Weight Loss & Lifestyle Tips to A Lean Healthy Physique: Dr. Natan Schleider Shares His Medical Secrets (Shhh Don’t Tell)

ARE YOU TOO FAT. Vintage weight loss advertisement circa 1900

By Natan Schleider, M.D.

December 12th, 2018

Gone are the days where I could simply skip desert and stay rather lean and toned. Having just turned 43, I literally feel my metabolism slowing and all I need to do is look at carbs and they go straight to my gut by osmosis. 

I weighed about 175 pounds (standing 5’9″) into my late 30s but after a recent physical I weighed in at 220 pounds and have shrunk to 5’8″. At this rate I’d be a walking doughnut with a head so I left my doctors office determined to get lean using every bit of advice I could find in the world of medicine, science, and technology.

Its been two weeks and I am down to 205 pounds. I could say I feel great but I’d be lying. My internal barometer seems to want me obese which I qualify for using a Body Mass Index Calculator. I’m tired as I don’t sleep well when I’m hungry. I’m cranky but fortunately I get a lot of telemarketing calls which allow me to toy with people trying to sign me up for ‘limited time offers’ on credit cards, business loans, and Nigerian Gold Mines.

I presume my mood and body will get used to my goal weight which is 180 to 190 pounds if I can get there. 

So here is what has been working to get the weight off…

  1. I go to the gym at least 5 days a week and workout with a trainer. This is my life one big luxury but I am so lazy if I didn’t pay the trainer I would barely work out. The trainer doesn’t let me skimp on those last few squats that leave me dizzy and gets a good laugh when I fall on my face doing box jumps. Bottom line: if you can afford a trainer or have a motivated work out partner that really helps. That said, weight loss is about 80 percent diet so if you cannot afford a trainer and hate the gym most of success lies in meticulous eating.
  2. I started using a My Fitness Pal app which is a real pain because it takes about 5 minutes to enter calories for every meal depending on the number of ingredients. The simpler the meal the faster I can enter and count calories. I’m aiming for 1500 calories daily, a few hundred more if the workout has been strenuous. Some of the things I snacked on like a slice of American Cheese or Prosuciutto have way more calories than I thought so the app has been educational. Even cucumbers have calories and if you are going to lose weight, you need to be rather meticulous in your calculations
  3. I’ve stopped eating out or ordering take out as I cannot count these calories–plus I like to cook so not a biggie for me.
  4. I have prepared healthy meals ready to be cooked or simply heated. I have a great healthy tomato bisque recipe–if anyone is interested let me know.
  5. I have my ‘skinny jeans’ front and center in my closet and try to put them on every few days. They obviously don’t fit (yet) and this negative reinforcement pisses me off, re-motivating me to stick to the diet exercise plan.
  6. Studies show drinking diet beverages can actually cause weight gain and other issues but when I have a sweet craving, I’ll go for a Diet Cherry Coke which is better than Cherry Garcia.
  7. I bough a food scale for about 10 dollars and while I think anyone weighing their tomato wedges is nuts, it is the only way for me to know exactly how many calories I am eating (because the common advice ‘just portion control’ means instead of eating an entire pizza pie, I eat half for dinner and half for dessert).

Some of the above I am sure you’ve read while other may seem somewhere between fanatical and disciplined but if I am serious about weight loss, this is a discipline which takes time and I just hope I can stick with it to the point it becomes routine.

Anyway, thanks for reading!

Natan Schleider, M.D.

Humorism: Why Modern Medicine is Still an Infant or Maybe a Young Toddler

December 11th, 2018

By Natan Schleider, M.D.

‘The Four Humors’ by Granger Drawing Circa 1574

So its the 21st century, you had a physical, and the doctor collected body fluids like blood and urine for ‘sophisticated’ testing. Ah the marvels of modern medicine.

But wait, doctors have been doing this for thousands of years. I would have been one impressed Gladiator in Ancient Rome if my doctor tasted my urine and explained I was feeling weak and urinating a lot because I had too much sugar in my blood. And doctors did just that. No glucose strips or little battery powered devices. Diabetes mellitus was diagnosed with a simple taste test, not blood test. 

Perhaps that doctor sends me to a specialist in Gladiators (who had the status and value of today’s NBA and NFL stars when Rome ruled the world) who likely would do a blood test. Sounds perfectly reasonable. Who wouldn’t want to know if their four humors (black bile, yellow bile, phlegm, and blood) were out of whack.

Today, we honor those four humors and their inventor, a physician known as Hippocrates (460-370 BC):

  1. Doctors take the Hippocratic Oath
  2. We take humors like phlegm and blood of out peoples bodies to test (IE for infection or anemia) and treat them (IE for Polycythemia)
  3. Doctors keep their patients humors in balance by reducing phlegm if they have too much of it so they can breathe

Around the 1500s doctors realized that there may be more to medicine than the four humors but that didn’t stop doctors from bleeding patients therapeutically for virtually any ailments into the early 1900s. Did you know George Washington died of being bled by his doctors for a throat infection. Seriously!

The greatest advances in medicine in the last few centuries include soap (probably saved more lives than all the antibiotics ever created), antiseptic surgical technique, and Viagra (not necessarily written in order of importance).

Sure we have fancy breathing machines, pictures that let us see inside our bodies, and robotic surgery. 

I’m no surgeon but I have to wonder about the bedside manner of robots, I mean, after fixing my heart valve will they reassuringly rest their arm on my shoulder and take a sip of my urine to confirm my diabetes is under control?

Thanks for reading!

Natan Schleider M.D.

Ten Signs You Are Seeing the Wrong Doctor

December 8th, 2018

By Natan Schleider M.D.

If dustballs in the corner of the doctor’s exam room and bullet proof glass separating your from the receptionist aren’t good enough, here are ten signs that you probably are not seeing the best doctor:

  1. An old expression states if the ink on the diploma is to wet or too dry, seek treatment elsewhere. If the diploma is a pile of dust behind a dingy glass frame, run.
  2. The doctor’s lab coat is dirty. This simple observation reflects the doctor’s hygiene and their respect for medicine. Dirty lab coat, dirty doctor.
  3. Magazines in the waiting room are over 10 year old. This shows the office is not up on the times, that is, if they can’t even update their magazines, what kind of archaic medicine is being practiced.
  4. The doctor spends less than a minute with you and can never remember your name. While I grant many doctors are overworked, they can spare a few minutes and knowing their patient’s names.
  5. The doctor is a social media star who does nothing but tweet, post, take selfies, and promote his brand. While I’m sure these doctors are attractive and interesting, they probably are not practicing as much medicine as the good old fashioned doctor–oh, excuse me for a second, someone just liked my latest post on instagram, just joking.
  6. The appointment is spent talking about the doctor and not about the patient (for example, ‘So you just had a little heart attack, big deal, I get my coronaries rota-rootered every year and since my 8th heart attack and some Lipitor, I eat at the buffet daily).
  7. The doctor cannot make a decision and refers you to a specialist for every problem (IE that splinter in your finger is tiny but just to be safe, let’s have a dermatologist look at it to make sure nothing is being missed).
  8. The doctor’s office frequently cancels your appointment or is late for your appointment.
  9. You arrive on time for your appointment and realize yo have read Was and Peace before being called in to see the doctor.
  10. You are asked to disrobe in the exam room for a talk therapy visit.

I’ve seen variants of all of the above so keep the above in mind before choosing your next doctor.

Natan Schleider MD

Which ADHD Medicine is Right for Me?

by Natan Schleider M.D.

December 7th, 2018

So you think you have attention deficit hyperactiviy disorder (ADHD formerly ADD) and you are considering medicine options. If you are like most patients I see, you’ve already queried friends, family, and the internet so you can tell the doctor what you think is best. I have no issues with educated patients so I’ve put together a list of medicines I use and why.

Note the family of stimulants (IE methylphenidate, Adderall, Vyvanse, and others) are the first recommended treatment in general for patients but that varies by patient and whether they have other medical or mental health issues.

Stimulants can be habit forming so considering a non-controlled medicine (bupropion aka Wellbutrin, Strattera) for ADHD may be a nice option as they are not habit forming although tend to be milder and less strong.

While discussing stimulants, let me add that I am often asked ‘Can’t I just drink a lot of caffeine for my ADHD?’ Caffeine is a unique molecule and while it keeps most people awake and is activating, it does NOT help ADHD symptoms.

The first question to ask when it comes to stimulants are whether your want a short acting medicine that can be used a few times a day or a long acting medicine taken once a day. This is patient preference as some like flexible dose options with a short acting medicine while others just like to take one pill a day.

So here are your stimulantmedicine options for ADHD:

  1. methylphenidate (best known as Ritalin) which is the oldest and comes as short acting (last 2-4 hours) and long acting (last 6-12 hours for Concerta or Focalin or Vyvanse–I find they last closer to 6 hours in most patients). Note Daytrana is a patch that lasts up to 10 hours
  2. Dextroamphetamine/amphetaime (Adderall) which comes as short acting or long acting (Adderall XR) and super long acting (Mydayis) at up to 12 hours.
  3. Dexedrine and Dexedrine Spansules are popular amongst a handful of my patients althugh they re hard to find at pharmacies.

 
And here are your non-stimulant medicine options for ADHD:

  1. Atomoxetine (Strattera) which takes about 3 days to kick in and dose can be adjusted from 40 mg to 80 mg (the standard dose) in 3 days.
  2. bupropion (Wellbutrin) is a very activating antidepressant approved for ADHD, tobacco cessation, and depression.

My patients tend to prefer Vyvanse which is the least speedy of the stimulants but every patient breaks the medicines down differently so it may take some trial and error to find the right choice.

When reviewing medicine options with patients I go over the above in detail. While talk therapy helps for most other mental health illneses, it is less effective for ADHD (but no harm in trying it).

If you have any questions or comments please reach out to me on Twiter or Instagram or facebook.

Thanks for reading,

Natan Schleider, M.D.

Herbal Supplements: Helpful, Harmful, or Harmless when using Prescribed Medicines?

Herbal Supplements: Helpful, Harmful, or Harmless when using Prescribed Medicines?

By Natan Schleider M.D.

December 6th, 2018

One of the first things a good doctor does when discussing medical management of an illness is figuring out what treatments the patient is interested in.  Chances are they have already tried cranberry for their urinary tract infections, St.John’s Wort for mood, and a host of other over the counter herbs or supplements which their mother, butcher, or favorite celebrity has recommended.

When these patients come to see me, the melatonin is not really working for sleep and the horny goat weed has not helped libido. These patients may consider trialing a standard medicine when indicated as they feel so bad. Concurrently, they have a strong aversion to taking chemicals bundled into pills that the evil pharmaceutical companies are marketing. After all, if it is natural, it must be better?

When I prescribe a medicine, I need to make sure it will not interact with the herbs that millions of American take so I am writing this blog to weed out (pun intended) the supplements that you can take with other drugs and those that should be avoided or used carefully.

HERBAL DIETARY SUPPLEMENTS WITH LOW RISK OF DRUG INTERACTIONS:  Black cohosh, Cranberry, Gingko, Ginseng (American), Milk thistle, Saw Palmetto, Valerian

HERBAL DIETARY SUPPLEMENTS WITH HIGH RISK OF DRUG INTERACTIONS: Goldenseal, Green Tea Extract, St. John’s Wort

I have not discussed vitamins much and this may lead to a further blog. For example, iron supplements (along with calcium, antacids, and cholesterol drugs) impair absorption of thyroid supplements so take your thyroid medicine 1-2 hours before or after you’ve taken your other medicines and supplements.

I’ve scratched the surface of a major issue but most importantly, tell you doctor and pharmacist what supplements you take so they can tell you how they may or may not interact with your mediation.

Thanks for reading!

Natan Schleider, M.D.

SOURCE: AMERICAN FAMILY PHYSICIAN V.96 No.2 July 15th, 2017

Do I Have Clinical Depression or Am I Just Feeling Badly Because Life Just Dealt Me Crap?

Do I Have Clinical Depression or Am I Just Feeling Badly Because Life Just Dealt Me Crap?

By Natan Schleider, M.D.

November 18th, 2018

So you just broke up with your fiancee, you or a loved one just got diagnosed with a serious illness, or you just started litigation. These are some of the most common reasons patients see me wondering if they are depressed.

So how do doctors and mental health care providers determine if someone is depressed and warrants treatment or is going through a normal grief reaction or ‘adjustment disorder?’

For me it is quite simple–as are the screening guidelines for depression.

A simple 2 questions (called the Patient Health Questionnaire 2 Screening Instrument for Depression or PHQ-2 for short) is all we need to screen for depression:

  1. Over the past 2 weeks, how often have you felt little interest or pleasure in doing things [you normally enjoy]?
  2. Over the past two weeks, how often have you been feeling down, depressed or hopeless?

Not At All=Zero Points, Several Days=1 point, More than half the days=2 points, Most days=3 points.

A score of 3 or more would be a positive screen for depression at which point your health care provider should dig deeper with more detailed questions. I would not give a patient with a score of 2 a slap on the back and a lollipop and say ‘suck it up’ but the PHQ-2 helps catch at least 90 percent of depressed patients.

I am commonly asked: ‘Since I know the cause of my depressed mood, do I really need further evaluation or treatment?’ The answer is: nearly all of my depressed patients know why they are down, if they have clinical criteria for depression such as changes in sleep, interest deficit, guilt (hopelessness, regret, etc), appetite changes/weight changes, psychomotor retardation (trouble coordinating and concentrating), and/or suicidal thoughts or plans treatment is indicated.

That does not mean the patient is committing to a pill for life–a common fear. Talk therapy, herbal medicines like St.John’s Wort, and other non pharmaceutical treatments are available.

If you are feeling down and think you may be depressed, you are not alone–about 8 percent of the US population is depressed.

If you enjoyed this article and have questions, comments, or concerns please let me know via this blog or twitter or facebook or instagram.

Thanks for reading!

Natan Schleider, M.D.

SOURCE: AMERICAN FAMILY PHYSICIAN V.98 NO.8 OCT 15TH, 2018

Ten tips to be sure you have been prescribed the right antidepressant?

Ten Tips to be Sure You Have Been Prescribed the Right Antidepressant

By Natan Schleider, M.D.

October 15th, 2018

‘So my mood is much better,’ said my patient last week, ‘but I can’t get it up.’

Antidepressant medicines (not a great name for what they do since many also treat anxiety without depression, nerve pain, fibromyalgia, etc) come in many families and varieties. Choosing the right one is difficult, espcecially since many share the same common side effects like weight gain and sexual side effects.

If you have been prescribed an antidepressant for any reason, always consider whether possible side effects outweigh potential benefits and ask ‘Am I on the right antidepressant for me?’. Here are some tips on how to do just that:

  1. If you are concerned about weight gain, the Selective Serotonin Reuptake Inhibitor (SSRI) family, the Tricyclic Antidepressant Family TCA), and some other antidepressants like mirtazapine (Remeron) can cause weight gain. I find escitalopram (Lexapro) weight neutral, that is, most of my patients do not gain weight with it althoug it is an SSRI.
  2. Sexual side effects like poor libido or trouble obtaining or maintaining an erection can occur with TCAs and SSRIs
  3. The SSRIs tend to be one of the most common first choices doctors prescribe as they are inexpensive and have a pretty good safety profile; however, they are not all equal in action. Some are more activating and I use these with patients who are depressed, apathetic, oversleeping and overeating. Others are more sedating, good for someone also suffering from poor appetite, and feeling wired or anxious. Here is a list from most activating to least activating (although some patients will react to them differently): fluoxetine, sertraline, paroxetine, escitalopram, citalopram, fluvoxamine (an interesting SSRI not FDA approved for depression but anxiety).
  4. If other symptoms are present that the antidepressant can help with, why not kill too birds with one stone. For example duloxetine (Cymbalta) can be used for depression and/or anxiety and/or nerve pain and/or fibromyalgia.
  5. If you or a first degree relative have had success with a particular antidepressant in the past, that would be a reasonable one to trial
  6. If you are good at remembring to take your pills daily, great. If not, I would avoid venlafexine (Effexor XR) which is broken down quickly in the body and leave you in an uncomfortable withdrawal if not taken at the same time daily.
  7. If you have had side effects from one family of antidepressants, good chance you will have them from all medicines in that family so consider switching to a different family.
  8. If your mood can be managed without a daily medicine, for example talk therapy why not go for that first?
  9. If you are on other mental health medicines, double check there is no interaction between them. Most medicine labels may read do not take your antidepressant with alcohol–this is a common question. textbook answer is ideally don’t drink while on mental health medicines as they can confuse the diagnosis or medicines effect, especially if you like your medicines with a mimosa every morning.
  10. If you have failed the older families of medicines, try some newer antidepressants like vilazodone (Vybrid), Vortioxetine (Trintellix), or levomilnacipran (Fetzima).

Hope that answers some questions! Questions, comments, concerns? Contact me:

Twitter: @DrSchleider

Testosterone Therapy Part I: ‘I’m On an Opiate [buprenorphine, Suboxone, methadone, morphine, etc] and My Mood and/or Libido are blah’

Testosterone Therapy Part I: ‘I’m On an Opiate [buprenorphine, Suboxone, methadone, morphine, etc] and My Mood and/or Libido are blah’

by Natan Schleider, M.D.

August 19th, 2018

While the USA suffers through another opiod use epidemic (yes, we’ve had them before but I’ll give you the history lesson another time), the focus of press and medical/government powers that be are appropriately focused on preventing overdose and death. Far less attention is paid to adverse effects of chronic opiate use.

Whether used for pain management or for Medication Assisted Therapy (MAT) [IE using buprenorphine or methadone to manage Opiod Use Disorder formerly called opiod dependence] here is an important medical fact: if you are taking any opiate, you are at risk for testosterone deficiency. While not life threatening directly, common signs and symptoms of testosterone deficiency are decreased libido, depressed mood, lack of energy, diminished muscle mass/trouble gaining muscle size and strength at the gym, increased body fat, erectile dysfunction, and infertility.

Opiates reduce leuteinizing protein (LH) and follice-stimulating protein (FSH) production at the brain’s pituitary gland. LH and FSH tell the testicles to make testosterone.

In my practice, 50% to 75% of my male patient’s on opiods have low testosterone and half of them have some of the symptoms listed above.

I would argue that suffering the above symptoms poses risk of relapse to illicit opiod use and should be investigated and treated when indicated.

The good news about testosterone supplementation: it can help many of the symptoms above. The bad news: testosterone supplementation increases risk of prostate disease, prostate cancer, blood clots, and possibly heart disease (depending on the study).

Testosterone is broken down/destroyed by the stomach if swallowed so it has to be supplemented via transdermal gel (that goes on the skin daily) or by injection into the muscle (usually the gluteus) weekly to monthly. A few formulations I am not that experienced with as I can rarely get them covered are available: buccal (melts in the mouth) Striant, intransal gel (Natesto) [has to be given 3 times daily–annoying].

Most of my patients prefer the injectable formulations being least expensive and allowing for the patient and I to optimize how frequently to give the shot. I find weekly injections the best as if given less often, testosterone levels tend to peak for several days after the injection and wear off faster than the manufacturer suggests.

I would love to hear your experience or horror stories or opinion about testosterone therapy in opiate users via Twitter.com @DrSchleider or Facebook or Instagram.

Thanks for reading and stay tuned for part II, testosterone supplementation in women and transgender patients.

A Family Doctor’s Visit to See a Cosmetic Dermatologist for Sun Damaged Skin Part I: Poikiloderma of Civatte

A Family Doctor’s Visit to See a Cosmetic Dermatologist for Sun Damaged Skin Part I : Poikiloderma of Civatte

By Natan Schleider, M.D.

Dr. Natan Schleider’s Forehead. Note what appears different color tones which was diagnosed a poikiliderma.

I don’t wear skinny jeans. I wear flip flops whenever I can which apparently are out of style. And while starting to go bald–which I’ve decided to ‘own’ rather than pursue hair plugs or the ever popular toupee, the sun-damaged skin on my forehead has been bothering me (only when I look in the mirror).

Having spoken to my regular dermatologist, Dr. Roy Seidenberg (great, brilliant physician), he suggested a cosmetic dermatology consult for possible laser treatment.

Now I’ve had laser treatment before in my early 30s: laser hair removal on my back and chest. After 18 months of treatment every 6-8 weeks for a total package deal of about $3500, my back and chest were about 60% improved but I learned one valuable lesson: as I aged new hairs began to sprout on my back and chest (not to mention my ears, yikes!). So what I presumed–and is often advertised as a ‘permanent’ fix–not the case with me.

Friends have raved about various laser treatment for skin as the definitive cure while many patients of mine love Retin-A, a prescription cream or gel FDA approved for anti-aging (improving fine lines and sun spots). I tried Retin-A for a few weeks but realized I was soon forgetting to apply it at night (when I was negotiating with my 5 year old daughter Elie on the benefits of tooth brushing, a nightly debate).

Treatment for this would not be ‘one and done’ but would require a ‘series’ of treatments–the doctor would not commit on even a ballpark number but I would surmise 5-10 treatments. lasting ‘minutes’ after a numbing cream was applied. The stronger the laser each session, the better/faster the final results (meaning the more sun-damaged blood vessels are destroyed). If the laser is put on mild, minimal downtime, skin feels slightly sunburned, you can work same day. If laser is put on high power, skin is very red and inflamed and downtime expected to be 1 week. The cosmetic dermatologist suggested an in between setting.oping for a ‘one and done’ laser treatment to leave my forehead smooth and uniform in color, I saw a cosmetic dermatologist yesterday.

I tried to get a price idea on these laser treatments before the consult but found no great source?

Anywho, while I do have a few sun spots medically called solar lentigos, my primary problem in poikiliderma, a benign discoloration of blood vessels brought on by sun exposure underlying the skin leaving colors darker and lighter.

Treatments would occur about once a month and I ultimately got a price of $450 per treatment (which I think is low in the NYC area as it is a small region of skin being zapped as opposed to chest or neck where poikiloderma occurs more commonly.

The staff seemed surprised when I declined treatment at this time. Given this would be a long expensive process with best outcomes (based on my research) about 75% improvement, I paid my $200 consult fee and told them ‘I’d think about it’ which I will do.

The treatment would involve some type of laser which would take ‘a few

Any comments or experiences with cosmetic dermatologic treatments appreciated via Twitter.com or Facebook.com or Instagram.com.

Thanks for reading and I’ll keep you posted if I go back for laser treatment.

 

 

 

Medicine Changes It’s Mind Every 10 Years, Case in Point, Vitamin D Supplements No Longer Advised

Medicine Changes It’s Mind Every 10 Years, Case in Point, Vitamin D Supplements No Longer Advised

By Natan Schleider, M.D.

August 13th, 2018

Having been in practice 13 years now, I’ll let you in on a secret: fifty percent of everything you learn or read about in the news regarding health and medicine will be obsolete or wrong, sometimes even harmful, within 10 years or so. Does that mean I should ask for 50% of my money back from my medical school, hmmmm?

Case in point: In the 2000s, a lot of interest in Vitamin D testing and supplementation ensued with the consensus being, take Vitamin D if you don’t get enough sun, have low levels (my lab says low levels are less than about 30 ng per ml), are elderly and at fall risk, have mood disorder such as depression, are at risk for heart attack…the list went on.

Less than a decade later, recommendations have shifted 180 degrees, that is, studies in recent years show no benefit to taking Vitamin D for all the disorder above unless your levels are below 12-20 ng per ml making you Vitamin D deficient. If you are deficient in Vitamin D or your diet lacks the needed 600-800 IUs recommended daily, take Vitamin D (FYI most multivitamins have about 200-400 IUs of Vitamin D).

I’ve stopped supplementing with Vitamin D and plan on checking my levels in a month or two.

If you have been prescribed Vitamin D but are not in fact deficient and have questions or comments, speak to your doctor or contact me on Twitter. Facebook, Instagram, etc.

SOURCE: AMERICAN FAMILY PHYSICIAN V.97 NO.4 FEB 15th, 2018