Glucose is your blood sugar. Insulin is a hormone, arguably the most important hormone of all. Insulin determines what your body does with the calories you consume. Do you store them as fat or burn them as fuel? Insulin is a major determining factor of how your body functions, what your body composition is (percentage of body fat vs. percentage of muscle and bone), and even how hungry you are and what you’re craving. Insulin is an anabolic (tissue-building) hormone made and secreted by the pancreas that regulates blood glucose levels.

One of my favorite work assignments is to make rounds as the cardiologist in charge of the Cardiovascular A Service at Saint Luke’s Hospital of Kansas City. I get to work with young doctors and medical students, who teach me as much as I teach them. During their decades-long medical education, they will receive virtually no training in nutrition. This is unfortunate because we have an increasingly evidence-based understanding of how the right diet and lifestyle can help us avoid or treat nearly all the most common diseases and ailments that shorten our lives and make us miserable. When I am on rounds, I encourage the team— a cardiology fellow, residents, interns, pharmacists, and medical students— to read Why We Get Sick by Benjamin Bikman, PhD, and Metabolical by Robert Lustig, MD. The theme of these books is that a high-sugar diet of ultra-processed foods is at the root of most chronic diseases. Both teach that the sure-fire and inexpensive path to a sexy waistline and robust metabolic health is a diet of whole-natural foods devoid of fast and processed foods.

What and how often we eat affects our hormonal balance. In turn, those hormones, especially insulin, ramp up the appetite and store calories as fat inside the abdomen. Consuming refined carbohydrates drives insulin levels up. Eating frequently keeps insulin levels high. Protein stimulates only a small insulin spike. Fat is the only macronutrient that does not affect your blood sugar or insulin level. So fat is your friend if it’s from nuts, seeds, avocados, extra virgin olive oil, and fish. On the other hand, processed carbs (added sugar and refined grains) are the evil villain; when you eat these foods, the insulin spike tends to turn those calories into belly fat, which eventually causes inflammation and disease.

A seemingly “healthy” breakfast of a whole wheat bagel and orange juice spikes your blood sugar, causing your insulin to rocket up. For lunch, you have a sandwich, a bag of chips, and a Diet Coke. The afternoon snack is a muffin, then for dinner, you have spaghetti with ice cream for dessert. This is the Standard American Diet. It keeps your insulin levels sky-high all day, and in no time your body becomes numb to the effects of chronically high insulin, causing your cells to become insulin resistant.

Insulin resistance causes most of the diseases that we are prone to get in the modern world. To make matters worse, insulin resistance makes you tired, fat, irritable, and constantly craving more sweets, carbs, and junk food. High insulin levels also raise blood pressure and cholesterol levels and cause inflammation and fluid retention.

How the blood glucose and insulin levels go up and down is influenced by how easily digestible the food is; how much sugar, white flour, and other refined carbohydrates it contains; how much fiber you consume; how well you slept last night; how much exercise you’ve done recently; your genes; your body composition; and even your gut microbiome—the trillions of microbes inside your intestines that help you digest food and boost your immunity.

People who have diabetes and are taking insulin are often prescribed a continuous glucose monitor (CGM). It measures and records your glucose levels 24 hours a day, sending results to an app on your smartphone. Until recently, CGMs were very expensive, about $400 per month, and only people with diabetes and good insurance had access to this game-changing technology. In the past year, less expensive CGMs have become available that can be affordable for people without diabetes.

I have been wearing a CGM monitor for much of the past 12 months, and I love it. A CGM is the most powerful behavior modification tool ever. For instance, sometimes when I was on call and got hungry, I would wolf down a bag of corn chips for a snack. When I did that while wearing a CGM, I was shocked to see that this tasty snack spiked my glucose to 150 mg/dL. That CGM feedback convinced me that I need to avoid chips.

Insulin changes blood sugar into triglycerides and stores it as fat in the abdomen and in your liver. The fat in your belly, called visceral fat, churns out inflammatory hormones, makes you insulin resistant, and causes disease and aging. On the other hand, subcutaneous fat—the kind that you can pinch or jiggle—is generally harmless.

Your muscles are the primary engine that burns 80% of the sugar in your bloodstream. So any sort of physical activity will combat insulin resistance because it removes glucose from the bloodstream without the need for insulin. Along with more exercise, the best ways to restore insulin sensitivity is to avoid sugar and refined carbs. Also try to follow a gentle fasting routine whereby you don’t consume any calories or artificial sweeteners for at least 12 hours every night, especially the three to four hours before bedtime. Fat is stored energy; thus, your body fat is what you burn when you fast. More fasting = less belly fat.

Avoid drinking any beverage that contains sugar, including fruit juice, which floods your body with fructose—a particularly addictive and metabolically damaging sugar that generates an insulin spike and gets stored as belly fat. One exception I make is low sodium V8 juice, which has only 7 grams of sugar in 8 ounces and is loaded with healthy nutrients. Fruit in moderation is OK because it has lots of fiber and other nutrients that offset the sugar.

In Good Health,
James O'Keefe, MD

Lifestyle Improves CV Risk

Lifestyle strategies can produce weight loss and improve long-term health outcomes for people who have diabetes. Dr. Y.B. Zhang and colleagues in a recent issue of the Journal of Mayo Clinic Proceedings reported that people with diabetes who followed a healthy lifestyle had much lower risks of CV disease and death from any cause during a 10-year study. This was a large international study that included more than 100,000 individuals living with diabetes (about 50% were from the U.S., and about 25% each from China and the United Kingdom); 93% of the participants were over age 30 when diagnosed, indicating that the vast majority likely had type 2 diabetes.

The five healthy lifestyle factors assessed were: having an optimal body weight with a waist measurement of less than 33.5 inches for women and less than 35.5 inches for men; following a healthy diet; performing regular physical activity (at least 150 minutes per week of moderate exercise, like walking); being a nonsmoker; and drinking a low-to-moderate amount of alcohol regularly (not more than seven drinks per week for women and not more than 14 drinks per week for men). Study participants following four or five healthy lifestyle factors compared to those following only one or none, had a highly statistically significant 40% lower risk of death during the decade-long study. Attaining each one of the healthy lifestyle factors was associated with a statistically significant 16% lower risk of death during the study. People following four or five healthy lifestyle factors, compared to those following only one or none, also had a significant 33% decreased risk of heart attack and stroke.

Clearly, healthy lifestyle habits are essential for longevity and robust heart health. However lifestyle-based weight loss strategies, such as diet and exercise, though often effective in the short term, tend to be less effective in the long term because most people with obesity tend to regain their excess weight over time. For this reason, safe and effective medications to help people lose weight and keep it off are desperately needed.

New Wonder Drugs

In 1921, Dr. Frederick Banting discovered the first effective drug for diabetes by extracting insulin from the pancreases of young cows and using it in his diabetic patients. One century later, we have 13 classes of glucose-lowering drugs, including hundreds of FDA-approved medications for the management of type 2 diabetes. Though all these drugs reduce blood glucose, not a single one had been proven to lower the frighteningly high risk of CV death among people with type 2 diabetes until 2015, when a study called EMPA-REG Outcome showed that Jardiance (empagliflozin) reduced risk of CV death by 38%.

In the past seven years, many randomized outcome trials of medications called sodium glucose cotransporter 2 (SGLT2) inhibitors (examples include Jardiance, Farxiga, and others), and glucagon-like peptide 1 (GLP-1) receptor agonists (examples include Ozempic, Trulicity, and others), have proven that these two classes of anti-diabetic drugs bestow important benefits, including lower risk of heart failure, heart attack and stroke, as well as kidney disease. Because of these benefits, professional societies across the world recommend these medications in individuals with type 2 diabetes who already have—or are at high risk for—heart and kidney complications. Notably, these drugs are also effective for promoting weight loss for overweight and obese individuals.

These agents also help lower blood pressure and decrease the risk of chronic kidney disease progression. Importantly, SGLT2 inhibitors have now been found to be effective for improving outcomes in patients with heart failure and kidney disease even if they don’t have diabetes. Similarly, GLP1- RAs have been shown to result in substantial weight loss in individuals with overweight and obesity, but no diabetes (and are being evaluated for potential CV benefits in such individuals).

Here at the Haverty Cardiometabolic Center of Excellence and the Duboc Cardio Health & Wellness Center, we specialize in using these potentially lifechanging new treatments to improve the outlook for our patients with diabetes, prediabetes, and other cardiometabolic conditions, and help people get back to a healthy weight and waistline.

Safe and Effective for Weight Loss

Half of American adults have either diabetes or prediabetes, conditions that are frequently linked to overweight and obesity. Getting rid of excess weight around your abdomen can improve many CV risk factors, including high blood pressure, high cholesterol/triglycerides, fatty liver, and sleep apnea. Substantial weight loss can significantly improve diabetes control, and occasionally can even make type 2 diabetes go away.

When patients ask us how much they should weigh, we tell them, “You don’t need to focus on weight as much as waist measurement. Ideally, your waist should measure not more than half your height in inches.” So, if you are 6’ tall (72 inches), your waist should be no more than 36 inches; if you are 5’6” (66 inches), your waist should be no more than 33 inches.

Semaglutide (Ozempic) and liraglutide (Victoza) are GLP-1 receptor agonists that are FDA-approved for weight loss. These agents lower body weight by up to 5–15% by reducing appetite and slowing the rate at which your stomach empties thus increasing the feeling of fullness after you eat. Most people find that their cravings for junk food, sweets, and sometimes even alcohol are diminished. The weight loss is gradual, as the dose is increased slowly over three to six months in order to maximize their tolerability.

Empagliflozin (Jardiance) and dapagliflozin (Farxiga), the SGLT2-inhibitors most commonly prescribed in the US, are medications taken by mouth that generally produce relatively modest drops in body weight, typically 3–4% in obese people, and blood pressure, about 4 mm/Hg in people with high blood pressure. Importantly, the weight loss is additive when these two classes of drugs, SGLT2-inhibitors and GLP-1 agonists, are used together (and importantly their cardiovascular benefits may be additive as well).

Best Drug Ever For Weight Loss

Tirzepatide (Mounjaro) is a new once-weekly injection that represents a novel class of drugs that is now available for type 2 diabetes and is being studied for the treatment of obesity. This medication binds to the receptors in the body for two natural incretin hormones, GLP-1 and glucose-dependent insulinotropic polypeptide (GIP). So far, it’s approved for treating type 2 diabetes; however, tirzepatide looks to also be a highly effective drug for weight loss.

A randomized placebo-controlled clinical trial published in the New England Journal of Medicine studied tirzepatide for weight loss among obese individuals. Low-dose tirzepatide (5 mg injected subcutaneously once per week) caused a 15% decrease in body weight; full-dose therapy (15 mg/week) lowered weight 21%, or about 50 pounds on average. Tirzepatide also reduced waist measurement, blood levels of cholesterol, triglycerides, insulin, and glucose, and improved blood pressure. Side effects were limited to gastrointestinal symptoms, such as nausea, diarrhea, and constipation, which tended to diminish after a few days to a few weeks.

Take Home Message

Lifestyle strategies like diet and exercise are effective for improving heart health and life expectancy, and these remain first-line strategies for conferring well-being. You should always consult your physician before starting any prescription drug. But now, for the first time, we also have safe and effective drugs for improving CV outlook for patients with diabetes and for getting weight down to healthier levels in people with obesity. At Saint Luke’s Mid America Heart Institute, in the Haverty Cardiometabolic Center of Excellence and the Duboc Cardio Health & Wellness Center, we use these medications routinely in our patients, and we have been observing truly impressive results. Most importantly, our patients tend to come back happier and feeling better than they have been in years. In the future, many more cardiologists and other health care providers will be using lifestyle modification along with appropriate use of SGLT2-inhibitors and GLP1-RAs to treat people with obesity and/or diabetes, especially if they have established heart disease or are at high risk for complications. For us and our patients at the Haverty and Duboc Centers, the future is now.

In Good Health,

James O'Keefe, MD

Dr. McCallister was one of my all-time favorite people. He was always genuinely concerned about his family, patients, and colleagues, as well as the nurses, techs, and maintenance staff at the hospital. A happy and optimistic soul with a great sense of humor, he was a genius at program development. He devoted virtually all his boundless energy to the people in his life, his profession, Saint Luke’s hospital, and the Kansas City community.

In his late 70s, Ben began to have memory problems and became increasingly confused. Tragically, he was diagnosed with Alzheimer’s disease, which progressed rapidly. About 18 months after he was diagnosed, his son told him that they were looking at admitting him to a skilled nursing unit. Upon hearing this, Ben never uttered another word and immediately stopped eating or drinking anything. It was like a deep part of his personality that was still intact decided a hunger strike was his last, best option. He slowly drifted into a coma and died just one week later.

It broke my heart to see this happen to Ben. He was an iconic leader in American cardiology and gave so much to the world, yet in the end had to endure such a tragic fate. Still, if he could see Saint Luke’s Cardiovascular Constultants today, it would make him smile to recognize that his legacy remains the foundation of our group: cutting-edge excellence in a diverse and collegial healthcare team that follows his dictum, “The best interests of the patient are the only interests to be considered.”

Alzheimer’s is perhaps the worst disease of all as it robs us of our personality and leaves us unable to care for ourselves so that we become a burden on our loved ones. With the improved life expectancy over recent decades, more and more of us are vulnerable to this increasingly prevalent scourge. Today, we have no cures or effective therapies for this type of dementia so it is essential to get out in front of it and prevent it from someday destroying our brains.

Thankfully, we are increasingly able to prevent Alzheimer’s, and the beauty of this evolving strategy is that it’s also a sure-fire recipe for keeping you fit, happy, and healthy with a good heart. If you make it a priority to try to follow the steps outlined below, you can almost certainly avoid ever having to deal with the dreadful consequences of Alzheimer’s, even if you have a family history of dementia or genes like Apo E4 that predispose to it.

Good for the heart, good for the brain.

Most of the risk factors that cause atherosclerosis, heart attacks, and strokes also increase the risk for Alzheimer’s. These troublemakers include high blood pressure, high LDL cholesterol, obesity, inactivity, depression, bad diet, sugar, junk food or ultra-processed foods, and smoking. Vascular dementia can be prevented by making sure these risk factors are controlled. We recently completed a notable study that showed having blood levels of omega-3 in the top quintile reduced the risk of stroke by 17%.

We know for sure how to prevent strokes and heart attacks by stopping smoking, and minimizing the use of alcohol to not more than seven drinks per week for women or up to 10 drinks per week for men. It is also essential that you are conscientious about following a healthy diet high in fiber from vegetables (especially leafy greens and cruciferous veggies like broccoli, kale, and cauliflower), fruit (particularly berries), nuts, and fish or seafood. It’s equally important to avoid the dietary villains, including anything with added sugar, white flour, and other highly processed foods. Additionally, you need at least 150 minutes per week of exercise— moderate activity is ideal, and more is better. Make sure your blood pressure is low-normal and keep your blood sugar level under 100 as much as possible.

Lifestyle affects Alzheimer’s risk.

Emerging research indicates that other factors are linked to dementia. By modifying these risk factors, we can lower the risk of dementia including Alzheimer’s disease.

• Social isolation and loneliness. Take a class, join a group, or attend religious services regularly. Connect with your family, neighbors, and friends every chance you get. Humans are among the most social creatures on Earth - we are happier and healthier when we bond with other people, animals, and plants. Dr. O.E. Wilson, a famous Harvard biologist, dubbed this “biophilia,” or love of living things. This is the notion that we Homo sapiens possess an innate tendency to seek connections with other forms of life. An instinctive need to connect with natural creatures, including other humans, is deeply ingrained in our DNA.

• Physically inactive lifestyle. Make it a priority to be more active. It’s one of the best ways to reduce the risk of dementia. Exercise is extremely beneficial, particularly if it’s done outdoors, with a friend or a dog, or by playing interactive sports. Shoot for 8,000 to 10,000 steps per day. Get an activity tracker or just use your phone. Pro-tip: You will get credit for more steps per day if you are wearing a tracker on your wrist rather than using your phone to count your steps.

• Hearing loss. Protect your ears when around loud noises. If you have hearing loss that’s making it hard to communicate with others, get hearing aids. They get better and more affordable all the time. Now hearing aids are available without a prescription, which makes them much less expensive.

A Therapy that shows promise.

• Statins. A recent definitive meta-analysis of 46 observational studies that included almost six million participants focused on the effects of long-term statin use on the risk of Alzheimer’s disease. Surprisingly, this study found that statins were associated with a highly significant 32% reduction in the risk of Alzheimer’s. Rarely, do people complain of temporary brain fog on a statin, and there is an urban myth in America that statins cause brain problems. This authoritative study indicates that the opposite may be true—statins help to protect your brain and prevent Alzheimer’s in the long run. If you have high cholesterol but can’t or won’t take statins, talk to your doctor about ezetimibe or Repatha—drugs that have minimal side effects yet lower cholesterol and reduce the risk of heart attack, stroke, and CV death.

• Keep your blood pressure normal, ideally under 120/80 most of the time. A healthy lifestyle and diet help to keep blood pressure down but take prescription BP meds if needed.

• Flu vaccine. A recent study of 2 million Americans found that those who routinely got an annual flu vaccine were 40% less likely to get Alzheimer’s. One more reason to get your flu shot each fall.

Practical steps to slash the risk of Alzheimer’s and dementia:

• Be an avid reader and listen to audiobooks.

• Study a foreign language.

• Learn to play a musical instrument.

• Volunteer in your community. Here at Saint Luke’s, the volunteers are a force for good that help make our patients feel truly cared for.

• Play group sports, such as pickleball, tennis, soccer, golf, bowling, softball, or frisbee.

• Explore new activities or hobbies.

• Cultivate an active social life.

• Prioritize getting at least seven to eight hours of restful and restorative sleep.

• Garden and care for plants.

• Adopt a dog into your home.

• Protect your head with a helmet when bicycling, etc. Don’t dive into water.

In Good Health,
James O'Keefe, MD

Studies have shown that yoga can also help lower cholesterol levels and reduce inflammation, both of which are key factors in heart disease. A regular yoga practice will also reliably augment balance, flexibility, and strength. Moreover, yoga is an excellent way to improve sleep quality, which is essential for maintaining good mental health. James often does 20 minutes of yoga just before going to bed. He streams one of the hundreds of free Yoga With Adriene sessions available online. Adriene Mishler has been called the patron saint of the pandemic and now has 12 million followers on YouTube. At least four times a week, James rolls out his mat on the back patio under the stars or in front of the
flames from a gas fireplace.

The sympathetic and parasympathetic (or vagal) nervous systems are two branches of the autonomic nervous system that work together in a yin-yang relationship to regulate various bodily functions. The sympathetic nervous system is responsible for the “fight or flight” response, which is activated when the brain perceives a threat or danger. This response stimulates cortisol and adrenaline, which increase heart rate, blood pressure, and breathing. On the other hand, the parasympathetic (vagal) nervous system is responsible for the “rest and digest” response. Vagal stimulation slows the heart rate, calms breathing, and lowers blood pressure while increasing blood flow to the digestive system and other organs involved in metabolism and immunity.

Opposing energies create balance. An equilibrium between the sympathetic and parasympathetic nervous systems is crucial for maintaining optimal mental and physical health. Our frenzied, over-stimulated 21st-century lifestyles tend to tip our autonomic balance towards the “fight or flight” response. Regular yoga practice is an ideal way to balance the yin-yang energies that constantly ebb and flow through your autonomic nervous system. The slow deep breathing, gentle mindful stretching, and spiritual grounding that are the essence of yoga work harmoniously to induce a state of relaxation, and when done regularly can improve both physical and mental health, and boost overall well-being.

Belonging to a group that meets regularly has been shown to be good for your health and happiness by brightening your mood and improving overall mental health. If the group is focused on physical activity, such as yoga, a team sport, or a fitness class, you may be more likely to engage in regular exercise, which can improve cardiovascular health and reduce the risk of chronic diseases. Being part of a group that shares your interests or engages in activities you enjoy can contribute to a sense of purpose and life satisfaction, and help combat feelings of loneliness and isolation.

Yoga postures and breathing exercises can help improve blood flow throughout the body and brain and may reduce chronic inflammation, which has been linked to heart disease, depression, and dementia. Some studies suggest yoga may be helpful for preventing atrial fibrillation (AFIB), a condition where the heart beats irregularly and rapidly. This may in part be because yoga tends to reduce risk factors that predispose to AFIB, such as hypertension, obesity, and stress. One study published in 2018 found that a 12-week yoga intervention was associated with a reduction in AFIB symptom burden and improvements in quality of life in people with intermittent paroxysmal AFIB. Another study published in 2019 found that in people with high blood pressure, a 6-month yoga intervention was associated with reductions in blood pressure, body weight, and stress levels.

Yoga is beneficial for heart health. Whether you are looking to reduce stress, boost cardiovascular fitness, or improve your overall well-being, yoga is an excellent option. By practicing yoga regularly, you can enjoy the many benefits it provides and reap the rewards of a healthier body and a more focused mind.

In Good Health,
James O'Keefe, MD and Kathleen O'Keefe

In fact, Kathleen figured out long before modern science did that the best eating style for health and longevity was a traditional Mediterranean diet. Joan grew up eating lots of fresh vegetables, berries and nuts, beans, fish, and seafood, along with a large salad dressed with extra-virgin olive oil and red-wine vinegar at the start of each evening meal. Kathleen’s angst-motivated mission to find and follow the healthiest diet enabled her to live to age 99. Joan was an only child, and her father, Leonard was about the least anxious person I’ve ever known; he lived to age 94. Paradoxically, Kathleen’s distress about being diagnosed with diabetes was a key turning point that changed for the better the trajectory of all three of their lives. The diet that Kathleen fed their little family kept Leonard happy and vigorous for over nine decades and inspired Joan to become a dietician.

Jim Morrison famously said, “You shouldn’t take life too seriously; nobody gets out alive anyway.” This existential angst—worry that goes along with being alive—is unavoidable. It’s part of what makes life so precious, and it is a powerful motivator to accomplish big things. Like most millennials, my kids—as they were growing up, and even today—complain about their anxiety as if it were an illness. Their generation grew up thinking that anxiety is dangerous and destructive and that the solution to its discomfort is to eradicate it as if it were an illness. I tell them, “Look around; the people who make a real positive difference and who change the world for the better, are generally not well-adjusted individuals.” Abraham Lincoln was pathologically depressed most of his life, and it goes without saying that he wasn’t on Prozac. Mikel Jollett is a brilliant author and singer-songwriter who has struggled with anxiety, anger, and depression since being raised in an orphanage in a commune/cult in Northern California in the 70s. His memoir Hollywood Park is one of my all-time favorite audiobooks. He says, “Take the pain and make it useful. The longing, the fear, the heartache, and the dread. The ability to see these broken pieces of yourself like cracks in your armor through which you are better able to see the world: too broken to be normal, just broken enough to see beauty.” Many successful people have learned to harness stress, nervousness, and fear and use it to fuel their productive and creative ventures. Face it—you are going to have some chronic anxiety, even if it’s subconscious, and that’s okay. It’s even a good thing if you can redirect that energy into motivation to become more productive.

When we accept that anxiety is unavoidable in our day-to-day lives and understand that it is meant to be a useful emotion, we can transform it into a positive force for our well-being. Kathleen learned how to leverage her distressing anxiety, rather than be overwhelmed by it, and this allowed her to discover fundamental insights about how to eat for longevity 50 years before modern science finally figured it out. This can be a lesson for all of us in our struggles with inescapable anxiety. If Kathleen had complained to her physician that she was paralyzed by worry about her diabetes, he probably would have prescribed her Valium, a benzodiazepine. This would have kept her “comfortably numb” but would have also completely melted away her energy and motivation to figure out her own solution. What’s more, “benzos” like Xanax and Ativan are alarmingly addictive and over decades of use can increase the risk of depression and dementia.

When we chronically medicate our angst and worries with chemicals like anti-anxiety meds and/or alcohol, we short-circuit our natural coping mechanisms for dealing with stress, and thus, those skills atrophy. Play, pets, meditation, music, dance, yoga, reaching out and connecting with family and friends, prayer, attending religious services, exercise, and outdoor activities like gardening can all be remarkably effective for dissipating anxiety. On the other hand, popping a pill instead is like sweeping dirt under the rug. If you are not harnessing your worries as a motivation to think up solutions and make changes, you are doomed to a downward spiral of unsolved problems and maybe even issues related to dependence and addiction.

Dr. Tracy Dennis-Tiwary in her book, Future Tense, argues anxiety is a protective response that arose via evolution in response to potentially threatening situations. That sense of worry is there for a reason—to spur us on and boost our creativity and problem-solving powers. It helped our ancient ancestors endure in the wild, and it is also essential for your health and survival today. Although stress and fear are uncomfortable emotions, they can be valuable motivators to imagine an uncertain outlook and do things now to make the future safer and better. In that way, anxiety is inextricably linked to hope.

Shortly after our son Evan started medical school, he called to tell me in a distressed tone, “I don’t think I can get through this. There are just so many opportunities to fail.” I reassured him and quoted an old Jewish adage that I often recite to myself: “The price of security is insecurity.” Evan leaned into his sense of self-doubt to motivate him to pay close attention during lectures and study endlessly during his medical school years. By leaning into his insecurity, he ensured that he would not fail, and secured his future.

Achieving a new mindset that “stress can be our friend” won’t alleviate anxiety by itself. Kelly McGonigal, PhD, in her book Upside of Stress, encourages us to change our mindset about stress so that instead of doing everything we can to reduce it or sedate our minds, we learn how to embrace stress and use it to make us stronger, smarter, and happier. There is a close link between resilience—the human capacity for stress-related growth—and one’s mindset. Beliefs have the power to shape reality. When you cultivate a mindset that focuses on the potential benefits of stress, it can make all the difference and transform a toxic emotion into a force for personal growth and newfound strength.

If you can change your mindset about the emotion of anxiety so that you think of it not as an illness that needs to be eradicated but instead as a signal of potential trouble on the horizon and a tool to motivate change, it can be a source of ingenuity and willpower.

Your brain is designed to learn from stress, whereby challenging experiences can help you grow stronger and wiser. Emotional stress can provide focus and energy. Navigating your way through a stressful period together with others, whether at home or at work, can help you bond and strengthen close relationships.

Prisons and graveyards are full of people who didn’t have enough anxiety. They saw an unlocked car that was running with nobody in it and decided, “Heck yeah! What could go wrong?” Or they drove their motorcycle 140 miles an hour because it was exhilarating and they felt bulletproof and immortal. Anxiety is a warning sign of danger ahead. Stress is a motivator to make you more resourceful. Forget about trying to be comfortably numb; instead, channel your anxiety into actions to make your life better.

In Good Health,
James O'Keefe, MD

In centuries past, this healing touch was sometimes all the physicians had to offer, and indeed they relied heavily on the power of placebo to help cure their patients. Yet even today I believe our patients will get better quicker and feel less emotional anguish if we provide reassuring, professional, and compassionate care, which includes laying on of the hands. The power of a placebo, which can amazingly effective, is conferred in direct proportion to the trust the patient has in their care provider. I tell medical students and physicians in training that if you don’t touch your patients, they may not recover as quickly as they should, nor will they fully trust that you genuinely care about them as a person.

Human touch has been shown to have various physiological and psychological benefits, and it has been used as a therapeutic intervention in many cultures and medical practices throughout history. Gentle, affectionate touch, like a hug, can stimulate the release of hormones such as oxytocin that fosters bonding and social support. Touch can also reduce stress, promote relaxation, lower blood pressure and boost the immune system’s ability to fight off disease.

For newborns especially, touch is essential if they are to thrive. When our four children were little, Joan insisted that whenever possible, one of us was holding the baby rather than having him or her sit in a bassinet. My oldest son, Jimmy, was a preemie, born five weeks early. During the last trimester of that pregnancy and for the first six months after delivery, Joan was being treated with radiation therapy for Hodgkin’s lymphoma. I was a busy cardiology fellow, and Joan was exhausted, so her mother, Kathleen, came to live with us for the first six weeks after Jimmy was born. He would wake up hungry and crying every couple of hours during the night. Kathleen, who was 75 years old at the time, was an angel about holding and bottle-feeding baby Jimmy, day and night. Touch promotes bonding between the newborn and the parent or caregiver, which is crucial for creating a strong emotional connection and building a secure attachment. It’s been 11 years since Kathleen passed away, but even now she occasionally shows up in Jimmy’s dreams as a reassuring and loving presence who is always there for him.

Sadly, there have been experiments in the remote past where infants were subjected to minimal physical contact to prevent infection. As part of the Hospitalism Study conducted during the 1940s, infants in an orphanage were cared for in a sterile, hospital-like setting in which they received little to no cuddling or affectionate touch and were rarely even held. These babies’ touch deprivation caused developmental delays and emotional distress, and some of them even died of “failure to thrive.” These kinds of studies made it abundantly clear that nurturing/affectionate touch is an essential “nutrient” that must be prioritized when caring for a baby. Although this is also true for adults, touch is often an overlooked need by many people.

Psychologically, affectionate touch can bestow comfort, reassurance, and emotional support, which can have a positive impact on mental and emotional well-being. Touch can also promote a sense of connection and empathy between people and may help to improve communication and trust in therapeutic settings. By the way, affectionate interactions between people and dogs or cats, such as petting or grooming the animal, cuddling, hugging, or receiving kisses (licks) can help boost mood, melt stress, promote relaxation, and lower blood pressure. Joan and I have three dogs and one cat; we are being physically affectionate with them many times during our waking hours.

About once a month I get a professional massage, which feels like such a luxury on my achy muscles, but its benefits go beyond relaxation. At first touch, the heart rate slows and blood pressure falls. The stress hormone, cortisol, drops, and feel-good hormones like serotonin, endorphins, and dopamine rise, leaving the body in a state of relaxed bliss. Massage can reduce anxiety and depression, boost mood, and improve sleep quality, all of which are beneficial for heart and brain health. I often give Joan a foot massage just as she is dozing off in bed. She loves it and says it is good for her soles and her soul. Look for ways to give and receive a more affectionate, wholesome touch; it’s a proven way to strengthen interpersonal bonds and make you healthier and happier.

Overall, touch can be a powerful means of supporting mental and physical health. Whether it’s a hug from a loved one, a massage from a professional, or even a gentle pat on the back, incorporating touch into our lives can have numerous benefits. Of course, it’s important to always ensure that touch is consensual and appropriate and that we respect personal boundaries and preferences.

In Good Health,
James O'Keefe, MD

If you had to guess the single most important strategy for maximizing your future well-being and longevity, you’d probably say more exercise, better diet, or quitting tobacco. But Peter Attia in his superb new book, Outlive, makes a strong case for tending to emotional health as the top priority if you’re on a quest to lead a long and vigorous life. For the past century in America, life expectancy had been rising from 47 years in 1900 to 68 years in 1950 to 79 years in 2019. But then it suddenly it reversed course and started falling—to 77 years in 2020 and 76 in 2021. This abrupt U-turn in longevity was due in part to the COVID pandemic, but also to rising deaths of desperation—suicide, drugs (mostly opioids), alcohol, car accidents, and gun violence. These fatalities typically result from risky and self-destructive behaviors arising out of emotional distress and social isolation.

Despite being among the hardest working and wealthiest nations in the world, the U.S. faces a mushrooming emotional health crisis. For millennia, our lives were inevitably woven into a fabric of interconnectedness while living in small tight-knit communities with lifelong friends and neighbors, and extended families nearby, often with a shared religion and worldview. Now most of these traditional sources of emotional support have unraveled, leaving many people feeling isolated and vulnerable.

Rat Park

The Rat Park study was an experiment designed to investigate the effects of living conditions on drug addiction. Rats were given a choice of two water bottles—one that was pure water, and the other that had water laced with morphine. When the rats were housed in standard bare metal laboratory cages with no social interaction or stimulation, they consistently chose the morphine-laced water and became addicted to it. Yet when the rats lived in a more stimulating natural environment with fellow rats to socialize and play with, and they had plenty of room to explore, they showed no interest in the morphine-laced water and didn’t get addicted to it.

The message of the Rat Park study for humans is that addiction is not solely caused by the chemical properties of drugs, but also by environmental and social conditions. It suggests that a lack of social support, connection with others, exercise, and fulfillment may contribute to addictive behavior.

The Good Life

Drs. Robert Waldinger and Marc Schulz in their splendid new book, The Good Life, assert that our most essential need in life is meaningful connections with others. What makes for a vibrant life that is fulfilling and meaningful? The simple and intuitive answer is relationships. The stronger our relationships, the more likely we are to follow a healthy lifestyle, which eventually translates into a long, happy, and satisfying life. Dr. Waldinger is the current director of the Harvard Study of Adult Development, which has been closely following a group of about 700 people year after year for their entire adult lives. This study, which has been going on for 85 years and counting, reveals that more than cholesterol, blood pressure, or any other factor, the strength of our connections with others determines how gracefully our bodies and our brains age.

Relationships in all their forms—family, friends, romantic partners, coworkers, pickleball pals, bicycling buddies, garden or book club members, Bible study groups, pets, and even plants—all contribute to a happier, healthier, and longer life. It’s never too late to improve the relationships you have and never too late to build new ones. According to Dr. Waldinger, “Good relationships keep us happier, healthier and help us live longer. This is true across the lifespan, and across cultures and contexts, which means it is almost certainly true for you, and for nearly every human being who has ever lived. We are sustained in a web of relationships that give our lives meaning and goodness.”

Neighbors with Benefits

In my humble opinion, neighbors are an important and often overlooked source of mutually beneficial emotional support. My mother, Leatrice, taught me by example that if you want to have a friend, you need to be a friend. She had about 15 people who considered her their very best friend, many of whom were neighbors. When I was growing up during the Baby Boom of the 1960s, my siblings and I would run outside into a backyard that was contiguous with 15 other backyards on our block in Grafton, North Dakota, a town of 4,000 people. There were about 60 kids within a few years of age of each other whose backdoors opened onto our shared backyard, with virtually no fences and very few hedges. We all knew each other and scampered in and out of various neighborhood homes like they were our own. My mother would frequently have coffee or birthday club with the other moms on the block. When the weather was nice, my parents would have happy hour on the back patio, where Helen and Bill and other neighbors often sauntered across the backyard to join them for a beer.

Each of us lives in a custom-built world—for better or worse—that is created by how we treat other people. Joan and I have throughout our lives tried to get to know our neighbors and befriend them. It hasn’t always been easy. About 23 years ago we moved next door to an older couple, let’s call them John and Mary. Our kids were little at the time and they would climb the neighbors’ trees and sometimes light fireworks off in their yard. And our dogs might have been barking too much or relieving themselves on the neighbor’s lawn. So, Mary would frequently call and leave nasty-gram messages on our answering machine, sometimes threatening to report us to the city. In contrast, it was easy to make friends with their black lab, Rory, and we offered to have him stay with us when they were out of town. That changed the whole relationship, and through the years we have gotten to be good friends with John and Mary and their family. When John developed Alzheimer’s, he would show up
confused at our front door, looking for Joan to reassure him that everything was going to be okay. She would take him by the hand and gently lead him back home.

Neighbors who become friends share a unique bond—one of place, a common turf. It’s reassuring to know that you have people in your neck of the woods that you can count on to watch your back. Good neighbors keep an eye on each other’s homes when one of them is out of town. We have other close neighbors with whom we exchange home-grown vegetables and fruits— depending on whose garden or fruit trees are producing at the time. It is much easier to spontaneously visit with and socialize with neighborhood friends since you often bump into them coincidentally.

Your Neighbor Might Just Save Your Life

On the other hand, we have neighbors down the street who for decades have walked by regularly and pretended to not know us. This just seems like a waste of a potential resource. Don’t delude yourself into thinking you live in isolation just because you can climb into your car, click the garage door opener, and never take the time to get to know your neighbors. They could save your life one day, or you could save theirs. Our friend and neighbor Kathy was out walking her Scotty dog last fall when she heard faint but distressed cries for help that she couldn’t localize. She immediately called 911 and within a few minutes, first responders arrived on our block and discovered Sara, another friend and neighbor, at the bottom of her basement stairs, collapsed and hemorrhaging with a broken hip. Kathy saved Sara’s life that morning. Whatever differences you may have with your neighbors are generally not more important than the things you share— like the desire to live in a safe, friendly, and familiar neighborhood. Keep in mind that neighbors can be friends regardless of age differences, and try not to take personally the political signs they might put up in their yards.

My son Jimmy and his husband Darren used to live in Manhattan, New York, and hardly knew their neighbors. But about two years ago they bought a brownstone apartment in a gentrified Brooklyn neighborhood. Now they live in a storybook setting where they walk their dog, Theo, to Prospect Park a few blocks away every morning to frolic with her canine playmates. They’ve gotten to know folks who are routinely out pushing baby strollers, or walking their dogs; they see familiar kids playing on the sidewalks after school and neighbors out doing errands. Living in a real neighborhood has become a wellspring of joy for Darren, Jimmy, and Theo.

Having friendly relationships with your neighbors can be beneficial for both your mental and physical health.

1. Social support. Neighbors can provide a sense of community and social support. Having someone nearby to talk to and share experiences with can help reduce feelings of loneliness and isolation.

2. Physical activity. Being friends with your neighbors encourages you to be more physically active. You may be more likely to garden, take a walk, or participate in other outdoor activities if you have someone to interact with.

3. Safety. Knowing your neighbors and having a good relationship with them can help create a sense of safety and security in your community. You may feel more comfortable leaving your home and your children in the neighborhood if you know your neighbors are looking out for you.

4. Reduced stress. Having a positive relationship with your neighbors can help reduce stress levels and allow you to feel more comfortable asking them for help with tasks such as caring for your plants or pets when you go on vacation.

Being friends with your neighbors is a unique opportunity to strengthen personal bonds and improve your sense of belonging. Like Mr. Fred Rogers said, “All of us, at some time or other, need help. Whether we’re giving or receiving help, each one of us has something valuable to bring to this world. That’s one of the things that connects us as neighbors—in our own way, each one of us is a giver and a receiver.”

In Good Health,
James O'Keefe, MD

By placing your store-bought white button mushrooms gill-side up in direct sunlight for 15-20 minutes you can increase their levels of vitamin D.  With 100 grams (about one cup of mushrooms) you can increase the vitamin D2 from 40 IU to 400 IU!  This will not be enough to replace supplementation as Vitamin D2 is not as well absorbed as Vitamin D3 but can provide a tasty boost to your diet.

Some additional potential health benefits of mushrooms include:

• Immune system support: Mushrooms contain beta-glucans, which have been shown to stimulate the immune system and help fight infection.

• Anti-inflammatory properties: Some varieties of mushrooms contain compounds that have anti-inflammatory properties, which may help reduce the risk of chronic diseases such as heart disease, diabetes, and cancer.

• Improved brain function: Mushrooms are a good source of choline, a nutrient that is important for brain health and may improve memory and cognitive function.

• Weight management: Mushrooms are low in calories and high in fiber, which can help you feel full and satisfied while eating fewer calories.

• Improved nutrient absorption: Mushrooms are a good source of copper, which is important for the absorption and use of iron in the body.

Remember to not overcook the mushrooms as this does diminish fat-soluble vitamins such as A, D, E and K.  So, set some in the sun, then toss them on your salads, scrambled eggs or as a cup to hold your favorite healthy dip.

For a delicious mushroom recipe featuring pan-seared salmon and spinach, take a look at the one below I found through the Oh Snap! Let's Eat! food blog.

Pan Seared Salmon with Spinach and Mushrooms

Ingredients:

• 1 lb salmon fillets

• 2 tablespoon olive oil

• 3 cloves garlic, minced

• 8 oz mushrooms, sliced

• 6 oz spinach fresh

• Salt and pepper, as desired

• 1 tsp paprika

• 1 tsp garlic powder

Instructions:

• Heat 1 tablespoon of olive oil in a cast iron or large skillet on medium-high heat.

• When the oil is hot, add salmon fillets to pan. Sear for about 4 minutes on medium-high heat. Flip the salmon fillets to the other side. Season with salt, and then let it cook for another 4 minutes or until cooked thoroughly.

• Remove salmon from the skillet and set aside.

• In the same pan, add another tablespoon of olive oil, minced garlic, and mushrooms. Cook stirring occasionally for about 2 minutes or until mushrooms are tender.

• Add spinach to pan. If too much to add in the beginning, add it in batches.

• Cook stirring occasionally until wilted, which only takes about 1 minute. Season with salt, pepper, paprika, and garlic powder.

• Sometimes if I’m worried that the Salmon cooled down too much, I dump it back for a second in the pan to warm up before serving.

• Remove from heat, and serve with pan-seared salmon.

In Good Health,
Joan O'Keefe, RD

A systematic review and meta-analysis aimed to investigate the effect of Coenzyme Q10 (CoQ10) supplementation on fertility outcomes in women undergoing assisted reproductive technology procedures (ART). The review included 5 randomized-controlled trials with a total of 215 infertile women who received CoQ10 supplementation and 234 infertile women who received a placebo. The analysis found that CoQ10 supplementation significantly improved clinical pregnancy rates in women undergoing ART procedures. This effect remained statistically significant when women with poor ovarian response and polycystic ovarian syndrome were analyzed separately. The authors concluded that CoQ10 supplementation may be a beneficial adjunct therapy for women undergoing ART procedures.

CoQ10 has also been found to have potential benefits for male fertility. A systematic review included 24 studies with participants receiving daily CoQ10 dosages ranging from 20mg to 400mg. The analysis found that CoQ10 supplementation significantly improved sperm concentration, motility, and morphology in infertile men. Additionally, CoQ10 supplementation was found to decrease oxidative stress and improve DNA integrity in sperm cells. The authors concluded that CoQ10 supplementation may be a safe and effective therapeutic option for improving sperm quality in infertile men.

It is important to note that CoQ10 supplementation may not be beneficial for everyone. The body's ability to produce CoQ10 naturally declines with age, so older individuals may benefit more from supplementation. Additionally, those with certain health conditions, such as mitochondrial disorders, or people taking a statin cholesterol-lowering medication may have a higher requirement for CoQ10.

In conclusion, CoQ10 is a promising nutrient for improving fertility in both men and women. Its antioxidant properties may help improve egg and sperm quality, leading to a higher chance of conception. However, as with any supplement, it is important to speak with a healthcare professional before starting CoQ10 supplementation, particularly if you have any pre-existing health conditions.

In Good Health,
James O'Keefe, MD

As we age, the levels of CoQ10 in our body decrease, which can lead to the breakdown of collagen and elastin in the skin. These proteins are responsible for maintaining the skin's elasticity, and their breakdown can lead to wrinkles and sagging skin. By supplementing with CoQ10, the body is provided with the necessary antioxidant protection to combat free radicals that can cause skin damage, and produce a healthy inflammatory response that stimulates an increase in collagen production.

Another way that CoQ10 may help with anti-aging is by supporting mitochondrial function. Mitochondria are the powerhouses of the cell, responsible for generating energy in the form of ATP. As we age, the function of mitochondria declines, which can lead to a decrease in energy production and an increase in oxidative stress. CoQ10 plays an essential role in the electron transport chain, which is the final step in ATP production within mitochondria. By supporting this process, CoQ10 may help improve mitochondrial function, thereby promoting youthful energy levels and reducing the effects of aging on the body.

Studies have shown that topical application of CoQ10 can improve the appearance of fine lines and wrinkles, reduce sun damage, and improve skin elasticity. Additionally, oral supplementation of CoQ10 has been found to improve skin hydration, texture, and overall appearance.

One interesting double-blind, placebo-controlled study involving 33 healthy participants aimed to examine the impact of daily supplementation with 50 and 150 mg of CoQ10  for 12 weeks on skin parameters and conditions. Although previous in vitro research indicated that CoQ10 could offer some protection against UVB exposure, the amount of UV radiation needed to cause a minor reddening of the skin did not change significantly between the participants who took CoQ10 supplements and those who took a placebo. However, the intake of CoQ10 helped to prevent seasonal degradation of viscoelasticity, the ability of the skin to maintain its elasticity and bounce back to its original shape after being stretched, and reduce some visible signs of aging, such as wrinkles and microrelief lines, while improving skin smoothness.

Take home message - CoQ10's ability to protect against free radicals, produce a healthy inflammatory response, increase collagen production, and help with wrinkles makes it a powerful ingredient in reducing the signs of skin aging and having vibrant youthful energy levels.

In Good Health,
James O'Keefe, MD