The health and wellness blog by Dr. Vik Ahluwalia covers a wide range of topics related to common health issues and conditions. Read more for tips and advice about living a full, well-balanced life! 

 

 

Sleepytime Tips That Sidestep the Drug Store

 

Sleep struggles are common among adults. Often, these struggles result from work-related stress. This is especially true for those in leadership roles. As ZenBusiness notes 86% of those in managerial roles report being extremely to moderately stressed at work. Other stressors, such as financial problems, raising children, and certain conditions like ADHD and anxiety can make it even harder to settle in after a long day. 

 

While some supplements, like melatonin, can help, there are plenty of other ways to convince your brain and body to shut down for eight hours. Here are a few tips, presented by Dr. Vik Ahluwalia, that may help you get to sleep faster and remain in a restful state the whole night through. The best part is that there are no potentially harmful prescriptions required!

 

Eat a healthy snack.

 

Most experts recommend forgoing a heavy meal right before going to bed. But, the right snack will keep you full and may even help your brain produce hormones that make it easier to sleep. One example: almonds. According to lifestyle blog Healthy Way, almonds have magnesium, tryptophan, calcium, niacin, and protein — each of these nutrients promotes sleep. Don’t like almonds? Talk to a nutritionist about other wonderful foods that offer similar benefits.

 

Listen to soothing music.

 

Music has the power to change a mood instantly, but so do other sounds. Plan to listen to soothing tunes or nature noises as you settle in for the evening. If you’re worried about bothering a roommate or bed partner, a pair of earbuds are a great addition to your tech collection. For those of you that sleep alone, a sound machine with a timer is an excellent piece of technology to add to your arsenal. Couple either of these with a dimmable set of LED light strips, and you can instantly change the mood of your bedroom to promote healthy sleep.

 

Turn down the temperature. 

 

The human body is programmed to work in 24-hour cycles. We naturally get sleepy as the night sky and cooler evening temperatures take over. According to the New Haven Register, lower temperatures inside of your home may help you fall asleep faster. Plus, a great night of sleep may help keep your weight in check while lowering your risk of certain metabolic dysfunctions.

 

Try yoga.

 

Yoga is more than just a trendy opportunity for housewives to get together at 10 AM on a Tuesday. It is an ancient and revered form of exercise that helps you get connected with your mind and body. A few simple stretches are all you need to get started.

 

Get intimate with your partner.

 

We all know that sex is an important part of a healthy relationship. But, it is also an excellent avenue by which to get yourself to sleep. When you engage in intimate acts with someone you love, your brain automatically releases serotonin, dopamine, and oxytocin. All of these hormones, like melatonin, encourage the body to go into a state of total relaxation.

 

Cozy up under a weighted blanket.

 

No partner? No problem. You can get some of the same benefits by using a weighted blanket. A weighted blanket wraps you in warmth and pressure, much like a hug. According to Penn medicine, this type of pressure therapy can induce a sense of calmness and help alleviate sleep disorders, which affect up to 70 million adults each year.

 

You don’t have to rely on potentially harmful prescription medicines to help you get to sleep. A few simple changes to your home, such as turning down the temperature and adding a weighted blanket to your bed, and activities, like having sex or doing yoga, may be just what you need. Try the above tips and you may soon enjoy sleep no matter how elusive it’s been in the past.

June Duncan

 

Image via Pexels

 

How You and Your Family Can Plan for the Transition to Long-Term Senior Care

Decisions about long-term care for yourself or for a loved one are never easy. But sooner or later, these decisions will need to be made. And when you are faced with this necessity, things will go more smoothly for all concerned if you’ve planned carefully and had the difficult conversations in advance. So, tempting though it might be to put off worrying about long term care options, consider making a plan and setting a budget well in advance of the time when care will be needed. This will be easier on your finances and less of a strain on familial relationships. And above all, it will reduce stress for the individual facing this major life transition.

What should you talk about when you plan for long-term care?

Getting the conversation started can be the most nerve-wracking part, especially for caregivers concerned about causing anxiety for a senior loved one. Sometimes caregivers may feel guilty or second-guess themselves as they begin the conversation about long-term care options. It’s important to remember that seeking more comprehensive or specialized care for a senior loved one is not a failure on your part. It means you are putting their needs first.

It can be helpful for all parties concerned to discuss what kind of timeline they anticipate before more extensive care will be needed. Are there any health factors that need to be taken into consideration, such as existing ailments or possible hereditary illnesses? What changes can be made now to make a senior family member’s present living situation safer or more comfortable?

Caregivers should respect the needs and the wishes of their senior family members. It’s important to listen when they express worries about their future and to take their lifestyle preferences seriously. Seniors should not be afraid to ask family caregivers to help them do research into what care options are available to them. Some seniors may require only occasional assistance in a more user-friendly residence. But others may need daily attention and medical or memory care.

What financial concerns are associated with transitioning to long-term care?

Making a lifestyle change of this magnitude can be overwhelming. Add the financial concerns associated with moving to long-term care, and it’s clear why this topic can be so fraught for families. This is another reason why it’s important to initiate the conversation well in advance of any move: so you and your family can budget for your long-term care needs.

Some cost considerations include medical expenses, the cost of care facilities, and the length of time one anticipates using those facilities. Assess all likely costs you anticipate. Then, look at what finances you have to work with, from savings and retirement or from any sustainable passive income sources. This will help you determine both what you can afford and whether you need to access more funding. Also make sure you have accurate information about what your insurance will or will not cover when it comes to senior care and any additional medical needs. Medicaid and long-term care insurance will cover many services, but some types of insurance will not.

Likely you will already have discussed your plans for your existing home. If you need additional funds to transition to long-term care, selling your home might be a good option, depending on what you are likely to get for it on the current market. Have a realtor take charge of the busy work if you do opt to sell your home so you don’t end up exhausting yourself on organizing showings and keeping up on paperwork.

This can be an emotional time for you and your loved ones, so remember to be gentle with yourselves, respect one another’s needs, and practice self-care when needed. Family caregivers, also make sure your senior loved ones have access to self-care resources. Follow Dr. Vik Ahluwalia’s Health and Wellness Blog if you are interested in learning more about general wellness for you and your loved ones. 

June Duncan

Image via Pixabay

Vertigo, Balance and Fall Risks In Our Senior Population.

This article is actually my response to a health reporter query on vertigo to be published soon. That's why it differs from my usual writing style as I am actually answering the reporters questions.

-What are the causes of vertigo in seniors? Is this a condition that commonly develops with age? Is it lifestyle-related, hereditary or a combination of the two?

Vertigo is a sensation of whirling and loss of balance, associated particularly with looking down from a great height, or caused by disease affecting the inner ear or the vestibular nerve.  Patients have different experiences and symptoms.  Some say, they feel unsteady, someone else would explain it in visual terms like they are spinning.  Both dizziness and vertigo can be caused by a wide variety of things including being sick, blood pressure disorders, or blocked ears.(1)

Dizziness is common in elderly people; 30% of people older than 65 years experience dizziness in some form,[1–4] increasing to 50% in the very old (older than 85 years).[1]  It can be caused by a wide range of benign or serious conditions.[5,6] In 20% to 40% of dizzy patients in primary care, the underlying cause remains unknown.[7–9](2)

Symptoms of a sense of lightheadedness or disorientation (dizziness) and/or a mild to violent spinning sensation (vertigo) can have a variety of causes: vestibular (inner ear) disorders, central nervous system disorders (such as stroke), cardiac problems (including low or high blood pressure), low blood sugar, infection, hyper-ventilation associated with anxiety attacks, medication side effects or interactions between drugs, or an inadequate or poorly balanced diet. A thorough evaluation by a physician is usually necessary to help sort out these different possible causes and arrive at a correct diagnosis. This task can be even more complicated when multiple problems are present. In such cases, the trouble in any one system may not be severe, but the combined effects may be enough to cause a serious problem with balance. For example, an elderly individual with arthritis in the ankle joints and a mild degeneration in vestibular function may be able to balance adequately until under-going an operation to remove cataracts. The disturbance in vision during the healing process and the adjustment to the new glasses or contacts may then be sufficient to result in imbalance and falls.

Specific vestibular disorders in older adults

Of all vestibular disorders, benign paroxysmal positional vertigo (BPPV) is one of the most common in older adults. BPPV causes vertigo, dizziness, and other symptoms due to debris that has collected within a part of the inner ear. This debris, called otoconia, is made up of small crystals of calcium carbonate (sometimes referred to colloquially as “ear rocks”). With head movement, the displaced otoconia shift, sending false signals to the brain and causing dizziness or vertigo.

Symptoms of BPPV are almost always precipitated by a change in head position. Getting out of bed and rolling over in bed are two common “problem” motions. Some people feel dizzy and unsteady when they tip their heads back to look up.

Ménière’s disease is another vestibular disorder that causes dizziness. Ménière’s disease produces a recurring set of symptoms as a result of abnormally large amounts of a fluid called endolymph collecting in the inner ear. These symptoms typically include spontaneous, violent vertigo, fluctuating hearing loss, ear fullness, and/or tinnitus. The incidence of Ménière’s disease is generally known to increase with age.

Other vestibular disorders that may occur in older adults include vestibular neuritis (inflammation of the vestibular branch of the vestibulo-cochlear nerve, resulting in dizziness or vertigo but no change in hearing) and ototoxicity (exposure to certain chemicals that damage the inner ear or the vestibulo-cochlear nerve, which sends balance and hearing information from the inner ear to the brain). Ototoxicity can result in temporary or permanent disturbances of hearing, balance, or both

Most people are familiar with the problems associated with the aging of senses such as vision and hearing. However, the vestibular system is another sensory system that can also begin to function poorly with age, leading to a diminished quality of life.

The vestibular system is a complex structure of fluid-filled tubes and chambers that constitutes part of the inner ear. Specialized nerve endings inside these structures detect the position and movement of the head and also detect the direction of gravity. The signals sent from the nerves of the vestibular system are critically important to the brain’s ability to control balance in standing and walking and also to control certain types of reflexive eye movements that make it possible to see clearly while walking or running

.

-What are the main dangers of vertigo, particularly for the aging population? Is vertigo the kind of ailment that, if severe enough, would force someone to move into some type of assisted living situation?

-Likewise, what are some harm-mitigating steps for people who already have vertigo?Is the condition progressive, and can its progression be slowed through certain healthy habits?

One of the leading health concerns for people over the age of 60 is falling, which is often related to balance problems. Because, balance is a complex function, there is often no single identifiable cause of falls in an elderly person. However, older people with chronic dizziness or imbalance are two to three times more likely to fall in comparison with older people who do not experience these problems.  Each year, between 20 and 40 percent of adults over 65 who live at home fall. The consequences of falls can be disastrous; between 12 and 67 percent of elderly adults who fracture a hip die within one year. As a result, major scientific efforts are devoted to determining the causes of falling in older adults in an attempt to reduce this significant health hazard.

Balance in walking and standing is dependent on many factors. Good balance requires reliable sensory input from the individual’s vision, vestibular system (the balance system of the inner ear), and proprioceptors (sensors of position and movement in the feet and legs). The elderly are prone to a variety of diseases that affect these systems, including cataracts, glaucoma, diabetic retinopathy, and macular degeneration, which all affect vision; diabetic peripheral neuropathy, which affects position sense in the feet and legs; and degeneration of the vestibular system.

Balance is also dependent on good muscle strength and joint mobility. A sedentary lifestyle and arthritis or diseases of bones and muscles can compromise strength and mobility.

-What are some preventative steps seniors and even pre-retirees can take to prevent the onset of vertigo?

Although the problem of imbalance in older persons can be complex, there are a few simple precautions that everyone can follow to help ensure an active old age. Balance in standing and walking is at least partly a skill that older adults can learn to maintain and/or improve, and it is dependent on good general physical condition. Therefore, sound nutritional and health habits—including regular exercise can go a long way toward preventing balance trouble.

In older people, a regular physical examination by a doctor familiar with the problems of aging can help identify and correct potential problems before a serious fall. In addition, making sure that the elderly person’s environment is safe (with good lighting, secure footing, clear walkways, handrails and anti-skid devices in bathrooms, etc.) can help prevent falls and their attendant injuries.

The elderly have a higher risk of contracting many different kinds of diseases. As a result, the average elderly person is more likely to have a disease that interferes with balance than a younger person. A tendency to fall and symptoms of dizziness should not be dismissed as unavoidable consequences of aging but may be important signs of a disease that might be cured or controlled. The vestibular system should not be ruled out as a source of these symptoms.

The ability to move about freely is an important factor in the quality of life for both younger and older people, and a healthy vestibular system is vitally important to freedom of movement.

- See more at: http://vestibular.org/node/10#sthash.TXxPdTZL.dpuf

 How is Vestibular Neuritis and Labyrinthitis Treated?

Acutely, vestibular neuritis is usually treated symptomatically, meaning that medications are given for nausea (anti-emetics) and to reduce dizziness (vestibular suppressants). Typical medications used are "Antivert (meclizine)", "Ativan (lorazepam) ", "Phenergan", "Compazine", and "Valium (diazepam) ". When a herpes virus infection is strongly  suspected, a medication called "Acyclovir" or a relative may be used. When a circulation disturbance is suspected, an agent that reduces the likelihood of stroke may be used.

Acute labyrinthitis is treated with the same medications as as vestibular neuritis, plus an antibiotic such as amoxicillin if there is evidence for a middle ear infection (otitis media), such as ear pain and an abnormal ear examination suggesting fluid, redness or pus behind the ear drum. Occasionally, especially for persons whose nausea and vomiting cannot be controlled, an admission to the hospital is made to treat dehydration with intravenous fluids. Generally admission is brief, just long enough to rehydrate the patient and start them on an effective medication to prevent vomiting.

It usually takes 3 weeks to recover from vestibular neuritis or labyrinthitis. Recovery happens due to a combination of the body fighting off the infection, and the brain getting used to the vestibular imbalance (compensation). Some persons experience persistent vertigo or discomfort on head motion even after 3 weeks have gone by. After two-three months, testing (i.e. an ENG, audiogram, VEMP, and others) is indicated to be certain that this is indeed the correct diagnosis and a referral to a vestibular rehabilitation program, may help speed full recovery via compensation.

 Steroids (prednisone, methylprednisolone or decadron) were previously suggested. Strupp and others (2004) reported that steroids (methylprednisolone for 3 weeks) significantly improved the recovery of peripheral vestibular function in patients with vestibular neuritis, while valacyclovir did not. However, a meta-analysis of 4 similar studies concluded that all studies suggesting improvement had significant methodological bias, and that there is currently insufficient evidence to recommend use of steroids for treatment of vestibular neuritis (Fishman et al, 2011).

How might vestibular neuritis affect my life ?

You will probably be unable to work for one or two weeks. You may be left with some minor sensitivity to head motion which will persist for several years, and may reduce your ability to perform athletic activities such as racquetball, volleyball and similar activities. After the acute phase is over, for a moderate deficit, falls are no more likely than in persons of your age without vestibular deficit (Herdman et al, 2000). Persons in certain occupations, such as pilots, may have a greater long term impact (Shupak et al, 2003).

You may also have mild problems with your thinking. Even in persons who are well compensated, sensory integration seems to require more attention in persons with vestibular lesions than normal subjects (Redfern et al, 2003).

Recurrent vestibular neuritis -- Benign recurrent vertigo (BRV)

Fortunately, in the great majority of cases (at least 95%) vestibular neuritis it is a one-time experience. Rarely (5%) the syndrome is recurrent, coming back at least once, and sometimes year after year. When it is recurrent, the symptom complex often goes under other names. These include benign paroxysmal vertigo in children (Basser, 1964), benign recurrent vertigo (Slater 1979, Moretti et al, 1980), or vestibular Meniere's syndrome (Rassekh and Harker, 1992). Many authors attribute this syndrome to migraine associated vertigo. There is often a familial pattern (Oh et al, 2001), and it may instead be an entity by itself (Lee et al, 2006) but lacking any clear diagnostic findings that distinguish it from recurrent vestibular neuritis or acephalgic migraine.

~Dr. V

references:

1)seniormag.com

2)Medscape.com References

    Jönsson R, Sixt E, Landahl S, Rosenhall U. Prevalence of dizziness and vertigo in an urban elderly population. J Vestib Res. 2004;14(1):47–52.

    Tinetti ME, Williams CS, Gill TM. Dizziness among older adults: a possible geriatric syndrome. Ann Intern Med. 2000;132(5):337–344.

    Colledge NR, Wilson JA, Macintyre CC, MacLennan WJ. The prevalence and characteristics of dizziness in an elderly community. Age Ageing. 1994;23(2):117–120.

    Sloane P, Blazer D, George LK. Dizziness in a community elderly population. J Am Geriatr Soc. 1989;37(2):101–108.

    Sloane PD, Baloh RW. Persistent dizziness in geriatric patients. J Am Geriatr Soc. 1989;37(11):1031–1038.

    Sloane PD, Coeytaux RR, Beck RS, Dallara J. Dizziness: state of the science. Ann Intern Med. 2001;134(9 Pt 2):823–832.

    Lawson J, Fitzgerald J, Birchall J, Aldren CP, Kenny RA. Diagnosis of geriatric patients with severe dizziness. J Am Geriatr Soc. 1999; 47(1):12–17.

    Madlon-Kay DJ. Evaluation and outcome of the dizzy patient. J Fam Pract. 1985;21(2):109–113.

    Kroenke K, Lucas CA, Rosenberg ML, et al. Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care. Ann Intern Med. 1992;117(11):898–904.

3)http://vestibular.org/node/10#sthash.TXxPdTZL.dpuf

Age related common body pains, their treatment and prevention.

Another health reporter query and my answers in a question/answer format......

As we age we have many different common pains related to our age group. I tried to effectively breakdown these in a broader age brackets and I have noted the causes, treatment and the general prevention. 

The most common pains in the 30’s are

1. Aches and pains, especially in the knees and low back area.
2. Menstrual pain/cramps in women in the child bearing age group.
3. Headaches are very common in young men and women in their thirties.

1a. What typically causes each of these?

1. Joint pains are very common in this age group, especially with men and women who are involved in physical activities at work or at the gym. Heavy loading in the form of work related activities or at the gym such as running or weight training are the most common causes. Running or even mild jogging on a treadmill can be the main culprit of joint pains in men and women who otherwise live a sedentary life style.
2. Menstrual pains or dysmenorrhea is a major reason for pain in young women with incidence as high as 30 to 50% women suffering from it and about 15-20% cannot even perform the activities of daily living during their periods. Hormonal problems, Pelvic inflammatory disease, uterine fibroids and endometriosis (uttering lining growing outside the uterus) are some of the major causes of these pains.
3. Common headaches are generally caused by stress related issues either at work or at home. Men and women in this age group are in the prime of their career as well as the at peak of family/home building phase of life. All these factors along with impeding financial issues if any can cause stress/tension headaches in other wise healthy individuals and cause stress headaches. 

1b. What can be done to fix and possibly prevent each pain?

1. OTC (over the counter) medicines like the common pain relieving pills are the first line of treatment in such cases. If the conditions remain unresolved for a few days then a doctor has to be consulted. Prescription strength drugs and or diagnostic tests may be needed to counter any serious problems. Avoiding heavy loading at gym or work can prevent these pains in the long run.
2. Unfortunately in a lot of cases menstrual pain is not even reported to their doctors due to various reasons. A lot of younger women just feel that they have to simply deal with such issues as a part of being a women. Some women feel better with OTC pain pills and a heating pad but in a lot of cases profession intervention like an Ob-Gyn needs to be consulted. Healthy diet, regular exercise and gentle stretching seem to ease and prevent menstrual pains.
3. Most people just take tylenol or other meds like aspirin in most cases for headaches. Non medicinal interventions like de-stressing, breathing, relaxation activities and aerobic exercise should be encouraged for headaches prevention rather then the pain meds. If the headaches do not resolve in a few days and if are persistent then professional consolation is needed to uncover any serious underlying reasons. Good communication/understanding among spouses and significant others can reduce some of the stresses of life and can also prevent or at least reduce the occurrence of these stress headaches.

2. What are 2 or 3 common pains people experience in their 40s and 50s?

A lot of pains which affect the people in their 30’s generally extend in their 40’s and 50’s too but clinicians see a lot more of the patients complaining about the following in their 40’s and 50’s

1. General body pains, a little more in intensity then the regular aches in thirties, especially in the neck area are very common on this age group.
2. Shoulder pain in men and women involved in a lot of shoulder activities, such as long spells of cooking or prolonged over head activities as simple as cleaning or reaching out to move heavy stuff.

2a. What typically causes each of these?

1. Early onset of O.A.(Osteoarthritis) can be the reason for pain in joints in this age group. OA is a condition where the cartilage lining between the joints starts to breakdown causing bones to rub onto each other. Clinicians have started to see a lot of early onset in recent years in younger age groups.
2. Men and women involved in shoulder activities like strenuous upper arm exercises can cause shoulder injuries and cause persistent pain in their 40’s and 50’s. Men who use heavy over head weights as in dead lifts and/or wide pushups over time can have chronic shoulder pain. Some women performing even light over head weights at gym can injure their shoulder due to relatively weaker upper body muscles especially if those muscles are not used to such exercise since the early years. Main muscle group involved in the shoulder injuries is the Rotator Cuff and it can very quickly become chronic if stays unresolved.

2b. What can be done to fix and possibly prevent each pain?

1. Healthy life style habits like, weight management, regular exercises, regular stretching like Yoga and leading an active life style on a daily basis can help not only with the condition but can help prevent the onset of OA. Including time for workouts or even regular medium pace walking in the busy home and work routine will help.
2. Slower increments in weight training and utilizing the available trainers at the gym can really help to prevent these injuries and help maintain injury free exercise regimen. Avoiding long spells of prolonged over head activities even as simple as cleaning and reaching out to move heavy stuff can prevent serious shoulder injuries in future.

3. What are 2 or 3 common pains people experience in their 60s, 70s and older?

1. OA (Osteoarthritis) is the main reason for pain in joints in this age group. OA is a condition where the cartilage lining between the joints starts to breakdown causing bones to rub onto each other. In older seniors it can cause debilitation and lack of mobility which is a major deterrent to an otherwise healthy and independent senior lifestyle. OA in this age group affects almost all joints in the body.
2. Osteoporosis is a condition where the bones begin lose their density and and are at a risk factor for fractures even after a minor fall. Osteoporosis can also cause the loss of height, chronic and severe pain, especially in the back area and can cause permanent disabilities in some seniors. Even the intensity of pain is different then the regular arthritis pain. Pain associated with Osteoporosis can be really severe and regular pain pills do not seem to relieve it.
3. Chronic Hip pain is a major annoyance in the 60’s and 70’s even when no major physical activity is involved. It may and may not be just simple arthritis. In the aging body the blood supply to various joints decreases, especially the hip joint due to the anatomical nature this ball and socket joint. 

3a. What typically causes each of these?

1. Causes of OA are, age related degenerative changes in the joint (similar to graying of hair), old joint injuries manifesting later in life and other stress like excessive body weight on the joints. Life long abuse of joints at work, home or gym activities such as regular running on concrete like surfaces over the course of life can also deteriorate the joint cartilage or the ‘cushion’ between the joints.
2. Osteoporosis: Our bones of made of dense organic material which gives them the strength and helps the bone support the body. Then bones constantly renew as the old bone material is broken down and new one form. As the body ages, the bone mass is lost much faster then its generated. Over time the bones become brittle and weak and causes extreme pain.
3. Necrosis or death of bone material due to age related decreased blood flow can be the main culprit for the chronic hip pain which occurs in seniors. It also limits range of motion of the hip joint and can cause other related problems like groin pain, low back pain and muscle tightness.

3b. What can be done to fix and possibly prevent each pain?

1. Treatment of arthritis in seniors is different then in the younger people as the condition at times has already become chronic. Disability, lack of mobility and quality of life becomes a major factor in determining the course of treatment. Physical therapy, pain meds, and regular stretching seems to be the logical treatments. Unfortunately for a vast majority of seniors, more aggressive and invasive such as surgeries and even joint replacements are needed. Seniors seem to get a lot of benefits from aqua or water therapy as it is gentle on the joints and a full range of joints can be achieved under water with minimal pain. Proactive prevention is the key to OA. Seniors needs to be educated and encouraged to stay active and healthy. Seniors should try to join the free aqua classes if offered in their communities and participate. Early diagnosis and early treatment helps reduce long term disabilities.
2. Osteoporosis generally requires a slightly different treatment plan like talking bone density (hormonal) and calcium supplements as directed by their doctors. Early diagnosis is again important here. Regular bone density tests are an easy way to keep up with the early detection. Regular exercise, healthy diet and limiting alcohol and smoking goes a long way in limiting osteoporosis.
3. Age related hip joint necrosis can be effectively treated by physical therapy and cortisone injections for pain relief. More invasive treatments are surgical relief and reconstruction of the joint. The condition can be prevented by being healthy and active in early life, good nutrition and limiting cortico-steroids in general.

~Dr. V

Healthy Airport Eating! An article by my friend Cole Millen.

You can follow Cole Mills on his blog: http://colemill.blogspot.com/

Healthy Airport Eating

It's a fact: When you take trips, it is difficulty to eat healthy. Airports are chock full of restaurants touting greasy fried foods and food that is full of fat and low on nutrition. After partaking of these offerings, you arrive at your destination feeling bloated and queasy, and you've just blown your vow to eat healthy right out the window. Then you have to turn around and do it all again when you go home.

Take heart, travelers: You can fly and still eat healthy. With a few tips and tricks, you can cut your consumption of unhealthy foods and forgo both the guilt and physical symptoms that sometimes come with eating badly. Read on for some good advice.

Eat a big, healthy meal right before you go to the airport. Fix yourself something delicious and nutritious right before you have to fly and fill your stomach full of good food. If you arrive at the airport already satiated, you will be less tempted by foods that are bad for you, and you won't have to grab something quick between flights.

Bring along nutritious snacks. Stay away from the salted pretzels and nuts they hand out on the plane - all that salt can make you feel bloated, and your hands and feet may swell. Fruit, veggie slices, and protein bars are also easy to transport and ultra good for you.

If eating beforehand isn't an option, check out the restaurants in the airport ahead of time.  Read menus and see if they have nutrition information available (many restaurants do), and pick the best of them. Don't just rush in and grab a cheeseburger and eat it on the run - with a little research, you may be able to find something that suits both your digestive system and your diet. Some restaurants have inherently healthier options than others - for example, choose Mexican food with beans and without extra cheese and sour cream instead of Chinese. You'll have a high fiber meal that will keep you full for hours. Alternatively, try one of the chain restaurants that offer salads with grilled chicken breast. Just make sure to order it with the dressing on the side and without some of the high-fat extras. Avoid caffeine, processed, greasy, or sugary foods. If you don't, acid reflux and indigestion may very well be in your future.

It is also important to check out the city that you are traveling too and may have a layover in. Nobody expects to have a flight cancelled but things happen. The last thing you want is to be left in an unknown city over night to fend for yourself. I experienced this once in JFK airport in NYC. Fortunately, I was able to do some quick research on a site I found with consumer reviews. I got a great list of New York City hotels and restaurants and was able to plan accordingly and even follow my nutritional eating plan. Needless to say, it is very important to plan for anything!

Give yourself plenty of time to eat. Enjoy your food and take time to savor it. Even the healthiest of foods, if eaten fast, can give you indigestion and make you feel bad. The last thing you want to do is feel sick on the airplane. Give your system time to adjust to the food, and give yourself a chance to unwind.

Make sure you drink plenty of water. While you can't bring water past security, you can bring an empty water bottle and fill it up at the closest water fountain. Flying can dehydrate you, and you need plenty of fluid. If you want to make sure that you don't retain that extra water, bring along lemon slices to add to the bottle.

Eating healthy while traveling is always an option. With a little preparation, you can arrive at your destination feeling healthy and ready to enjoy your vacation or business trip, instead of sick, bloated and tired.

TBHQ... What is TBHQ and where does it fit in our life?

Every once in a while suddenly people start talking about something new and it takes almost everyone by surprise. The new names and terms pop up out of the blue on us like wild mushrooms and it evens leaves the health care professionals a bit puzzled. 'Internet informed' patients ask us something and we draw a blank? Specially when its not a medical condition or not even a real medical term. It happened to me when a patient asked me if her headaches are caused by TBHQ and I was caught off guard.


At that particular moment for the life of me, I could not comprehend was the heck was TBHQ? I asked some of my physician friends and none seemed to know or care too much about the perils of TBHQ. Basically dismissed it as "virtual virus"and not a real threat. I am just glad it was not a medical related term that I bombed on? and I am not alone?

So what in the world is TBHQ anyways? why are we all talking about it so much suddenly and what is it really doing to us? I did a lot of research but still this will be a comparatively a smaller blog topic, as usual please feel free to email me your concerns and comments.


TBHQ?

TBHQ is the acronym used to describe "tertiary butylhydroquinone", which is an antioxidant that comes from petroleum and is related to butane. It is often used as a preservative, applied either to the carton of fast food items or sprayed directly onto them, as well as in various other prepackaged food items. Also found in the paint varnish. That does not sound good for our body?

What it Butane?

As TBHQ is a Butane related product and we all have heard and used Butane so here is a brief summary of what Butane is? Normal butane is mainly used for gasoline blending, as a fuel gas, either alone or in a mixture with propane. Isobutane is primarily used to enhance the octane content of motor gasoline.When blended with propane and other hydrocarbons, it is referred to commercially as LPG, for liquified petroleum gas. It is used as fuel for cigarette lighters and as in aerosol sprays such as deodorant.


Where is it used?

TBHQ is actually an anti oxidant which reduces oxidative deterioration in foods it is applied to, delaying the onset of rancidness. It is particularly effective in reducing the deterioration of fats and oils and aids in reducing nutritional loss over time and extending storage life.

Is it Toxic?

As a food additive, the FDA does allows TBHQ to make up no more than 0.02 percent of the total oils in a food. Consuming up to a gram of TBHQ can cause variable toxicity, and up to 5 grams can be fatal. Fatal is the real threat here but it would actually take 312.5 McDonald's chicken nuggets (if they contain a full 0.02% of TBHQ) to consume a single gram so about 1500 nuggets at one time to be fatal.

 What happens if we ingest it?

Consuming high doses of TBHQ (between 1 and 4 grams, approximately) can lead to lot of symptoms, including nausea, vomiting, tinnitus (ringing in the ears), delirium and collapse. But the sheer amount of food consumption necessary to be afflicted by TBHQ toxicity generally makes these symptoms extremely rare. 


Does it cause Cancer?

In toxicity studies, long-term, high-dose TBHQ administration in lab animals showed a tendency for them to develop cancerous precursors in the stomach, as well as causing DNA damage. But unlike other antioxidant additives, it did not cause lung lesions in laboratory animals. So the answer seems to be no?

So now at least we know a little bit more about TBHQ and it sure is a great product and is needed for a lot of things but as far as I am concerned this should not touch our food chain at all. It still does not seem to be as scary though as it really does not interfere with our food too much and when it does its usually is used in really small quantities. As long as we keep the fast foods consumption in limit and as usual portion control is my main advice to avoid a lot of health related issues. Can it cause headaches though? That still seems to be an unanswered question for me?







~Dr V.

Can you overeat on holidays and weekends and still maintain your "flat belly" plan for the next weekend.

As soon as the schools open in fall, I personally can only think of all the Holidays approaching and yes they creep up faster than we can vision and the issues of overeating on those long weekends already start to "weigh down" some of us! Indulging in the rich, sugary, creamy fatty foods over the holidays just cannot be avoided as its the part of traditions of these holidays, maybe it be of any faith. I guess in the olden ages people didn't seem to be obsessed with calories like we do? The holiday season starts with the Jewish holidays like Rosh Hashanah, Yom Kippur and continue to Hanukkah, Diwali for Hindus, Ramadan for Muslims and Christmas for Christians and Kwanza by December. December is also the season for all the parties and new year's celebrations!
In U.S. the sugary traditions start in the fall with Halloween candies. Average Americans consumed 25 pounds of candy per capita last year. 40% percent of parents admitted to sneaking candy from their own give away bowl and about 90% admitted to sneaking candies from their kids loot. We will also consume about 675 million pounds of turkey on Thanksgiving day itself! This is not counting the accompaniments along with it, not to forget Christmas dinners the very next month. Feeling guilty already? There goes the "flat belly" plan for a lot of us and specially the ladies working on strict diets and exercise regimens of summer. How can we keep the belly flat, the weighing scale steady and keep the love handles in check the morning after the holidays but still indulge? Many are already planning on their next "new years resolution" of weight loss plans and  "I will join the health club once all the parties are over". Some will go on the "GM Plan" "Red-Code", "I was once 300 Pounds"and "You too can l lose 25 pounds in 2 weeks" yo-yo fad diets and avoid carbs for a few days. They will lose their water weight for a few weeks but be a "pain in the rear" for the rest of us by their crabby, dizzy, hypo-glycemic selves and then gain it all back in no time! Only a few strict and highly disciplined health buffs will do the right things and will stay in shape regardless but what about the rest of us?

Well this particular discussion is really about those few extra 3-5 pounds we tend to gain over long holiday weekends  and few days of continues parties and is not the discussion about the long term weight loss plans! I still believe that personal discipline is the key in the long term healthy life style. I want to tackle those monday morning "weighing scale blues" lets see what can be done to flatten the stomach for the next weekend as soon as the  'party hard' weekend gets over. Same actually goes for the vacations. I will never suggest the crazy extreme diets or starving. This discussion is more about those "belly bloat" which comes with the goodies. Fortunately its quickly reversible and easy to do! So here are some ways reduce the guilt and the pounds without starving and missing out on the holiday goodies......

A) Lets tackle the Carbs issue first. Do not cut the carbs down to zero, or diet severely as that will put the body in the starvation mode and the metabolism will slow down and you will be sapped out of energy. Instead cut down of heavy carbs like pasta, bagels and breads etc. You will then use the carbs stored in body for energy and will help you reduce bulk and water weight with out the negative effects.
If your belly bulges after a high-carb meal like pasta, complex carbohydrate-rich foods may be the cause of your bloat, says Jackie Wolf, MD, author of A Woman’s Guide to a Healthy Stomach. Most starches, including potatoes, corn, pasta, and wheat, produce gas as they are broken down in the large intestine. Gas can then make the stomach bloat. So reduce carbs but don't completely cut them off. Eat brown rice or switch to open face sandwich instead of two slices of bread with lean meats like white chicken or turkey!
B) Salt is a big culprit in the temporary weight gain holidays or not! When we intake higher-than-usual amounts of the salt, we’ll temporarily retain more fluid, contributing to that sluggish feeling, puffy appearance, and extra water weight. That will make the stomach look bloated and poofed out. Reduce salt and drink a lot of clear fluids the water retention will reduce. A lot of processed meats have excess salt so stay away from them along with the ready made TV dinners, they are awash in salt too.
C) If you are a fiery food lover like me then cut down the hot sauces etc for the time being. For some people hot food means a lot of gastric juices which can cause acidity and can cause gas. Avoid pepper, nutmeg, cloves, chili powder, onions, mustard, garlic,horseradish, and acidic foods such as tomato sauce, and vinegar. If you still crave hot food use lime or lemon juices and yogurt to cut down the acidity. 
D) Alcohol in moderation is the best policy always but during the weekdays avoid it completely. Alcohol in the body increases dehydration and the body tends to hold on to the water instead of letting it flush. Drink a lot of water and avoid hard drinks to avoid gastric acidity. Alcohol also has empty calories which should be avoided.
E) Sugar alcohols like Maltitol (sucrose) can also cause gas, bloating and even diarrhea. Even chewing gums can cause gas as some of them have sucrose.
F) Mild physical activity can actually reduce a lot of stomach bloating issues. Even if you are not a regular at a gym, mild activity which will increase heart rate and breathing stimulates the natural contractions of the intestinal muscles, helping to prevent constipation and gas buildup by expediting digestion.

G) Some kinds of meats and certain veggies can also bloat the stomach. Meats like red meat in particular and veggies like onions, artichokes contain fructose, a type of sugar, while another sugar, raffinose, is found in asparagus, and also in brussels sprouts, broccoli, and cabbages. Eat plenty of fruits and vegetables that are packed with water. Berries, grapes, and citrus contain a near-equal ratio of the sugars fructose and glucose, making them easier to digest than fruits with more fructose, such as honeydew, apples, and pears.
If you want OTC belly-flattening aids, you can try Gas-X.or  peppermint capsules to kill bacteria that cause bloat and aid digestion. Take a daily probiotic capsule or just simply yogurt. You can also try antacids like Pepto and mylanta for a few days.

In conclusion, we can certainly counter temporary belly float and those few extra pounds after a weekend of binge eating but remember that flat stomach v/s bloated stomach demon is more in your own head rather than public and is very subjective. You may feel "fat" but it may be impossible for others to notice at all. Don't jump on the scale multiple times a day and give yourself some breathing time to recover. You need to feel good about the holidays and relax so don't let these things ruin the holidays or vacations for you. As far as the exercise regimen and healthy diet goes, always remember that its never too late to jump back on the bandwagon again!

~Dr V

Four kinds of athletic pains, not to ignore.....adults or kids!

Schools and colleges have just opened again and the kids have started to practice and play various sports. As they will play, they will fall often, get up and continue but some injuries will be not as trivial. Contrary to popular belief most of us parents actually tend to 'under-react' as long the child says he or she is 'ok"? Most of the times thats usually the case and with ice, a couple of days of rest and some OTC painkillers kids jump back to normal and we all happily forget about the injures.

I thought this will be a good time to write a short blog about the sign and symptoms of sports injuries which we just should not ignore. A quick visit to the local urgent care if not the ER is indeed needed to make sure that the  injury is minor and not something serious. Urgent care visit will make sure that all is really 'ok" and you can still be sure of the homework been done that night.

Athletes really can tolerate more pain than the average person, so we have to take into the account the signs that come with the normal complaints of pain. The tricky part here is to decode the symptoms. Here are four signs you shouldn’t ignore while dealing with an injured athlete at home or even after a minor play ground incident in younger children.

1: Sharp, stabbing, shooting pain.

The mundane muscle and ligament injuries generally will not last more than a few days and will more be of a nagging soreness in nature than sharp localized pain. Soreness is not be be worried about but the localized pain, the kind that can be 'pin-pointed' to a specific part of the body and is persistent for more than 24 hours is to be worried about! Joint injuries as in the ankle where the range of motion is restricted and/or painful may be an issue. If the shoulder cannot be raised beyond a certain point will generally mean bigger issue than the simple muscle soreness. Sharp pains can be signs of everything from muscle spasms to strains or tears. It may even be a fracture and will not even show up on an X-ray done right away due to swelling and a repeat x-ray may be needed to confirm the doubt. So do not ignore any sharp pain in a joint at all. Most of the times you cannot weight-bear if there is a fracture but then some muscle injures can cause non weight bearing too and its best for a doctor to check it out.

2: Swelling

If a joint in question is visibly bigger than the other and even if its not an excruciating pain, swelling is a sign that something’s wrong. Pain depends on whether or not the muscle tear is complete—when it is, you can sometimes feel less pain, A ligament tear like an ACL usually causes swelling within hours of an injury. The area will be discolored and swelling will look like a tennis ball. A joint fracture like I mentioned is easy to notice as the pain will be immense and the joint will 'limp over' and will NOT weight bear or be able to lift up at all. Go to the ER or urgent care quickly.

3: Lightheadedness
“Hypoglycemia or low blood sugar" in college athletes sometimes very common when they try to do a heavy workout early in the morning without enough carbohydrates in their system. Low blood sugar can leave them feeling dizzy and lightheaded. It can lead to fainting and might end up in falling over. Taking rest and ingesting some sugar should help right away but more than fainting I will get worried about the resultant injury from the actual fall. Athletes need to have healthy carbs in the system especially before a long training session. Lots of clear fluids in the system will help keep the heat stroke away too.

4: Head injury, which gives a feeling of "not being well"

“Don’t put yourself at risk to take another blow to your head until you’ve recovered from the previous one,” says Allen Sills, M.D., professor of Neurological Surgery, Vanderbilt University. “Minor injuries add up to catastrophic ones.” I think these are some very wise statements and older kids generally boys don't tend to adhere to these advices. With a recent head injury of any kind, even a minor head bump which is not a full blown 'blow to the head' causing dizziness, sensitivity to light or noise, or fogginess, and/or throwing up should never be ignored and a visit to ER or even a 911 call would not be an over-reaction. It can be a precursor to a major head injury and can even be fatal. There are many studies that have proved that repeated head injuries can cause decreased mental function over time.

In conclusion if there is even a one percent chance that the injury is more than minor, it needs to be checked out by a Doctor and a few hours in the waiting rooms are well worth it. As usual email me for any further clarifications or questions.

~Dr V.

References:
images: www.healthofchildren.com

Raw meat eating, proper cooking, storing of food and the related food borne diseases.

I know a lot of people who like to eat their steaks raw and bloody and some also like to eat other meat dishes like Crudos. Many like fish (sushi) and oysters raw! In my opinion human race evolved eating meat as the primary source of nutrition and our system is apt to eating meat raw as in the prehistoric times food handling and cooking practices may have been questionable? Regardless to the debate about evolution and meat eating habits of humans or if some even count fish as "meat" I will elaborate on the diseases we can get by eating any meat raw. As in any other instance the human body can resist a lot of infections and not everyone eating raw meat will get sick or even have the symptoms but the perils are perpetual and imminent. I will also touch upon the food handling and food storing habits which can reduce many infections. 

Food when cooked and left out for just even more than 2 hours at room temperature, bacteria can multiply quickly. Most colonies of bacteria grow undetected because they don't produce a bad odor or change the color or texture of the food. While freezing the food can slow or stop bacteria's growth but it does not completely destroy the bacteria. The microbes can become reactivated when the food is thawed and reheated.

The risk of disease from ingesting infectious pathogens found in raw meat is significantly higher than cooked meat, although they both can be contaminated. Meat can be incorrectly or insufficiently cooked, allowing disease-carrying pathogens to be ingested. Also, meat can be contaminated during the production process at any time, from the slicing of prepared meats to cross-contamination of food in a refrigerator. Most food borne infections are undiagnosed and unreported, though CDC estimates that every year about 80 million people in the US become sick and about nine thousand die due to food borne illness.

The following are some of the sources, symptoms and pathogens of common food borne illnesses. 

Sources of illness: Raw and undercooked meat and poultry
Symptoms: Abdominal pain, diarrhea, nausea, and vomiting
Bacteria: Campylobacter jejuni, E. coli O157:H7, L. monocytogenes, Salmonella

Sources of illness: Raw foods; unpasteurized milk and dairy products, such as soft cheeses
Symptoms: Nausea, vomiting, fever, abdominal cramps, and diarrhea
Bacteria: L. monocytogenes, Salmonella, Shigella, Staphylococcus aureus, C. jejuni

Sources of illness: Raw and undercooked eggs. Raw eggs are often used in foods such as homemade hollandaise sauce, caesar and other salad dressings, tiramisu, homemade ice cream, homemade mayonnaise, cookie dough, and frostings.
Symptoms: Nausea, vomiting, fever, abdominal cramps, and diarrhea
Bacterium: Salmonella enteriditis

Sources of illness: Raw and undercooked shellfish
Symptoms: Chills, fever, and collapse
Bacteria: Vibrio vulnificus, Vibrio parahaemolyticus

Sources of illness: Improperly canned goods; smoked or salted fish
Symptoms: Double vision, inability to swallow, difficulty speaking, and inability to breathe. These things are serious and I would go to ER right away!
Bacterium: C. botulinum

Sources of illness: Fresh or minimally processed produce; contaminated water
Symptoms: Bloody diarrhea, nausea, and vomiting
Bacteria: E. coli O157:H7, L. monocytogenes, Salmonella, Shigella, Yersinia enterocolitica, viruses, and parasites

You may have to be worried and go see a doctor right away if any of the following symptoms occur with diarrhea:

• High fever—temperature over 102.
• Blood in the stools.
• Diarrhea that lasts more than 3-4 days.
• Prolonged vomiting that prevents keeping liquid down.
• Signs of severe dehydration, such as dry mouth, sticky saliva, decreased urination, dizziness, fatigue, sunken eyes, low blood pressure, or increased heart rate and breathing rate.
• Signs of shock, such as weak or rapid pulse or shallow breathing.
• Confusion or difficulty reasoning.

Most cases of foodborne illnesses can be prevented through proper cooking or processing of food, which kills most of the bacteria. In addition, because bacteria multiply rapidly between 40°F and 140°F, food must be kept out of this temperature range.

I will point out some tips to keep the food from going bad and become a risk to health...

• Refrigerate foods promptly. If prepared food stands at room temperature for more than 2 hours, it may not be safe to eat. It does apply to the left over pizza on the bedside table and eating it for breakfast as done regularly in dorm rooms! Set your refrigerator at 40°F or lower and your freezer at 0°F.
• Cook food to the appropriate internal temperature—145°F for roasts, steaks, and chops of beef, veal, and lamb; 160°F for pork, ground veal, and ground beef; 165°F for ground poultry; and 180°F for whole poultry. Use a meat thermometer to be sure. Foods are properly cooked only when they are heated long enough and at a high enough temperature to kill the harmful bacteria that cause illnesses.
• Prevent cross-contamination. Bacteria can spread from one food product to another throughout the kitchen and can get onto cutting boards, knives, sponges, and countertops. Keep raw meat, poultry, seafood, and their juices away from all ready-to-eat foods.
  
  
  
• Make sure to wash your hands for at least 20 seconds with warm, soapy water before and after handling raw meat, poultry, fish, shellfish, produce, or eggs. 
• Wash utensils and surfaces before and after use with hot, soapy water and sanitize them with diluted bleach. 
• Keep cold food cold and hot food hot. (This is actually a really good tip, I have found in my research). 
• Maintain hot cooked food at 140°F or higher.
• Reheat cooked food to at least 165°F.
• Refrigerate or freeze perishables, produce, prepared food, and leftovers within 2 hours.
• Never defrost food on the kitchen counter. Use the refrigerator, cold running water, or the microwave oven.
• Never let food marinate at room temperature—refrigerate it.
• Divide large amounts of leftovers into small, shallow containers for quick cooling in the refrigerator.
• Remove the stuffing from poultry and other meats immediately and refrigerate it in a separate container.
• Wash all unpackaged fruits and vegetables under running water just before eating, cutting, or cooking. Scrub firm produce such as melons and cucumbers with a clean produce brush. Dry all produce with a paper towel to further reduce any possible bacteria.
• Do not pack the refrigerator. Cool air must circulate to keep food safe. 

  
  

  So what does all this really mean as far as "eating meat raw or bloody"? I personally like my steak medium-well done and even butter flied (it makes it easier to get it thoroughly cooked) and I am not a big sushi fan but that's just me. I will leave it to the readers and their own personal taste preferences but as I mentioned the risks are real and its better to take precautions proactively. Once ingested there is nothing much which can be done to prevent an infection till you have the symptoms and some times we can be late to react and seek treatment. So its best to keep the above mentioned symptoms in mind and act quickly if they get you worried.
  
  ~ Dr V.
  • 
    

    References

    Ahn, D. U., Jo, C., Olson, D.G. “Analysis of volatile components and the sensory characteristics of irradiated raw pork.” Meat Science 54.3 (2000): 209-215. Print.

    Altekruse, Sean F. DVM. “A multi-state survey of consumer food-handling and food-consumption practices.” American Journal of Preventive Medicine 16.3 (1999): 216-221. Print.

    Altekruse, S. F. et al. “Vibrio Gastroenteritis in the US Gulf of Mexico Region: The Role of Raw Oysters.” Epidemiology and Infection 124.3 (2000): 489-495. Cambridge University Press. Print.

    Bestor, Theodore C. “Supply-Side Sushi: Commodity, Market, and the Global City.” American Anthropologist 103.1 (2001): 76-95. Blackwell Publishing on behalf of the American Anthroplogical Association. Print. Stable URL: http://www.jstor.org/stable/683923

    Duffy, Geraldine et al. “A review of quantitative microbial risk assessment in the management of Escherichia coli O157:H7 on beef.” Meat Science 74.1 (2006): 76-88. Print.

    Hulebak, K.L.; Schlosser,W. “HACCP History and Conceptual Overview.” Risk Analysis. 2002. Vol 22. Pgs 547-552. Print.

    Ingham, Steven C., Losinski, Jill A., Becker, Katie L. “Growth of Escherichia coli O157:H7 and Salmonella Serovars on Raw Beef, Pork, Chicken, Bratwurst and Cured Corned Beef: Implications for HACCP Plan Critical Limits.” Journal of Food Safety 24.4 (2004): 246-256. Print.

    Jalali, Mohammad et al. “Prevalence of Salmonella Spp. in Raw and Cooked Foods in Isfahan-Iran.” Journal of Food Safety 28.3 (2008): 442-452. Print.

    Kegode, Redempta B. et al. “Occurrence Of Campylobacter species, Salmonella species and Generic Escherichia coli in Meat Products from Retail Outlets in the Fargo Metropolitan Area.” Journal of Food Safety 28.1 (2008): 111-125. Print.

    Li Y., Zhuang S., Mustapha A. “Application of a multiplex PCR for the simultaneous detection of Escherichia coli O157:H7, Salmonella and Shigella in raw and ready-to-eat meat products.” Meat Science 71.2 (2005): 402-406. Print.

    Myint, M.S. et al. “The effect of pre-enrichment protocol on the sensitivity and specificity of PCR for detection of naturally contaminated Salmonella in raw poultry compared to conventional culture.” Food Microbiology 23.6 (2006): 599-604. Print. Sammarco, M.L., Ripabelli G., Grasso, G.M. “Consumer Attitude and Awareness towards Food-relate Hygienic Hazards.” Journal of Food Safety 17.4 (1997): 215-221. Print.

    Scanga, J.A et al. “Microbiological contamination of raw beef trimmings and ground beef.” Meat Science 56.2 (2000):145-152. Print.

    Smil, Vaclav. “Eating Meat: Evolution, Patterns, and Consequences. Population and Development Review 28.4 (2002): 599-639. Print.

    Tebbutt, G.M. “An Evaluation of Various Working Practices in Shops Selling Raw and Cooked Meats.” The Journal of Hygiene 97.1 (1986): 81-90. Cambridge University Press. Print. Stable URL:http://www.jstor.org/stable/3863214

    Wallace, Barbara J. MD et al. “Seafood-associated disease outbreaks in New York, 1980–1994.” American Journal of Preventive Medicine 17.1 (1999): 48-54. Print.