What do you think are the most important ways to stay healthy this year? Add your comments below.

 

 

 

 
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The Diagnosis, and the First Year After

Near Santa Fe, New Mexico

Instead of a new blog posting this week, I'd like to refer you to two Quora posts I wrote recently about my diagnosis with MS and the year afterwards. 

 

I answered two questions:

1) How would you react if you were diagnosed with multiple sclerosis: https://www.quora.com/How-would-you-react-if-you-were-diagnosed-with-multiple-sclerosis

 

2) How was your first year after your multiple sclerosis diagnosis: https://www.quora.com/How-was-your-first-year-after-your-Multiple-sclerosis-diagnosis

 

If you like my answers, please upvote them on Quora. And please share your own experiences, questions, and comments below. 

 

 

 

 
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New Year's Resolutions or Reflections?

Artwork by Clara Williams (age 11)

I don't usually make New Year's resolutions. If I decide I need to change something in my life, I'll try to change it, no matter what time of year it is.

 

But, with the hecticness and stress of Christmas behind me, and a quieter week at home and work, I do find that the end of the year and the beginning of the new one are well-suited for reflection.

 

Several years ago, Don and I attended a mini-retreat about how to have "the best year yet." While I found it a little overhyped, one useful recommendation I carried away from that day is to review the year that has passed – alone or with a friend or partner – and consider what worked and what didn't, what lessons can be learned.

 

I am starting to do that now for 2018. Ok then…

 

What worked?

- Visiting friends around the country

- Traveling to well-appointed destinations

- Biking the MS150

- Starting dance classes for our older daughter; continuing swimming and rock climbing for the younger one.

 

My MS medicine, with its requisite infusions every six months, is tolerable with no noticeable side effects. It seems to be preventing progression so far.

 

What didn't work?

- Sending my daughter back to a middle school she didn't like

- Overscheduling myself and everyone else.

 

What have I learned?

- Don't be excessive with summer travel; staying in town for a few weeks will be OK.

- Connecting with others with MS is reassuring and empowering – I'm looking forward to more activities and involvement with the National MS Society this year.

- Prioritizing fun and family time leads to a happier life!

 

Perhaps the most important lesson of the year has been to leave room for the unexpected.  My father-in-law spent many weeks of 2018 in the hospital. A dear friend's child became very ill, and my friend asked for my help. My daughter had to switch middle schools only two weeks after starting 8th grade. I can't plan or prepare for everything, and I need to be limber enough to shuffle schedules, prioritize, and jump in when I'm needed.  

 

After rehashing the past year, I consider the year ahead. I try to think big (but be realistic) and set goals. Here are some of mine:

- Ride the MS150 again, this time with my mom.

- Learn about and experiment with vegan baking.

- Plan and execute a fun, enriching, and exciting summer for my kids.

- Read more books.

- Help my kids transition to new schools in the fall (one will start middle school and the other will begin high school).  

 

Share some of your goals in the comments below. For extra help, check out this article by The Invisible Mentor and consider investing in a copy of Your Best Year Yet  by Jinny Ditzlerthis. Here's to a happy and healthy 2019!

 

 
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The Most Wonderful Time of the Year?

Those two lumps are my kids who were both sick - with different illnesses - on the same day recently.

Does anyone else want to scream every time you hear that now, right now, is The Most Wonderful Time of the Year?

 

My response: Really? God, I hope not!

 

My younger daughter has been sick for 10 days, with fevers to almost 105 degrees. She missed seven and a half days of school, was seen in the ER, and then saw three different specialists this week.

 

Here are some memorable tidbits from the last week and a half (all are me speaking to my daughter):

 

-          "If you think you're going to throw up before I can pull over, throw up in your jacket, not all over the car."

 

-          (On the phone, after making a special trip to the grocery store) "They don't have cherry or blue raspberry popsicles. Do you want strawberry, mango, lime, or pineapple? . . . No? OK, well I guess I'll just come back home [empty-handed]."

 

-          "I know you can't sleep, but it's 1:00 in the morning, and I would like to sleep. Can you please, please, please just stay in your room and do a quiet activity?"

 

-          (Shouting across the house) "The remote control is two feet away from you. Do you really need to me to come in there to hand it to you?"

 

My daughter didn't want to miss the expedition to get our Christmas tree last weekend, but then she spent most of the time in the car, crying to go home.

 

My older daughter was sick too – with a different illness – and missed two days of school this week.

 

My father-in-law just left the hospital after a three-week admission. We spent part of Thanksgiving Day touring nursing homes.

 

The most wonderful time of the year?

 

The weeks preceding Christmas are some of the most difficult of the year. I sound like the Grinch, but the notion that everything should be joyful and perfect right now sets up unrealistic expectations.

 

My dizziness – my main symptom of MS - has been acting up this week, probably because I'm stressed and sleep-deprived. Chronic disease doesn't pause for the holidays. We still have to take our medicines and battle fatigue and struggle with bodies that don't want to do what we tell them to. PLUS, we have to shop and plan and cook and send holiday cards.

 

All this forced cheerfulness is draining.

 

I know I'm not alone. Many of my patients over the years have faced terrible loneliness and depression during December. The message everywhere seems to be "If you're not blissfully happy and surrounded by loving friends and family, there is something wrong with you."

 

Maybe there's something wrong with that message instead.

 

Well – I gotta run. Did I mention that we are hosting 60 people tonight for a holiday party?  

 
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Take a Break!

Exploring Meow Wolf in Santa Fe with my 3 lifelong friends. From left to right: Me, Hannah, Laura, & Rachel 

I don't take breaks. I spend my mornings, afternoons, and evenings racing around like I'm competing in a track and field event. Get up – exercise (while reading materials for work) – get kids to school – work, work, work. I don't stop for more than two to three minutes for a meal – just to heat something up or throw together a salad. If I have a doctor's appointment or an infusion day, I bring my laptop and just keep going.

 

I pack my schedule like an overstuffed suitcase. I strive to be a master of efficiency, and I don't want to miss out on anything. Since I was diagnosed with MS, I'm even more aware of time slipping away. Who knows how long I'll be able to exercise, or get the kids to school, or work? I need to do everything now because I don't know how long now will last.

 

The problem, of course, is that I do miss out. All the details, the time to breathe, the time to be present with my friends and family. I am too busy racing to the next thing on my list.

 

I recently was introduced to the concept of PREcrastination. The term seems to be defined in different ways, but I discovered I am the type of precrastinator who puts off breaks and fun until all unpleasant and difficult tasks are accomplished. (And that happens when?) Although I pride myself on not procrastinating, I now realize that I am a skillful precrastinator.  

 

But this weekend I took a break. I put my life on hold for three short days to escape with friends to Santa Fe, New Mexico. One of the great blessings of my life is that I have three friendships that have endured since about the time I learned to read. My friend Hannah – a fellow MS Warrior – and I were born four months apart and have been friends since before we could talk. My other two friends who joined us in Santa Fe, Rachel and Laura, were close friends with Hannah and me in elementary school. Our lives have taken different paths, and we had not all been together in 17 years.  

 

We spent the BEST weekend together. Our hikes were long, but leisurely. We looked for rocks, noticed the light on the aspen trees and the lone bright yellow flower next to the path. We admired the stars, unencumbered by the light pollution of a big city. We packed in a lot – including visits to Meow Wolf (a crazy, interactive art exhibition) and a trip to the spa. I did have a seriously overstuffed backpack – unusually heavy with my new rock collection - to carry home.

 

I arrived back in Austin to a messy house, piles of laundry, unanswered email, stacks of regular mail. I needed to go grocery shopping and plan the week. But that break - and reconnection with my oldest friends – was so rejuvenating that the catch-up has been OK.  I need to do it more often. I need to take shorter breaks during the day – to meditate or stretch or take a walk. I need to see friends more often, to disconnect from media and technology in order to connect with the people I love. Please join me in taking more breaks and share your experience below.

 
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Stop telling me to vote!

Block walking with my new friend Mayra from Workers Defense

Stop calling me! I don't need another reminder to vote.

 

What? I have 28 NEW email? I just deleted everything like 15 minutes ago. Oh right – more pleas for money and volunteers.

 

So now you're texting me? I just donated 30 minutes ago, and now you want more? How about some gratitude?

 

 

These are all election-related thoughts I've had over the last few weeks.

 

But even though I'm irritated, I am relieved that others are so dedicated to keep calling/texting/stopping by/emailing.  It feeds my underlying guilt that I need to do more, more, more, but each interruption is still a little bit of hope.

 

My overwhelming stress/concern/frustration is that we are so close in Texas – and many other parts of the country – to making change happen in a big way next week. But we can only do that if people vote. I'm worried they won't. I'm worried they will be too disconnected, disengaged, cynical, hopeless, angry, and disempowered.  I hope I'm wrong.

 

I am from a political family – VERY political. My dad was elected to the Texas State Senate when I was 11 days old. He has spent his entire career in public service; I have spent my entire life supporting that career. We didn't go to baseball games or on camping trips when I was a kid. Instead, I rode with my dad in parades, went to fish fries and barbeques, shook hands at fundraisers, and smiled through long speeches. My dad is running for Congress again now, and I couldn't be more proud of his incredible tenure in the U.S. House. Elections are a very big deal for my family – our Super Bowl, our Academy Awards, but with much more at stake than a game or awards ceremony.

 

Now I also look at this election from the perspective of a patient. And the "elections don't matter" argument, espoused by many non-voters, now makes me madder than ever. Those of us with chronic disease are especially vulnerable to the whims of our leaders and special interests – the big pharmaceutical companies, the health insurers. In the next couple of years, decisions by those leaders could matter A LOT to people like me:

 

· They could make it hard or impossible for those of us with preexisting conditions to get health insurance.

· They could rein in the cost of prescription drugs, or they could continue to let them go unchecked. (Drug costs for MS routinely surpass the $60,000 mark per patient per year!) 

· They could restrict or allow access to certain medications that help people with MS.

· They could require reasonable quality standards for health insurance plans or allow junk plans to be sold.

 

Other issues are at stake too, like global warming – and our government's terrifying refusal to adequately recognize and address it. The consequences of climate change will soon touch nearly every living thing on this planet. I am not exaggerating or fear-mongering; we are on the brink of a point-of-no-return disaster with our climate. 

 

Public education, immigration, gun violence, workers' rights, poverty, the racial divide – these only scratch the surface of the issues that will be impacted by the outcome of this election.

 

Yesterday, I was honored to join a group from Worker's Defense in South Austin to block walk, urging everyone to get to the polls. This time I was the one interrupting people from their Saturday morning routines, annoying some and hopefully motivating others. On Election Day, November 6, I'll make phone calls to remind folks to get to the polls. This election is critically important for me, for my kids, for our community, and for everyone.

 

Please share what you're doing to help get out the vote and to support your chosen candidates during the next week. For more info and voting resources, check out VOTE411 or any number of other online resources.

 

And if someone knocks on your door to ask for your vote or remind you to cast your ballot, be friendly, and thank them for stopping by.

 

 
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Eat Your Veggies: Sneaky ways to add more to your diet

Here's my plot in the community garden last winter - a great source of veggies for my family. (I'm hoping soon the new fall/winter garden will look this good.)

FIVE servings a day of fruits and vegetables. MINUMUM. That's a pretty universal recommendation from nutrition experts. Yet, only one in 10 U.S. adults eats enough, according to the Centers for Disease Control. A plant-based diet, with lots of fruits and veggies, is one of the best ways to prevent cancer, heart disease, diabetes, and many other chronic diseases. Replacing less healthy options with fruit and vegetables can help people lose weight and keep it off. But it can be tricky to fit in those servings, especially if you're not used to it. Here are some ideas, especially to add more veggies to your diet:

 

1)      Eat more salad: These days salads are not just tasteless iceberg lettuce and tomatoes tossed with a store-bought dressing. With the right ingredients, salads can be exciting and make for a very satisfying entrée. Mix together different kinds of greens with whatever other veggies look fresh or in-season. Toss in nuts or beans. Add fruit – fresh or dried. Add a little olive oil and balsamic vinegar (no need to buy dressing), and voilà: you have a great meal with three to four servings of veggies.

 

2)      Choose veggie-centered soups and stews: With cooler weather coming, stews and soups can double as comfort food and healthy entrées or starters. When choosing a soup or stew in a restaurant or selecting a recipe to make at home, choose one with a lot of veggies. Go light on the cream and butter. Look for recipes with great combinations of colorful vegetables; you'll easily meet the serving recommendations and get lots of important vitamins and nutrients in the process.

 

3)      Grab a bowl: Bowls filled with veggies, sometimes with grains, beans, and/or an egg, have become popular over the last few years, and they are a great way to add veggies to the diet. Combinations like quinoa with roasted Brussel sprouts, broccoli, carrots and avocado, maybe sprinkled with toasted pumpkin seeds or pecans, can be a delicious way to get more veggies in the diet.

 

4)      Go vegetarian: You may not want to give up meat altogether, but choose at least one day a week to try out life as a vegetarian. Consider joining the movement for Meatless Mondays, for example.  It may help you shift your focus from seeing meat as the centerpiece of the meal and come up with more creative – and healthy – veggie-centered alternatives. Check out this great article from The Guardian on how a plant-based diet also helps the planet!

 

5)      Snack on veggies: Baby carrots, cucumber slices, or celery sticks make great snacks, and are much healthier than chips or cookies. Keep some handy in the refrigerator along with hummus or a healthy dip.

 

6)      Try baked sweet potatoes: Yams or sweet potatoes are far more nutritious that regular white potatoes. They also make a satisfying and healthy entrée, especially when stuffed or topped with other veggies like green peas, beans, or roasted peppers.

 

7)      Fill a tortilla with veggies: In my hometown of Austin, Texas, we live and breathe tacos. Tortillas filled with veggies are my favorite. Try black beans with sautéed spinach and mushrooms or carrots and broccoli. Pour on the salsa and add some guacamole for even more veggie goodness.

 

8)      Smoothies! I know this article is on veggies, but fruits are great too. A super easy way to get in three to four servings is by making smoothies in the blender at home. With frozen bananas as a base, add other in-season fruits and milk, juice, or a non-dairy alternative; mix; and you're left with a delicious healthy beverage, which can even work as an entrée for any meal. I sometimes throw in veggies with the fruit too: frozen kale stems (from my garden) are my favorite.

 

Share your ideas below. Adding more veggies to your diet is an excellent way to improve your health and feel better.

 

 
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Celebrate Autumn: Healthy Tips for a Fabulous Fall!

Barton Springs Pool, Austin, Texas

I just returned from Barton Springs Pool, the iconic spring-fed swimming pool, 1/6 of a mile from end-to-end, just across the lake from downtown Austin. We had a short break in the rain and decided to visit that magical spot for a short swim and meet-up with visiting friends. Summer is still going strong here in Texas, and the only signs that fall are coming are the pumpkins starting to pop up at local grocery stores.

But other parts of the country are experiencing the first signs of autumn, and soon it will be here too. I can't wait!

 

Here are some tips to make the most of this beautiful season:

 

1)     Catch up on your health screenings: Checking in with your primary care doctor may not be your top priority, and it's easy to put off, especially if you're healthy or if you already see a specialist regularly for a chronic condition. But staying up-to-date with screening tests for cancer and chronic diseases, like diabetes and hypertension, is very important and may even save your life. Fall is a great time to see your doctor, who is probably back from summer vacation and open for business. For all women, testing for cervical cancer (age 21 and up) and breast cancer (usually starting around age 45 or 50) is strongly recommended. Women with risk factors, some men, and all women by age 65 should be screened for osteoporosis. All adults also should be screened for colon cancer (usually beginning at age 50), HIV, high cholesterol, diabetes, and other conditions, depending on your age and risk factors.

 

2)     Get immunized: Immunizations are not just for kids; they are important for adults of all ages. A flu shot is recommended for everyone, every year, and the vaccines are available nowl. Flu shots do not cause the flu, and there are few contraindications. Tetanus shots are given every 10 years (One of those should be a TDaP). The new Shingrix vaccine is recommended at age 50 to prevent shingles (even for those who received the previous shingles vaccine called Zostavax). Two pneumonia vaccines, PPSV23 and PCV13, are recommended at age 65 (generally separated by a year) but may be given sooner depending on other health conditions and risk factors. 

 

3)     Take precautions to stay healthy: Respiratory viruses are common in the fall and winter. Do what you can to avoid getting sick. Vitamin C and echinacea don't work. I wish they did, but studies do not show that they are any better than placebo. But eating a health diet, getting enough sleep, and especially washing your hands regularly will help keep you from picking up an infection.

 

4)     Enjoy cooking again: In the summer, I'm not excited to spend time at the stove or to turn on the oven when it's already 100 degrees outside. But in the fall and winter, cooking can be pleasant and comforting. I love finding healthy, vegetable-packed soup recipes, roasting veggies, or making a big pot of risotto.

 

5)     Plan early for the holidays. I feel like the holidays sneak up on me every year and are a huge source of stress. Planning ahead can help. Book plane tickets now if you're plan to fly somewhere over the holidays. Consider shopping early to avoid a big rush at the end (and talk to friends and family about cutting back or giving nonmaterial gifts). Be careful to avoid overscheduling or raising expectations too high.

 

6)     Exercise! Developing a daily (or almost daily) exercise routine can do more to improve health than any medication. With cooler weather coming, sometimes that routine may need a little adjustment. In cooler climates, you may need to move your exercise indoors (or in Texas, I can move back outdoors!). Most authorities recommend at least 30 minutes of moderate-intensity exercise most days of the week. I like to exercise first thing in the morning before another activity gets in the way. It's a great way to start the day, leaving me with more energy and a sense of accomplishment. Make exercise fun with a good workout mix, fun group class, an audiobook, or exercising with a friend.

 

For more suggestions, I found a great article from Reader's Digest.

 

What are some of your favorite fall activities or suggestions for staying healthy?

 

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