How to use glucagon for treatment of severe hypoglycemia or low blood sugars!

Are you familiar with glucagon injections and how to use it?

Glucagon is a medication used to treat severe hypoglycemia. Hypoglycemia aka low blood sugar is typically defined by fingerstick values less than 70 mg/dl.

If you are a Diabetic, live with or care for a Diabetic (including teachers with a diabetic child in the classroom), or have a condition associated with low blood sugars -- then this information is very important to learn and share. Heck, this information is important for everyone really...as we could all be a first responder in case of a medical emergency involving hypoglycemia.

I recently was interviewed about a new intranasal version of glucagon that is currently in clinical trials, and I was reminded of the importance of instructing my Diabetics on how to use glucagon injections. Click here to check out my interview on intranasal glucagon. 

All diabetics using insulin should have access to a glucagon injection to help treat severe hypoglycemia. I tell my patients this is like the equivalent of an epinephrine pen for patients with severe allergies because it can be LIFE SAVING. 

Hypoglycemic symptoms can be mild, moderate or severe. See the image below for depiction of the symptoms in each category. Typically the mild and moderate symptoms of hypoglycemia can be treated with glucose tablets, orange juice, sugar, candies, etc. 

Today we are focusing mainly on severe hypoglycemia because these are the patients who need to receive glucagon!

What is glucagon?
Glucagon is secreted by the pancreas to help increase blood glucose levels. When the blood glucose levels are low (i.e. you are "hypoglycemic") glucagon is made by the pancreas to help increase blood glucose levels. I like to remember what glucagon does by the sound of its name which reminds me of "gluc (is) gone". 

Glucagon injections are important to help bring up blood sugars quickly when one is experiencing severe hypoglycemia. 

Remember - the symptoms of severe hypoglycemia include loss of consciousness (passing out), change in mental status (like confusion), inability to swallow, and seizures!

Glucagon injections could be difficult to use because it requires a few steps before administration...but if you become familiar with the steps it can be as easy as 1-2-3!

The instructions are usually in the kit itself, pictured here:

Here are 11 simple steps on how to use Glucagon:

If you or your loved one suffers from hypoglycemia, ask your doctor to prescribe them a glucagon injection kit. Even if you never use it, its best to be safe and prepared if severe hypoglycemia hits. 

Hope this information helps! Please feel free to email me at DoctorDeenaMD@gmail.com or ask/follow me on Twitter @Doctor_Deena

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How To Recognize Symptoms of Type 2 Diabetes

Dear Dr. Deena,
What are some of the common symptoms of Diabetes?
Thanks,
RA

Thanks for reaching out to me, RA. It's important to note that Diabetes can be a silent killer with no symptoms present. Approximately 1 in 4 people with diabetes will have NO symptoms.

Even if one does not experience symptoms related to Diabetes, they may still be at risk for developing the long-term effects of high sugars on the kidney, nerves, eyes, and other organs. We will discuss these complications at another time.

The most common symptoms of Diabetes are:

1. Increased frequency of urination 

When glucose levels are high, your body attempts to get rid of the excess sugar by urinating it out along with water. You may notice that poorly controlled diabetics are constantly going to the bathroom

2. Increased thirst 

As you urinate out more water and sugar – you lose fluid. When you lose fluid you become dehydrated and dehydration leads to increased thirst

3. Blurred vision 

High glucose levels can cause part of your eye (called the lens) to swell and make it difficult to see 

4. Extreme Fatigue

5. Weight Loss even despite no change in diet or eating more

This is more typically seen in Type 1 Diabetics as they lose skeletal muscle mass 

6. Tingling, pain, or numbness in the hands and/or feet

High blood sugars over time can cause nerve injury which lead to these symptoms, called "neuropathy"

7. Sexual dysfunction in men

High blood sugars over time can cause nerve injury and blood vessel injury around the penis which may lead to erectile dysfunction

If you or your loved one are experiencing the symptoms I have outlined above -- you should reach out to your doctor right away to be evaluated for Diabetes. The diagnosis can be made with a simple blood test!

I hope this information was helpful, RA. As always please feel free to send all questions and comments to DoctorDeenaMD@gmail.com.

Fun fact:

Do you know the story behind how this condition got its name?

Diabetes is short for it's full medical name -- Diabetes Mellitus which means "passing through of honey." (Remember that Diabetics have high amount of sugar (or glucose) in their blood and urine). The name was coined by Dr. Thomas Willis in the 17th century (the Circle of Willis was named after him as well!). 

Dr. Willis determined whether his patients had diabetes or not by sampling their urine.  If it had a sweet taste he would diagnose them with diabetes mellitus or "honeyed" diabetes. Interestingly -- he is not the first person to have done this...ancient manuscripts date back to the year 960 where the Persians mentioned this sweet taste of urine in patients who were very ill. This method of monitoring blood sugars went largely unchanged until the 20th century.

What is Diabetes?

Dear Dr. Deena,
What exactly is Diabetes? Can you please explain what happens in Diabetes in a simple way?
Thanks,

CW

Thanks for your question, CW. Diabetes happens to be one of my special interests, and I am very excited to teach you more about this disease.

The mechanisms by which people develop Diabetes is quite complicated, but I will try to explain it in a very basic way.

Most of us know at least one person who has Diabetes. According to the American Diabetes Association -- in 2012, 29.1 million Americans, or 9.3% of the population had Diabetes. This number is projected to increase every year, which is why it is so important to learn about this disease and what we can do to prevent it!

Diabetes is a medical condition that disrupts the way your body uses glucose. Glucose is often referred to as “sugar” and you may have many friends who refer to Diabetes as a “sugar problem”.  Sounds familiar right?

After you eat, your body breaks down the food you eat into glucose. Glucose is then absorbed into your bloodstream where it is taken up by cells. These cells use glucose as a form of energy to fuel most bodily functions. 

You may have heard of Insulin? Insulin is a hormone that is made by the pancreas.

The pancreas is located in your abdomen, and its main function is to produce insulin and other hormones which balance the levels of glucose in our bodies.

                                                                   
Insulin’s main role is to allow glucose (or sugar) to enter into cells. Without Insulin, glucose cannot enter into the cells.  This results in glucose building up in the blood which is exactly what happens in patients with Diabetes.

See the diagram below -- and picture a cell in your body with a door which leads into the cell. This door always stays locked and only the right key in this keyhole will unlock the door.

To let glucose into the cell, the door to the cell has to be unlocked.  Insulin is the special key that unlocks this door to the cell.

As long as the Insulin key works in the lock…. the door will open. When insulin unlocks the door to the cell, glucose can move from the blood into the cell to provide energy.

              

There are 2 types of Diabetes that exists -- Type 1  and Type 2. Its important to understand the difference, since both types require different medications.

Type 1 Diabetes occurs when the immune system attacks and destroys cells of the pancreas. Since the pancreas is destroyed it can no longer make Insulin.

Type 1 Diabetics cannot make Insulin, and are dependent on Insulin injections to survive. Type 1 Diabetes is most commonly seen in younger people, usually before age 40, but can occasionally be seen in adults. 

Let's go back to how Insulin is like a key which unlocks the door to cells to allow glucose to enter the cells. Since those with Type 1 Diabetes do not make insulin, there is no key to allow glucose to enter into the cells (the doors of the cell stay locked because there is no key).

As a result the level of glucose in the blood grows higher which leads to Diabetes.  Patients with Type 1 Diabetes have high levels of glucose and low levels of insulin.

Type 2 Diabetes is the most common type of Diabetes.

 In Type 2 Diabetes – patients are able to make insulin but the body does not respond to insulin in a normal way.

 In T2DM, cells that take up  glucose are “ resistant” to the effects of insulin, therefore glucose is less able to enter cells even when Insulin is present. When glucose cannot enter into cells – there is a rise in the glucose levels in the blood. This rise in glucose stimulates the pancreas to make even more Insulin.

To better visualize this- - lets once again envision Insulin as a key. Insulin is a key to the cell’s door which allows glucose to enter into cells. In Type 2 Diabetes the key to the door (Insulin) isn’t always working very well, and the door remains locked.

While the door remains locked…the glucose levels increase in the blood. The pancreas sees this, and makes even more keys (Insulin) with the hope that one of the keys will work to unlock the cell doors.

Eventually one of the keys is able to unlock the door and some glucose (but not all glucose) can enter into the cell. This why Type 2 Diabetics have high levels of glucose AND high levels of Insulin. 

Type 2 Diabetics can be trialed on oral medications to help treat their Diabetes since they make Insulin; however, majority of Type 2 Diabetics will require Insulin over time if their Diabetes is poorly controlled.

I hope that paints a clearer picture of what Diabetes is and the different types of Diabetes that exists!

Feel free to leave comments below, and please email me at DoctorDeenaMD@gmail.com with any further questions.

The importance of Vitamin A

Dear Dr. Deena,
I hear so much about taking Vitamins daily. Can you tell more about Vitamin A?
JJ


Vitamin A is important for proper functioning of our immune system and the maintenance of healthy skin, bone and teeth. Vitamin A is essential for our vision (especially during the night when light is dim), since it is the main component of a protein called rhodopsin (which helps our eye form images at low light intensities).

Who Is At Risk for Vitamin A Deficiency?

Vitamin A deficiency is quite rare in the USA, but is quite common in underdeveloped countries in the world. The most obvious symptom of Vitamin A deficiency is called "xerophthalmia" or night blindness. 

Some of those at risk for Vitamin A deficiency include:

-Those suffering from poor nutrition due to limited access to foods containing Vitamin A

-Those with diseases effecting the pancreas like Cystic Fibrosis, pancreatic insufficiency, chronic pancreatitis, pancreatic cancer, etc.
The pancreas releases enzymes that help break down fats, allowing for improved absorption in the intestines. Vitamin A is composed of fats. If the pancreas is not functioning properly, Vitamin A cannot be broken down and absorbed appropriately.

-Those with diseases effecting the gall bladder like Choledocholithiasis (or obstruction of the bile duct), Primary Sclerosing Cholangitis, Cholangiocarcinoma (gall bladder cancer), etc.

The gall bladder releases a substance called bile which helps aid in the absorption of fats, such as Vitamin A. If the gall bladder is not functioning properly, Vitamin A cannot be absorbed by the intestines.

-Those with diseases effecting the intestine like patients who have undergone surgical resection of the intestines, those with Inflammatory Bowel Disease, Celiac Disease, etc.

Fats, like Vitamin A, are absorbed in the intestine. If the intestines are not functioning properly, Vitamin A cannot be absorbed appropriately.

Sources of Vitamin A

Sources of vitamin A are highest in liver and fish oils. According to the Institute of Medicine - "the top food sources of vitamin A in the U.S. diet include dairy products, liver, fish, and fortified cereals; the top sources of provitamin A (a precursor to vitamin A formation) include carrots, broccoli, cantaloupe, and squash ."

Beta carotenes, found in plant products, are converted to Vitamin A in our body. 
Foods high in beta carotenes include:
-Bright yellow and orange fruits such as cantaloupe, pink grapefruit, and apricots
-Carrots, pumpkin, sweet potatoes, and winter squash
- Leafy vegetables like broccoli and spinach

Recommended Doses of Vitamin A

According to the The Food and Nutrition Board of the Institute of Medicine:

The Recommended Dietary Allowance (RDA) for vitamins is how much of each vitamin most people should get each day. The RDA for vitamins may be used as goals for each person.

Children (RDA)

1 - 3 years: 300 mcg/day

4 - 8 years: 400 mcg/day

9 - 13 years: 600 mcg/day

Adolescents and Adults (RDA)

Males age 14 and older: 900 mcg/day

Females age 14 and older: 700 mcg/day

How much of each vitamin you need depends on your age and gender. Other factors, such as pregnancy and your underlying health, are also important.

Too much Vitamin A can lead to a Vitamin A toxicity, which can lead to liver failure, kidney damage, brain swelling and ultimately death. This is why it is important to ask your doctor what dose is best for you. 
 
True or false:
 Eating too many carrots can turn your skin orange.

Answer: True!


This condition is called "carotenemia" and it is caused by the excessive intake of carrots or other vegetables which increase the levels of carotenes in the blood. This is a harmless condition and is usually seen in lighter-skinned individuals, infants, and young children. 

These "Carotenoids" are deposited in the thickest layer of the skin called the stratum corneum. This is why the color change is most notable in the areas where skin is the thickest:  palms, soles of feet, knees, and nasolabial folds.  

As mentioned before this condition is harmless, as the body will regulate the levels of carotenes. Those with carotenemia will get better slowly over weeks to months depending on how much carotene was consumed.   

Here is a photo of the palm of a patient with carotenemia compared to a normal palm:

I hope you found this information helpful! 

Please feel free to leave comments below, and email me at DoctorDeenaMD@gmail.com with any questions or tips that you would like me to discuss!

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All About the Flu!

Dear Dr. Deena,

What is the flu and how do I avoid it?

Thanks,

Rob

Hi Rob. Thanks for your question which is just in time for Flu season!

Flu is caused by a virus known as the Influenza virus. There are many different types of Influenza viruses. The Influenza vaccine protects us against the most common types of Influenza during that particular season -- but there is always a possibility of catching a strain that is not covered by the vaccine.

The flu virus is mainly spread through respiratory droplets in the air (via sneezing or coughing), but can also occur after touching surfaces which have been contaminated with the virus (mainly touching the contaminated surface with your hand and then touching one's eye, mouth, or nose). The reason the flu is so common in the wintertime is because the air is drier, allowing the virus particles to stay in the air much longer. When the air is humid, these virus particles are surrounded by water which increase its weight and cause it to drop down to the surface more quickly. Studies have shown that human influenza viruses generally can survive on surfaces between 2 and 8 hours. This is the reason why the flu is much less common in the more humid, warmer parts the world and more prevalent during certain times of the year.  The flu is also more common during the wintertime as more people stay indoors, which means you are more likely to come in contact with the germs of a sick individual. 

Common flu-like symptoms include runny nose, coughing, sneezing, sore throat, muscle weakness, chills and feeling tired. These symptoms usually get worse over 2-3 days, and then slowly get better over days to weeks! Generally those with underlying lung disease or poor immune status (patients on chemotherapy, people with HIV, etc,) take longer to recover from the flu.

Steps that can be taken to avoid the flu:
-Avoid close contact with sick people
-Keep at least an arm's distance away from sick contacts
-While sick, avoid close contact with others
-Cover your nose and mouth with a tissue when you need to cough or sneeze
-Wash your hands often with soap and water
-Wipe up all contaminated surfaces with soap and water or other disinfectants
-Get vaccinated. Click here to read who should get vaccinated.


Hope this helps! 

Please feel free to email questions to DoctorDeenaMD@gmail.com and share your comments below!

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Interesting Fact:
A single sneeze can release over 40,000 droplets. It only takes exposure to a FEW of these droplets to be infected by the flu!

How much calcium is right for you?

Today's blog is regarding the recent BMJ article concluding that calcium supplementation does not decrease fracture rates in men and women above age 50. 

Readers should be aware that there are many limitations in this article and it may not be appropriate to increase/decrease your daily calcium goals based on whats reported here. I will not detail these limitations, but my take home message to all of you is: not every man or woman above age 50 needs calcium supplementation, but in SOME people extra calcium might be necessary for fracture prevention. You should work with your doctor to find out what's the right dose for you.

There are so many factors involved when deciding how much calcium a person needs daily -- and I always believed that recommending one target dose for all men and women above age 50 is not ideal! This is why I am a firm believer in individualizing treatment plans, and hopefully I can convince some of you to do the same.

I liked this article because it proves to me the importance of "patient centered" medicine -- choosing therapies based on the individual patient & less based on guidelines. I try to practice this with my patients as often as possible because every patient or disease is not created equal.

Some women above age 50 may need 1200 mg of total calcium daily, and some may need only 800 mg. The difficult problem is figuring out how much calcium each individual actually needs every day. 

You may be wondering why women over age 50 have higher calcium requirements per the guidelines (~1200 mg daily) -- its because after menopause women make less estrogen and without estrogen there is increased bone loss. Some post-menopausal women are able to keep up with their bone loss by drinking a few glasses of milk a day, but others might depend on calcium pills to prevent bone loss that can eventually lead to osteoporosis and/or fractures. Our goal as a provider is to identify which patient needs what type of intervention and how aggressive we need to be with calcium recommendations. 

Rather than following guidelines, I would suggest tailoring a patient's calcium needs by looking at the patient's overall clinical picture which incorporates some of the factors listed below. 

My recommendations are only for those with normal calcium, normal vitamin d, and normal calcium excretion.

Here are some factors to take into consideration when deciding on a target daily calcium goal (this is only a partial list):

- underlying medical conditions (such as conditions causing lack of absorption of nutrients and minerals (like Celiac Disease), Hyperthyroidism, Inflammatory Bowel Disease...just to name a few)
- fracture history
- family history of osteoporosis or hip fracture (especially when diagnosed before age 50)
- social habits (smoking and excessive alcohol intake are risk factors for bone loss)
- diet (especially in patients with lactose intolerance who take minimal dairy)
- lack of exercise
- medications (like steroids which cause bone loss)
- bone density scan results
- low body weight

First we must attempt to fix the modifiable risk factors  (i.e. lack of exercise, tobacco use, excessive alcohol intake, use of certain medications, low body weight, etc.).....and then we should figure out how much daily calcium (through diet and/or pills) is appropriate for the individual (if any).

The only issue here is that not every person we deem as high risk, requires a higher level of calcium. This is why the next step is so important.

Before following the next step please make sure that the person does not have a condition associated with hypercalciuria (too much calcium in the urine) or hypocalciuria (too little calcium in the urine) -- since these patients will have abnormal urine calcium amounts independent of supplementation. Some of these conditions include kidney disease (specifically kidney stones), problems with the parathyroid gland, certain medications (like Lasix), etc. If your patient has a medical condition associated with hypocalciuria or hypercalciuria, they should be seen by an endocrinologist (a specialist in bone and calcium) or a nephrologist (a specialist in the kidney).

For those who do not have the conditions described above, one can determine whether or not a person's daily calcium goal is adequate, by measuring 24 hour urine calcium and creatinine. My Endocrinologist colleagues use this often to determine whether or not calcium intake is too high, too low, or just right. Remember this test can ONLY be used in patients who have no medical conditions or risk factors (like medications) associated with hypercalciuria or hypocalciuria (see above).

When I evaluate a 24 hr urinary calcium, I consider values >300 mg/day in women and >250 mg/day in men as high. 
A high 24 hour urinary calcium can suggest that a patient's daily calcium goal is too high--i.e. they are either consuming too much dairy, being over-supplemented with calcium tablets, or both.  Remember too much calcium in the urine is also a risk factor for developing kidney stones!
If a patient has high levels of calcium in the urine, I would recommend a lower daily goal for calcium depending on the level of hypercalciuria. 

If a patient has low levels of calcium in the urine, I would first check 25- Hydroxyvitamin D levels to ensure there is no issues with calcium absorption. If 25- Hydroxyvitamin D levels are normal, only then would I recommend a higher daily goal for calcium depending on the level of hypocalciuria. If 25-Hydroxyvitamin D levels are low, we must fix this number first before advising more calcium intake (since vitamin d is necessary for calcium absorption).

Once a change is made in the daily calcium dose, urine studies should be monitored every 1-2 months with dosing adjustments until the urine calcium levels are normal. If you ever have questions about this, feel free to refer your patient to an Endocrinologist (we specialize in bone disease!)

So with that.....I will end this by saying -- use guidelines for guidance only, don't let them dictate your care! Individualize patient care by treating every one of your patients differently.....it could lead to better outcomes. 

Hope this information helps! Please feel free to email me at DoctorDeenaMD@gmail.com or ask/follow me on Twitter @Doctor_Deena


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All the reasons why salt is GOOD for you (in moderation)!

Visiting the salt flats in Bolivia made made me think of the value of salt. Many people believe that too much salt is bad for you, and can lead to health problems. This is an ongoing debate with research supporting both sides of the argument. Unfortunately there's no definitive answer as to what's right or wrong-- so moderation is key.

I recently took care of a healthy 60 year old man who had continuous seizures in the ICU  due to restricting salt in his diet BC he believed that it was "the healthy thing to do". Giving him back salt, literally helped save his life! So I'm here today to talk about why salt is good for you!

The American Heart Association recommends less than 2 grams of salt per day. Those with heart disease, high blood pressure, kidney disease, stroke, or lower extremity swelling should take less than this amount.

Salt is important for the normal functioning of all our vital organs - like the heart and brain.

Salt, or sodium chloride, is broken up into sodium and chloride ions. Today we'll focus on sodium ions which are important for the functioning of many cell membrane transporters that allow for important cell communication and signaling. These transporters are located on the surface of the cells of many important organs. Without salt, these transporters don't function properly and lead to problems associated with delayed cell signaling -- like change in mental status, seizures, confusion, low heart rate, abnormal heart rhythm, etc.

Hormones depend on salt to maintain water balance in the body and blood pressure. Water is the main fluid in your body,and is roughly 60 percent of your body weight. Water is necessary to maintain the health of all our cells and organs. Salt signals hormones to shift water into different body spaces to help maintain fluid balance. This fluid balance is vital for our bodies to function normally. 

Salt is a source of iodine. Iodine is necessary for the creation of thyroid hormone. Thyroid hormone is important in maintaining your body's metabolic rate and proper functioning of all organs.

Iodine deficiency leads to goiter (or enlargement of the thyroid gland), like in this gentleman:

Hope this information helps! Please feel free email me at DoctorDeenaMD@gmail.com 
or ask/follow me on Twitter @Doctor_Deena or Instagram at  live.laugh.love.be_healthy 

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How to prevent and treat altitude sickness!

Last week I blogged about what altitude sickness is all about 
Today, I will discuss a few tips on how to prevent and treat altitude sickness! 

Firstly - its important to remember that altitude sickness can happen to anyone....old, young, healthy, innactive, etc. There's really no way to predict who will develop it! However; those who have an underlying medical condition (especially of the heart and/or lungs) should discuss w/ their doctor whether or not their body is prepared to deal with a higher elevation.

Here's a short list of tips to keep in mind: 

1. The key is acclimatization. Plan an itinerary so that you do not go directly to the destination with the highest altitude first. Stay in cities at lower altitudes (at least greater than 3000 feet) for 2-3 days and then gradually ascend higher every few days. Let your body get used to the lack of oxygen! (it takes about 2-3 days for your body to acclimatize to a new altitude)

2. Keep hydrated by drinking plenty of water

3. Go at your own pace. Some people will notice increased shortness of breath even after 1 flight of stairs. If you start getting short of breath....slooow down!

4. Obtain a prescription for acetazolamide or dexamethasone (if you have a sulfa allergy). Take these pills 2 days before you start your ascent & continue the medications until you have descended to a lower altitude

5. Be aware of the side effects of acetazolamide! (We all experienced these side effects during our trip to Peru!)These include numbness/tingling in the hands/feet, drowsiness, nausea, vomiting, taste changes, blurred vision, eye sensitivity to light, and/or hearing changes

6. If you have heart or lung problems (especially if you use oxygen) make sure you get medical clearance by a physician first. The worst thing that can happen is having a medical crisis in an area with no convenient hospitals! 

7. (If traveling to Peru) Drink coca tea aka mate de coca -- a local remedy for altitude sickness. The coca leaves, used to make the tea, contain alkaloids which many Peruvians believe help prevent altitude sickness

8. If your symptoms get worse-- seek out oxygen (tanks are usually available in hotels, clinics, hospitals, and even some pubtalic buses) and plan to descend to a lower elevation ASAP

Hope this information helps! Please feel free email me at DoctorDeenaMD@gmail.com 
or ask/follow me on Twitter @Doctor_Deena. 


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Traveling to a mountainous region? What you need to know about altitude sickness!

Being in Peru has inspired me to blog about altitude sickness, especially since I'm experiencing it myself currently!

I figured I'd write this blog from the highest altitude that I've ever experienced  -- Puno, Peru (where Lake Titicaca is located )-- at 12,600 feet and where I am having the most symptoms of altitude sickness. Rather than sight-seeing, I'm taking it easy and blogging instead (see how important you are all to me!)

If you are not aware or prepared for altitude sickness, it can be one scary journey... and this blog is meant to prepare you for this issue before you plan your next vacation in high altitudes.

As the name implies altitude sickness develops when one travels to a higher altitude, typically greater than 7,000 feet, though some report symptoms even at 5,000 feet.
At high altitudes there is less oxygen and the symptoms of altitude sickness occur because of this. The higher the altitude, the more likely you are to develop symptoms.

The most common symptoms include headache, shortness of breath, fast heart beat, nausea, vomiting, fatigue, weakness, difficulty sleeping and dizziness. These symptoms, especially the shortness of breath, occur more often with increased exertion.

The most serious symptoms of altitude sickness arise from edema-or fluid accumulation in the tissues of the body. At very high altitudes (typically between 12,000 to 18,000 feet), humans can get either high altitude pulmonary edema (HAPE) -- which results from fluid in the lung-- or high altitude cerebral edema (HACE) --which results from swelling of the brain. Extreme altitude, with the least amount of oxygen, occurs at greater than 18,000 feet and interestingly there is no permanent human habitation above 20,000 feet due to severe lack of oxygen.

Symptoms of HAPE include shortness of breath at rest and a cough productive of a frothy sputum. 

HACE is even more life threatening and can lead to altered mental status, loss of control of one's bowel/bladder, seizures, and muscle weakness or even paralysis.

Given the range of severity in altitude sickness, it's important to be aware of the tourist destinations where one may experience altitude sickness. 

Here are some of the most common tourist destinations associated with altitude sickness:

1. Mount Everest, Nepal at 17,600 feet

2. Lhasa, Tibet at 12,000 feet

3. Puno, Peru at 12,600 feet

4. Cusco, Peru at 11,000 feet

5. Vail, Colorado at 8,150 feet

6. Macchu Picchu, Peru at 7,970 feet

There are many cities that I have left off of this list. If you are ever planning to travel to a mountainous area-- consider your risk for altitude sickness.

Do you have any additional cities to add to the list? If yes, please feel free to add comments or email me at DoctorDeenaMD@gmail.com 

or ask/follow me on Twitter @Doctor_Deena.
 https://twitter.com/Doctor_Deena

Next blog, I'll chat with you about the ways to prevent and treat altitude sickness!

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Week 3 of My Fitness Challenge: Make Your Plate More Green, BUT Be Aware Of Those High Carb Veggies!

This week was all about discovering carb alternatives and what worked for me to limit my carb intake.

This is most important for all my Diabetic friends out there as high carb meals will cause spikes in blood sugar.

First rule of thumb -- the greener your plate, the better. The more veggies on your plate, the less room for carbs.

But be aware that some veggies can be high in carbs, and should be consumed in moderation!

What are those high-carb vegetables that are considered "starchy" or what I like to call "carby"?

They include: (in order of most amount of carbs to least amount of carbs):

1. Plantains (1 cup of plantains = 47 grams of carbs)
2. Yams (1 medium yam = 38 grams of carbs)
3. Taro (1 cup sliced taro = 30 grams of carbs)
4. Potatoes (1 medium potato = 26 grams of carbs)
5. Peas (1 cup of peas = 24 grams of carbs)
6. Parsnip (1 cup of parsnips = 24 grams of carbs)
7. Sweet Potatoes (1 medium sweet potato = 20 grams of carbs)
8. Corn (1 ear of corn = 20 grams of carbs)
9. Water chestnuts (1 cup of water chestnuts = 20 grams of carbs)
10. Winter Squash, Acorn Squash, Butternut Squash (1 cup of squash ranges from 16-20 grams of carbs)
11. Beets (1 cup of beets = 15 grams of carbs)
12. Carrots (1 cup of chopped carrots = 13 grams of carbs)

What are your favorite low-carb vegetables? Mine happens to kale, which can be made in so many great ways!

Please feel free to share with me your carb alternatives at doctordeenamd@gmail.com.

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