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Peripheral Artery Disease (PAD) is a medical condition in which blood supply to the outer parts of the body is interrupted. Normally Blood vessels act like a pipeline and carries blood to other parts of the body. In PAD, fatty plaques build up inside the blood vessels causing them to narrow down or getting blocked.

Who are at high risk to develop PAD?

• Patients with Diabetes
• Smokers
• Patients with high cholesterol
• Patients with High Blood Pressure

Symptoms of PAD

• Leg Pain and muscle cramping
  • Muscles need oxygen to function and the oxygen is carried by the hemoglobin cells in the blood. when blood flow is obstructed by these fatty plaques, patients can experience muscle cramp worsening with exercise and relieves with rest.
• Poor wound healing
  • Lack of blood flow to the extremities prevent immunoglobulins and nutrients to reach the wounds. Without the immunoglobulins, oxygen and nutrients wound healing process slows down and sometimes worsen.
• Trouble getting erection or trouble with sexual arousal
  • Poor blood flow to the genital organs contribute to poor sexual function.
• Dementia or memory loss
  • By blocking the blood vessels (cerebral artery ) that carry blood to the brain PAD contributes to inability to concentrate, memory loss, dementia and personality changes

How can you prevent from developing PAD

• Quit Smoking
• Eat low fat healthy meals
• Bring your High Blood pressure, Cholesterol and Diabetes under control
• Start walking every day
• Weight loss

Treatment options for PAD

• Medications such as Cilastazol and Aspirin can be used to thin the blood and increase blood flow
• Cholesterol lowering medications such as “Statins” can be used to prevent worsening of peripheral artery disease
• If medications fail and / or severe PAD a metal stent can be placed in the blood vessel to keep it open and to increase the blood flow.
• Bypass surgery – a blood vessel from a different part of the body is removed and placed above and below the area that is clogged.

Why is it important to make lifestyle changes ?

• Poor wound healing
  • As mentioned above, when there is lack of blood supply wound doesn’t heal well. The longer it takes for the wound to heal the more discomforts it will cause. Some of the complications include Worsening pain, worsening ulcer with malodorous discharge, wounds getting bigger in size and depth, infection spreading to the bones.
• Risk of Amputation
  • Without oxygen and nutrients cells of the body cannot survive. with time parts of the body start to die and decay leading to amputation of the extremities as the only option to prevent death.
• Other vascular disease
  • If one blood vessel is starting to clog, other blood vessels can clog as well. when the blood vessel in the heart clogs it leads to heart attack and even death. Clogging of the blood vessels in the brain can lead to stroke and residual deficits from the stroke.

2/3 Of Americans are Overweight or Obese. It costs 147 Billion dollars a year for health care cost due to complications from Obesity. Obesity is defined by a BMI of 30 or more. Studies have shown a close relationship between weight and medical comorbidities. Weight is a sensitive topic for many people. Being overweight or Obese affects your quality of life and limits your health and activities.

Complications due to Obesity

• High Blood Pressure
• Diabetes Mellitus
• High Cholesterol
• Heart Attack
• Heart Failure
• Sleep Apnea
• Non Alcoholic Fatty Liver Disease
• Polycystic Ovarian Syndrome
• Venous Stasis
• Acid Reflux
• Urinary Incontinence
• Degenerative Joint disease (Arthritis)
• Infertility
• Migraines
• Depression
• Stroke
• Gall Bladder Disease
• Certain type of Cancers
• And many more………………………………………………..

Lifestyle Modifications

Diet and Exercise are the cornerstone in the management of obesity. Without changing your diet and activity level, any other medications or surgeries that you pursue will only provide a short term weight loss.

Diet

Reducing the daily calorie intake by 500 Kcal/ day itself can help you lose weight when done in a consistent manner. One needs to cut down 3500 Kcal to lose 1 lb of weight. Daily calorie requirement for women is 1200 – 1500 Kcal / day and for men 1500 – 1800 Kcal / day. There are many popular diet programs available (Intermittent fasting, Mediterranean diet, Keto diet, Atkins, South beach diet etc) , however no diet is shown to be superior than other.

So pick a diet that you can adhere to and stick to it for better results.

Exercise

Any exercise is better than no exercise! Burning 3500 KCal helps you lose 1 lb of weight. Minimum requirement for healthy lifestyle is at least 150 mins of Aerobic activity such as running, swimming, Cycling per week and resistance training such as weight lifting, Squats, etc at least twice a week.

There are many variety of exercise activities available including but not limited to Boot camp, Yoga, Pilates, Zumba, Martial Arts, spinning class etc. Pick something that interests you and be compliant with it. It will not only help with weight loss but also help with increasing mobility and quality of life.

Medications for Weight loss

Medications alone is NEVER the answer for weight loss. If you think you can lose weight and maintain it just by taking 1 more medication, you will be disappointed very early. Medication gives a boost to help lose weight when you combine it with lifestyle modifications. Anything that you put in your body can give you some side effects. It is important to weigh the risks and the benefits prior to deciding the best option for you.

Urinary incontinence is involuntary leakage of urine. It is a common problem that affects the quality of life of many women by causing increased depression and anxiety, Increased risk of urinary tract infections, increased risk of falls from frequent rushing to the bathroom and skin infections. Although it is mostly seen in Older women, younger women can experience symptoms as well.

Types of Urinary Incontinence

There are 2 main type of Urinary Incontinence in women. Stress Incontinence and Urge Incontinence. There are other less common types of incontinence such as over flow incontinence, mixed incontinence and functional incontinence.

Stress Incontinence

Stress incontinence happens when there is weakening of muscles in the pelvic floor and around the urethra causing it to leak urine when there is increased pressure. Activities such as laughing, sneezing and coughing increases the abdominal pressure leading to involuntary leakage of urine. It is Common among women who had one or more vaginal deliveries and Obese females.

• Weight loss decreases the abdominal pressure and improves incontinence
• Treating constipation also improves incontinence by reducing abdominal pressure
• Smoking Cessation is known to improve incontinence
• Pelvic floor exercises such as Kegel Exercises can strengthen the pelvic floor

If conservative management fails, you can discuss with your doctor about pessaries or other surgical options available.

Urge Incontinence

It is also known as overactive bladder problem. People with this condition feels the urge to urinate more frequently and may have involuntary leakage on the way to the bathroom. Frequency of urination is also increased and may have to wake up multiple times in the middle of the night to urinate.

Alcohol, Drugs and Caffeine are some of the substances that can contribute to urge incontinence.

• Weight loss decreases the abdominal pressure and improves incontinence

• Treating constipation also improves incontinence by reducing abdominal pressure

• Avoiding Caffeine , alcohol and smoking cessation

• Bladder training is the most beneficial conservative management for urge incontinence
• Appropriate fluid intake by avoiding excessive fluid intake at night

• Scheduled bathroom breaks to avoid involuntary urination

• Kegel Exercises

If conservative management fails, you can discuss with your doctor about medications to reduce bladder spasms, other procedures such as Botox or other surgical options available.

Guide for Bladder Training

• when you experience the urgency to urinate, remain still
• Focus on reducing the urgency to urinate by distracting your self and relaxation techniques that work for you
• Once the feeling of urgency is controlled walk slowly to the bathroom

Kegel Exercise

• Kegel exercise is performed by contracting and relaxing the pelvic muscles.
• Initially practice kegel exercises by holding the urine during urination and releasing it without using the abdomen, buttocks or thigh muscles.
• When you contract the pelvic muscles hold the contractions for atleast 6 seconds before relaxing.
• Once you practice to isolate pelvic muscle and perform the contraction and relaxation you can exercise three sets of 10 contraction 2-3 times a week .
• Once you master the technique slowly increase the time of contraction from 6 seconds to at least 10 seconds.

Vitamin B₁₂ is a water-soluble vitamin that can be acquired by eating fish, meat, dairy products, fortified cereals and supplements. It is important for neurological functions, Red blood cell production and for the synthesis of DNA. There is no need to screen for vitamin B12 deficiency in asymptomatic adults.

High risk population for Vitamin B12 deficiency

Medical conditions & Medication use

• Pernicious Anemia
• Chron’s disease
• Postgastrectomy syndrome (Roux-en-Y gastric bypass)
• Atrophic Gastritis
• Bowel resection (Ileal resection)
• long term use of Proton Pump Inhibitors for gastritis or GERD such as (Nexium, Protonix, Prilosec)
• Long term use of anti histamines (Zantac, Famotidine) for Acid reflux
• Metformin use (Diabetic medication)

Decreased Intake of Vitamin B12

• Alcohol Abuse
• Elderly patient (Tea & Toast diet )
• Vegans or strict Vegetarians

Symptoms of Vitamin B12 deficiency

FOODS THAT ARE HIGH IN VITAMIN B 12

• Chicken, Beef, Turkey
• Organ meats such as liver
• Fish , Shell Fish
• Eggs
• Fortified cereal
• Milk, Yogurt, Cheese

Role of diet in diabetes

Diet plays a major role in the treatment of Diabetes In addition to medication . By making changes in the diet you will not only be able to bring your blood sugar under control but you will also be able to prevent long term complications such as kidney problem, heart problem and problems with vision. During my clinical experience I have seen many patients who brought their Hemoglobin A1C (blood sugar) under control and avoided the need to use insulin just by making healthy lifestyle choices and losing weight. Weight gain can cause increased insulin resistance and worsen Diabetes.  Most of the time people don’t realize that there are more food groups other than just sugars and desserts that are bad for a diabetic patient.  

What should your blood glucose levels be?  

Target Blood Glucose Levels for People with Diabetes Before meals should be between 70 mg/dl to 130 mg/dl. Postprandial or 1 to 2 hours after the start of a meal should be less than 180 mg/dl.  

what can you eat?

• Lean proteins such as meats, eggs, legumes, fish, nuts and seeds provide building blocks for the most components in the body. Because they take time a long time to break down they keep us full longer so stop us reaching for quick sugary snacks. 
• Healthy Fats such as fish, avocado, olive oil, nuts and seeds, eggs, coconut oil, butter and ghee increase satiety and balance blood glucose. 
• Fiber from vegetables, seeds, nuts and legumes plays a big part in keeping you full (without loads of calories), supports detoxification and helps balance blood glucose by slowing the rush of sugar into your blood stream.  

How about carbohydrates (carbs) ?

Carbohydrate food group can be further divided based on the glycemic index.

Food with high Glycemic Index raises blood glucose more than food with a medium or low Glycemic index. If you are eating food with a high glycemic Index, you can combine it with low Glycemic Index foods to help balance the meal. 

Foods with High Glycemic Index

• White bread or bagel 
• Corn flakes, puffed rice, bran flakes, instant oatmeal 
• white rice, rice pasta, macaroni and cheese from mix 
• Russet potato, pumpkin 
• Pretzels, rice cakes, popcorn, saltine crackers 
• melons and pineapple 

FOODS WITH Medium GLYCEMIC INDEX

• Whole wheat, rye and pita bread 
• Quick oats 
• Brown, wild or basmati rice, couscous 

FOODS WITH low GLYCEMIC INDEX

• Pumpernickel bread 
• Oatmeal (rolled or steel-cut), oat bran, muesli 
• Pasta, converted rice, barley 
• Sweet potato, corn, yam, lima/butter beans, peas, legumes and lentils 
• Most fruits, non-starchy vegetables and carrots 

Ideal Diabetic Plate 

• Half the plate should contain non-starchy vegetables, like salad, green beans, broccoli, cauliflower, cabbage, and carrots. 
• 1/4th of the plate should contain a grain or starchy food such as bread, noodles, rice, corn or potatoes. 
• Other 1/4th of the plate should contain protein, like fish, chicken, lean beef, tofu, or cooked dried beans. 

What can you drink? 

• Water, Water, Water!! There is nothing as good as water.  
• If you’re tired of drinking just water you can either try the sparkling water to get carbonated flavor or try adding the flavor packs (they are very low in calories 5-10 calories).  
• Even better you can make homemade infused water with your favorite fruit flavors. To make infused water, simply put water in the fridge with cucumbers, strawberries, fresh mint for a refreshing low-calorie drink. 
• If you drink milk choose low-fat 1% or fat-free milk 
• If you absolutely have to drink pop or soda, Diet pop or diet soda is a good alternative to regular soda.  
• Naturally derived sweeteners, stevia (Truvia, PureVia) and agave nectar, offer other sweetening options.  

What should you be avoiding? 

• Saturated fats. High-fat dairy products and animal proteins such as beef, hot dogs, sausage and bacon contain saturated fats. 
• Trans fats. These types of fats are found in processed snacks, baked goods, shortening and stick margarines. Avoid these items. 
• Bad Cholesterol. Sources of cholesterol include high-fat dairy products and high-fat animal proteins, egg yolks, liver, and other organ meats.  
• Sodium. Aim for less than 2,000 mg of sodium a day.  
• Unhealthy sugars. Avoid pop, sugary juices, deserts that are high in sugar 

Tips and strategies for meal planning

• Eating small frequent meals can avoid hypoglycemic episodes in addition to overeating the next meal 
• Check food labels to help you make smarter choices 
• Plan meals ahead and avoid picking meals last minute to satisfy your hunger  
• Remember to stop eating when you start feeling full 
• Replace fried foods with steamed or grilled foods 
• Replace desserts with fresh fruits  
• Watch your portion sizes  
• If you chose to drink, drink in moderation (less than 2 drinks/day for men and 1 drink for women) 
• Remove the skin from chicken or turkey to avoid excess fat  

Resource Links 

• For more diabetic meal options: https://www.choosemyplate.gov/ 
• Carbohydrate counting: https://www.niddk.nih.gov/health-information/diabetes/overview/diet-eating-physical-activity/carbohydrate-counting  
• Diabetes recipes: https://www.diabetesfoodhub.org/?loc=ff-slabnav