“Exercise is good for you!”

“Exercise is good for you.”  How many times have you heard this phrase?  It has been said so often that it rivals similar health mantras in frequency such as “Eat your vegetables”, “Stop smoking!” and “Take your vitamins” (the last one hopefully I disproved the value of in an earlier post!).  Yet, we seldom ask for explanations about why these recommendations are supposed to form the foundation of our habits.  This post will review the reasons we talk about exercise and health, specifically discussing benefits that go beyond the widely known effects of lowering the rate of heart disease.  Hopefully, after reading this you will feel even more committed to your current exercise regimen or will feel encouraged to start exercising if you are not currently doing so.

To begin with, let’s define the current recommendations you will hear from doctors and health care organizations regarding the amount of exercise to do weekly.  The two most common suggestions are to get at least 150 minutes of moderate intensity activity or 75 minutes of vigorous intensity activity weekly.  Moderate intensity is considered activities that make you breathe as hard as if you were taking a brisk walk.  In fact, a brisk walk is the most common moderate intensity activity people perform.  Strenuous activity would be one that makes your heart beat faster, makes you breathe heavier and sweat more.

Now that we are on the same page about the amount of exercise recommended, let’s turn our attention to the health benefits.

#1 Cancer:   Colon cancer is the second most common cancer in men and women.  According to the National Cancer Institute, there are over 50 studies to date evaluating physical activity and colon cancer risk.  The results are consistent that people who consistently participate in physical activity reduce their risk of developing colon cancer by 30-40% compared to those who do not exercise.  This benefit applies to those of normal weight, as well as those who are overweight or obese.

Breast cancer has been studied extensively as well.  The results of over 60 studies have shown consistent decreases in breast cancer risk for all levels exercise intensity.  This protective benefit applies to premenopausal and postmenopausal women.  Equally important is that some studies suggest a survival benefit for those women with breast cancer who exercise frequently.

There are similar results showing physical activity lowering rates of endometrial cancer, possibly lung cancer (although smoking cessation remains the most important intervention to lower risk), and slowing of progression of prostate cancer in men.

#2 Sleep quality:  In the United States, 35-40% of adults have difficulty falling asleep or feeling tired during the day.  A 2011 study in the Journal of Mental Health and Physical Activity by Paul Loprinzi and Bradley Cardinal found a 65% improvement in sleep quality in people exercising moderately compared to those who were sedentary.  This finding supports the idea that exercise is a healthier option for those with insomnia compared to sleep medicines that have multiple potential side effects.

#3 Decreased falls and bone fractures:  A meta-analysis (pooling together results from multiple individual high-quality studies) published in 2014 of 22 studies that in total included over 1.2 million people was conducted by Qu, et al.  The results found a 39% and 28% reduction in hip and wrist fractures, respectively, in those who exercise consistently compared to those who do not.  Fractures of the spine (vertebral fractures) did not show any reduction with exercise.

#4 Emotional Well-Being:  Another meta-analysis of 30 prospective studies published by Mammen and Faulkner in American Journal of Preventive Medicine found 25 of the 30 showing a lower risk of developing depression in people who exercised moderately.

#5 Life expectancy:  The National Institute of Health in 2012 found a direct relationship between the amount of exercise and prolonging your life.  For people doing half the recommended level of exercise weekly, the recommended level, and twice the recommended level, the gain in years of life averaged 1.8, 3.4, and 4.2 years.  This increase applied to men, women, African-Americans, Caucasians, and the increase was even more pronounced for those with a history of heart disease or cancer.

So now you know the specifics about physical activity and your health.   Whether you are concerned about heart disease, cancer, bone health, emotional well-being, sleep or simply want to live as long as possible, exercise should be a fundamental part of your life.  Hope to see you soon on the walking trails, biking trails or in the gym!

Next week’s post:  Benefits of high-intensity interval training

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Chronic Obstructive Pulmonary Disease (COPD):  Here are the facts.

  • COPD is the third leading cause of death in America, behind vascular disease (heart attacks and strokes) and cancer
  • smoking is the main risk factor for COPD accounting for 80% of the cases but almost 20% come from exposure to occupational industrial fumes
  • the two most common forms are chronic bronchitis and emphysema
  • the American Lung Association estimates 24 million Americans are affected with COPD, many don’t even know they have it
  • cough and shortness of breath with activity are early symptoms, while shortness of breath with decreasing amount of activity, wheezing and fatigue are late symptoms

These facts, which can be found easily with a Google search, are important.  Yet, they do not give a picture of what it feels like to have COPD.  I hope the following poem (written in a style called prose poetry) will provide a few insights into the thoughts and feelings of someone who has this progressive, devastating and dangerous condition.



“You sound like my Froggie,” my granddaughter chuckled.  Froggie is the stuffed animal she won at the local carnival last summer.  If you squeeze its mid-section, a most un-frog like high-pitched wheeze escapes from its belly.  The tag says “Made in Thailand” which makes me wonder if frogs in Thailand sound different than they do here.  Regardless, my granddaughter is right.  I do sound like Froggie.

My breathless episodes come more frequently.  A few years ago walking on a humid or pollen-laden day was challenging.  Today, I wouldn’t attempt a walk on the most temperate of days.  As a kid, I spent hours playing whatever sport was in season in the park around the corner.  I never imagined a time when my body would feel like its quarterback or pitcher was maimed.  Thoughts of childhood activities, like my curiosity about Southeast Asian frogs, are simply another stab at diverting my mind from the awareness of breathing–an action unnoticed by most people despite occurring 700 times an hour.

While my musings and reminiscing sometimes succeed in creating a mental diversion, nothing is able to deflect my attention from the wheeze.  As un-frog like as it sounds coming from Froggie, it is even more unnatural, un-human, coming from me.  Not quite a whistle or a squeak, it lasts just long enough at the end of exhaling so that getting up from this soft-bottomed living room chair to get a drink from the kitchen makes me think twice about whether I am thirsty after all.

Next week’s post:  Exercise and your health

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Heroin Addiction: An equal opportunity destroyer

Heroin is the most addictive drug known.  Simply hearing the word heroin makes parents cringe, communities worry and health care policy-makers lose sleep.  It’s hard to turn on the television, radio or read a newspaper without hearing about the growing epidemic of heroin addiction.  In fact, residents of New Hampshire considered heroin to be the most important issue facing their state during this year’s Democratic and Republican primaries.  Given the widespread concern, I decided to forgo last week’s initial suggestion to discuss COPD and spend this post talking about the heroin epidemic instead.

Heroin use has increased dramatically over the last decade, affecting all demographics of society, including age, gender and socioeconomic status.  According to the National Survey on Drug Use and Health, heroin use over this time has increased in women by 100% and in men by 50%. Similarly, young adults ages 18-25 years old have seen a 109% increase in use while those over 25 years old, 58%.  For income levels less than $20,000, $20,000-50,000, and over $50,000, the increase has been 62%, 77% and 60%, respectively.

Yet, heroin is rarely used alone and the risk of addiction increases in the setting of other drug use.  Specifically, the risk increases two-fold for someone addicted to alcohol, 15-fold for cocaine, and 40-fold for opioids, which are a specific class of painkillers.  It is the association with opioids that is particularly concerning.  These pain killers, oxycodone and oxycontin, are prescribed by physicians.  Usually a person has legitimate reasons for initially taking them, such as treating pain immediately after surgery or injuries from a motor vehicle accident.  However, the medicine use sometimes continues longer than necessary and soon the “need” for the drug is about something more than pain control.  At some point, a patient’s physician may refuse to continue writing the prescriptions.  If the person is addicted, they will look for illegal ways to obtain a comparable high.  Heroin treats the same cravings as oxycodone but is only one-fifth of the “street” price.  While it is cheaper to buy, heroin raises the degree of addiction and dangers to a new level.

Heroin comes from the Opium Poppy flower, which grows in dry, warm climates such as China, Mexico, Iran, Pakistan and Afghanistan.  It does not occur naturally and must be synthesized from the sap of the flower. The sap initially is refined to morphine and then undergoes chemical treatments to form heroin.  In its purest form heroin is a white powder but, more often, it is brown, yellow or black.  Black is becoming more common and referred to as “Mexican Mud” or “Black Tar”.

Heroin is most often injected.  Within seconds it’s converted in the brain to morphine which binds to specific opioid receptors that regulate feelings of pleasure, inhibit pain and slow heart rate and breathing.  The high from heroin is almost immediate and the intensity of the high is related to the amount of drug used.  With more frequent use, the body becomes tolerant to the effects of the drug and a higher dose is required.  But, here is the catch.  The tolerance builds up more quickly in the pleasure centers of the brain than in the centers that control breathing and heart rate. Ultimately, the craving for the high can drive a person to use doses that may cause them to stop breathing completely.  This difference in tolerance may also explain why people often die of heroin overdose after a period of time free from the drug, such as being in a rehabilitation center.  Their brain has lost much of its tolerance during this hiatus but they don’t realize it.  As a result, if they relapse they use a dose similar to that which they used before becoming “clean”.  Their respiratory center is overwhelmed and they stop breathing.

Heroin overdoses are not new.  There have been high profile overdoses for the last forty years.  John Belushi, River Phoenix, Kurt Cobain, and more recently, Cory Monteith and Philip Seymour Hoffman are just some of the famous people who died using heroin or heroin mixed with other drugs.

Naloxone is a medicine that can reverse the effects of heroin quickly in the event of an overdose.  It must be given soon after a person loses consciousness.  Simply, it can save someone’s life.  Naloxone is now carried by first-responders in most major cities including EMS workers, firefighters and police.  Many cities are wrestling with the idea of providing people who abuse heroin with this antidote to prevent accidental deaths.

Unfortunately, there is no consistent national policy to address the heroin issue.  There has been a four-fold increase in heroin-related deaths in the last decade.  Sadly, without more efforts to heighten awareness on a local, state and federal level, along with efforts by the medical community to decrease opioid prescriptions, this tragic epidemic will continue and, likely, worsen.

Next week’s post:  Living with COPD, a poem

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Taking Vitamins: 30 years of exaggerated claims

As I was thinking about this week’s post, I thought I would write about the most common vitamins people are taking today.  However, it occurred to me that such an approach only represents a small portion of what I wish people to understand about the world of vitamin supplements.  The more important information to share is that, just like fad diets, fashion or music, the “in vogue” vitamins change every five or ten years.  When I was in college in the 1980’s, Linus Pauling was spearheading the belief that taking vitamin C was essential for fighting off disease and having a healthy immune system.  In the early 1990’s, when I was starting my residency in internal medicine, magnesium was the vitamin being touted as critical to increasing survival after heart attacks. In fact, every patient with a heart attack in my hospital received intravenous magnesium as part of their treatment protocol.  The late 90’s ushered in vitamin E and B-carotene (vitamin A) as the vitamin supplements “du jour”.

So what happened to these vitamin fads and why don’t we continue to talk about them today?  Well, over time we conducted multiple studies that found no or limited efficacy to taking these supplements, and in some cases actual harm.  Specifically, we found no benefit to long term vitamin C supplementation in preventing infections and a lack of benefit of magnesium in improving survival after heart attacks.  Even worse, we found B-carotene supplements increased the risk of lung cancer in smokers, while vitamin E provided no heart health protection and could provide harm in high doses.

Fast forward to the last ten years with fish oil (omega-3 fatty acids) and calcium taking center stage.  For the most part, reviewing the scientific literature found similar findings to those “invaluable” vitamins of the past.  Fish oil supplements, initially hailed as essential for good heart health, quickly became important in preventing everything from nervous system issues to eye problems.  Unfortunately, over time we have found that the preponderance of evidence shows no benefit to fish oil supplements. However, a very important distinction is that a diet including several servings a week of foods rich in fish oils is still considered healthy.  Foods rich in omega-3 fatty acids include salmon, sardines, tuna fish as well as soybeans, tofu and walnuts.

Calcium has also been a critical vitamin in the last decade touted as essential for bone health.  Yet, over the last few years two camps regarding calcium supplement safety have been developing–those who believe it is safe and still important vs. those who feel the supplements may increase the risk of heart disease.  As with most things in medicine, when two strongly opposite views are held on a question, it usually means any benefit or risk will be far less than the initial exaggerated claims. Given that we are to first do no harm, I have been recommending to my patients that they focus on getting calcium through their diets rather than supplements.  Foods that are excellent sources of calcium include low fat dairy products such as yogurt, cheese and milk, leafy green vegetables, tofu and sardines.

Once again, as with last week’s post about the lack of benefit taking multivitamins, we should be cautious about assertions that any pill is going to have a significant benefit to our overall health.  There is no substitute to a healthy well-balanced diet with lean proteins, fresh vegetables, fruit and whole grains.  Over time, this approach continues to be associated with the best health outcomes, even if it is not as exciting to discuss as this year’s latest fad diet, super-vitamin or exaggerated claims about a newly found herb from South America.

Next week’s post:  COPD:  Breathing gets tougher in a polluted world

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Multivitamins: Are they worth the money?

“In addition to your prescription medicines, are you taking any over the counter vitamins or supplements?”  This is a question I ask every patient who comes to my office for a physical exam.  At least 50 percent of my patients respond that they are, which is consistent with the national estimates.  Of the 50 percent, multivitamins are by far the most common pill they take.  In fact, multivitamin use is so widespread that, according to the National Institute of Health, it accounts for almost 6 billion dollars in sales annually.  The main reasons I hear from patients as to why they take a multivitamin are that they don’t always eat enough fruits and vegetables so are making up the shortfall, and they heard a multivitamin daily will prevent disease.  Unfortunately, multivitamins don’t work for either of these reasons.

The scientific evidence against the benefits of multivitamins has been growing for twenty years.  More recently, The Physician’s Health Study II published in the Journal of the American Medical Association in 2012 found no health benefit in over 14,000 male physicians over the age of 50 after taking a multivitamin for more than a decade. Specifically, there was no difference in the number of heart attacks, strokes or death from vascular disease.  Similarly, the Women’s Health Study interim analysis published in the American Journal of Clinical Nutrition also found no benefit over 16 years of multivitamin use in reducing rates of heart attack, stroke or death from vascular disease.  Finally, in 2013 there were three articles published simultaneously in the journal Annals of Internal Medicine that found multivitamin use offers little or no benefit compared to placebo.  Keep in mind, these five articles I just referenced are only several out of many that have come to the same conclusion.

While studies are helpful in clarifying misconceptions, even without the evidence is it really surprising that our efforts to create a pill fall far short of nature’s ability to develop amazingly healthy fruits and vegetables? Think about it a moment.  Fruits and vegetables have hundreds, if not thousands, of vitamins, minerals and antioxidants that work together in concert to promote health in ways we don’t fully understand.  It is likely we still don’t even know all the components that are important.  If we agree this is true, then why would we believe a man-made multivitamin containing maybe twenty or so substances that were removed from their natural, organic form would be effective?  The short answer is it’s not.

While this scientific evidence and practical reasoning are terribly disappointing given the ease of taking a pill daily, it is better we know the facts so we can make choices that actually will promote our health now and in the future.  There is no substitute for nature.  So take the money you spend on multivitamins to the grocery store and stock up on delicious fresh fruits and vegetables!

Next week’s post:  Vitamins and Supplements, Part 2

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Five Weight Loss Myths

There’s nothing worse than gearing up to lose weight, setting the date to begin, finally initiating your plan, only to find your efforts fail.  Usually the failure is due to misinformation which is common nowadays given the endless articles, infomercials and word-of-mouth crazes we are bombarded with daily.  With this in mind, the following post will focus on debunking some common weight loss myths I hear frequently from patients in my practice.

Myth #1:  Skipping meals will help me lose weight.  It makes practical sense since skipping meals leads to less calories consumed.  Unfortunately, skipping meals also has the unintended consequence of slowing down your metabolism, making you less efficient at burning calories.  The net effect over time is that skipping meals makes it more difficult to lose weight and usually leads to having less energy in the day.

Myth #2:  Eating out frequently is okay as long as it involves healthy choices.  People often feel that a salad is a salad is a salad and it doesn’t matter if the salad is made at home or ordered in a restaurant.  While it would be nice and more convenient, this isn’t true.  To begin with, the portion size when eating out usually is twice the size of a salad made at home.  Twice the size means twice the calories.  Next, you have to consider restaurant salad toppings which almost always include unhealthy options such as croutons, crunchy Asian noodles or calorie-laden dressing.  Lastly, if you continue to rely on eating out, there will inevitably be stressful days when a salad won’t do and you will opt for food with more immediate gratification.

Myth #3:  Eating after 8pm will cause you to gain weight.  I am not sure where this concept began but the only place I know it applies is if you’re a Sumo wrestler!  Sumo wrestlers need to pack on pounds to be successful in their sport.  They tend to eat 20,000 calories a day with at least 10,000 of those calories late at night washed down with several pints of beer.  Unless you plan on moving to Japan and taking up this revered sport, it is safe to say that the problem with eating late has far more to do with the food choices you make at this hour than the hour itself.

Myth #4:  If I drink more water, I will lose weight.  Drinking water is healthy, and most people feel better when they are well hydrated.  They have less fatigue in the afternoon, less irritability, and are more likely to make positive food choices.  However, drinking more water will not help you lose weight unless the water replaces high calorie drinks such as soda, iced tea and fruit juices.  Next time you fill up your glass, remember that water has zero calories!

Myth #5:  If I exercise, I will lose weight.  Exercise may be the single best thing you can do for your health.  It will lower your risk of heart disease, high blood pressure and diabetes.  It will improve your mood, your balance and lower your risk of fractures.  Unfortunately, after the age of 35 or so exercise becomes an inefficient means of losing weight.  Consider if you take a three mile run.  You will burn approximately 350 calories, which may vary a little based on your size and speed.  Yet, there are 3,500 calories in a pound.  Your three-mile effort only burned 1/10th of a pound.  This doesn’t mean that exercise can’t assist in weight loss, as there are long term benefits regarding muscle development and metabolism.   However, the basic premise that beginning an exercise program such as walking or going to the gym by itself will help you lose weight successfully or quickly is not true.

So keep these thoughts in mind when planning your weight loss strategy.  Remember that, while not as exciting as the latest fad diet, focusing on a healthy lifestyle by preparing most of your meals and exercising moderately for health benefits is still the best and most successful means to a healthier and leaner you.

Next week’s post: The Truth About Taking Vitamins

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In 2013, the American Medical Association finally declared that obesity is a disease.  With that in mind, here are three facts I’d like you to consider:

  1. Over 35 percent of adults in the United States are obese.
  2. It is easier to gain weight than to lose weight.
  3. Almost all of us think about our own weight at some point each day.

The poem below hopes to shift the misconceptions those with obesity confront daily in favor of the understanding and empathy their plight to battle this illness deserves.


Morbid: a) characteristic of disease
b) characterized by gloomy or unwholesome feelings
c) grisly; gruesome

Today my doctor said
I am morbidly obese.

He said it with
a professorial tone
as I imagined
leather elbow patches
being sewn on his white coat.

He doesn’t know I was
a philosophy major
and I’m not certain
he remembers I’m a lawyer.
So he seemed surprised
when I responded:
“Doctor, I have read that
uncontrolled high blood pressure
is called severe,
and a person who ignores
their diabetes is
poorly controlled.
Even someone
with liver failure
is called cirrhotic.”
To which he nodded.
“So I have a weight problem
which may be severe, uncontrolled,
and even extremely unhealthy–
but I don’t think I’m morbid.”

Perhaps I was only arguing semantics
yet his shamed silence
did not give me the usual surge
I feel after winning a trial.
For these are the words
I did not share with him:

“I am reminded
of my fatness
when confronted
on the supermarket
checkout line
by beauty magazines
guaranteeing perfect abs
in six weeks.

I am reminded
of my fatness
when the person
boarding the plane
struggles a smile
when they realize
their seat is 16F
and mine is 16E.

I am reminded also
in the department store
when I tell the salesperson
who helped me find
a size 24 that
I’ll buy the dress now
but try it on at home.”

The world doesn’t see me
as a mother. They see
a fat mother.
They don’t see a wife
but a fat wife.
And a fat daughter,
fat lawyer and fat friend.

It’s a wonder
I am not gloomy,
gruesome or grisly.


Next week’s post:  Debunking 5 myths about weight loss

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Food Choices and A Busy Life

I recently decided to count the number of restaurants in a one-mile radius from where I work.  Specifically, I wanted to know the number of restaurants that I can place an order for lunch or dinner and receive it within fifteen minutes.  Having worked in the area for over twenty years, I guessed there are 25 restaurants or so within this distance.  To my surprise, there are actually 49 places to take-out food!

While this exercise could be used to check the accuracy of Siri or Google Maps, its real purpose is to highlight the ease of ordering dinner out. Unfortunately, over the last couple of decades our priorities as a nation of eaters have shifted, forgoing supermarkets and home cooking in favor of convenient, unhealthy and expensive take-out.  But is this a wise choice? Does this choice create habits that will lead to a lower risk of heart attacks, strokes or diabetes?  Does this choice help us lose weight?

Let’s look at the calorie content of some typical take-out options.  Jersey Mike’s is a popular sub shop in our city.  A standard turkey wrap with honey mustard has 539 calories.  If you add in a small bag of potato chips and sweet tea (I live in the South so this is a must), the total calorie count is over 900 calories.  Imagine if you were to make a turkey sandwich at home instead with whole wheat bread, tomato, lettuce and mustard.  With a piece of fruit and a bottle of water, the calorie count would be less than 300 calories.

Now on some days, a turkey sandwich simply won’t do and you need comfort food to combat the stressful day.  Chinese food would be that comfort food for me.  Well, according to PF Chang’s nutritional information, sesame chicken with fried rice would have 1,198 calories.  We won’t even discuss adding egg rolls or dumplings!

Here’s the fundamental point you will never hear recommended by the Department of Health and Human Services or the U.S. Department of Agriculture (USDA).  If you want to lose weight and be healthy, stop eating out frequently.

So what am I suggesting?  I recognize that stopping at the supermarket every night after a long day of work, then coming home to cook, is an unreasonable plan.  However, here’s an example of how to get from Sunday to Thursday eating dinners at home with minimal effort.  To begin with, on Sunday cook dinner with the purpose of having enough leftovers for Monday night.  Whatever you wish to cook is fine, as long as it includes a protein source such as chicken, fish or meat.  On Tuesday, stop at the supermarket on the way home from work and pick up a rotisserie chicken already cooked.  Don’t pick up the sides–only the chicken!  At home, microwave 90 second rice which all the main brands now have–whole grain or brown rice would be nice–while making a quick salad with lettuce and toppings such as tomatoes and cucumbers.  You will have leftover chicken for Wednesday to have a chicken sandwich with a side salad.  Finally, make Thursday a “breakfast for dinner” night with an omelet or different form of eggs, whole wheat toast and a piece of fruit for dessert.  The key to this plan is going to the supermarket on Sunday to buy everything ahead of time with the exception of the rotisserie chicken which you will get on Tuesday.  Try this for one week and I bet on Friday you will say:  “This week I ate delicious healthy food!  This week I saved money!  This week I lost weight!”

Next Week’s Post:  “Today My Doctor Said…”, a poem reflecting on living with obesity.

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Hello world!

“A bird doesn’t sing because he has an answer, he sings because he has a song.”

This quote by Joan Walsh Anglund, and associated with Maya Angelou, is the reason I am adding my name to the list of millions world-wide who have started a blog.  As a practicing general internist for over twenty years, I have perspectives and insights on health and nutrition borne out of tens of thousands of conversations with patients, families and colleagues.  The conversations have proven to me that oftentimes there are common themes to our health successes and failures–outcomes that are rooted in our similar experiences, challenges and cravings (translation:  I love chocolate!  I really do!).  I hope to share with you some of these themes by exploring relevant health topics, dispelling some common myths along the way (which may save you money in the health food store!), and answering any questions you may have.

Yet medical facts are not all I wish to share.  Facts alone can get boring and, more importantly, lose sight of the true impact and suffering illnesses create.  For this reason, I have spent several years writing poetry about specific medical conditions.  Poems are an effective way to gain insight into the personal, vulnerable, unscientific view of being sick. Whether suffering from cancer, dementia, migraines or obesity, searching the web can provide countless facts, scientific explanations and possible treatments but far too few websites speak about the actual experience of the illness.  So some of my blogs may start or end with a poem and all poems included will be archived for you to read separately if you wish.

I will post weekly and invite your feedback about the medical information, the poems, or suggestions as to topics you think would be helpful for me to write about.  At its heart, this blog is about sharing that which joins us together in our experiences and challenges to live a healthy and more compassionate life.

Thank you for reading!