Archive for May, 2010

Travel Medicine: Staying Healthy in Kokomo

by Georgina Lee, PharmD 2011 |

With summer just around the corner, your dreams of traveling are very close to becoming a reality.  You open up your inbox and find ten unread messages highlighted in bold.  One of them may be from Aunt Sally but the rest have subjects like “$99 roundtrip airfare to Jamaica!”  Suddenly, a spark ignites and you start clicking on ads from Expedia, Jetblue, and Virgin and the next thing you know, you and five other friends are going to Timbuktu next week.

Before you start debating whether to pack your blue swim trunks versus the red ones, there are a few important questions you and your travel mates should ask:

•    Will I be going out of the country? If so, how many countries will I be visiting?

•    When will I be leaving and how long will I be staying at each destination?

•    What are my accommodations and what kind of activities will I be doing?

•    How am I traveling at my destination? (Hike, backpack, train, etc.)

•    What is my personal medical history including current medications, allergies, and other considerations or limitations?

When most people think of travel medicine, they think “vaccines” and “bothersome.”  In a 2003 U.S. airport survey, only 36% of travelers sought travel health advice.  73% of them went to high-risk malaria regions and, of those, only 46% brought along anti-malarial medications.  Most were traveling to regions where Hepatitis A was prevalent but only 14% of travelers were immunized.  Overall, vaccination rates were as low as 11% and 13% with respect to Tetanus Diphtheria (Td) and Hepatitis B.

For those who are asking “Well, how dangerous could it really be?”  Here are some statistics that might raise your eyebrows:

According to a network of specialized travel medicine clinics called GeoSentinel, the number of travelers with likely exposure ranged from less than 100 to over 1000 people in places like Mexico, South America, India, and parts of Southeast Asia.

Likely Country of Exposure in Patients Seen After Travel

(September 2009; n=43,216 Travelers with Known Country of Likely Exposure)

GeoSentinel and the CDC also collected data on large samples of sick travelers, specifically those who traveled to many countries, after they returned home.  Based on 17,353 travelers seen at 31 clinical sites on six continents, the following region-specific disease occurrences were found:

•    Febrile illness is most likely from Africa and Southeast Asia

•    Malaria is among the top three diagnoses from every region

•    Over the past decade Dengue Fever has become the most common febrile illness from every region outside sub-Saharan Africa

•    In sub-Saharan Africa, rickettsial disease (which causes a number of illnesses including Typhus and Spotted Fever) is second only to malaria as a cause of fever

•    Respiratory disease is most likely in Southeast Asia

•    Acute diarrhea is disproportionately seen in travelers from South Central Asia

In addition, 226 out of every 1,000 sick travelers had a systemic febrile illness, 222 had acute diarrhea, 170 had a dermatologic disorder, 113 had chronic diarrhea, and 77 had a respiratory disorder.  This doesn’t even include road travel-related deaths, falls, drowning, heat stroke, homicide, or altitude-related injuries.

Starting to sound scary?  The good news is that you and your friends can still go camel back riding in Peru or climb the Great Wall of China without fear, as long as you take the necessary precautions before traveling.  An ounce of prevention before you leave can make or break your trip.

Routine Vaccines

Tetanus-Diptheria (Td) and Pertussis

Everyone should get Td because you can get contract these illnesses almost anywhere, from countries like Russia and Eastern Europe to your own backyard!  It’s important to keep in mind that a routine booster is required every 10 years.


This is also known as your flu shot, which is now available through both intranasal and injection routes of administration.  If you have a severe allergy to eggs or have other medical conditions, do not get the flu shot without consulting your doctor first.

MMR (Measles, Mumps, Rubella)

Did you know that most travelers should have 2 doses of MMR?

Update other routine vaccines

A pneumococcal vaccine is indicated for people who are 65 and older and individuals with certain medical conditions.  The Zoster vaccine (which protects you against chickenpox and shingles…note that they are caused by the same virus) is also indicated for people who are 60 and older so be sure to double check your immunization records before you hop on a plane.

Food/Water Borne Diseases

Catching a stomach bug while traveling is about as miserable as it gets.  Follow these simple tips to help prevent yourself from falling victim to the plethora of infections out there waiting to wreak havoc on your stomach.

“Cook it, peel it, boil it, or forget it!”

  • Make sure all your food has been thoroughly cooked and comes out steaming hot.

  • Avoid raw fruits and vegetables unless they can be washed in clean water and peeled by the traveler (think of the red apple from the movie Snow White).  If you can’t peel it yourself, you’ll have to trust that whoever brought it to you did a stellar job of washing it.  Are you willing to roll the dice?

  • Drink only beverages made with boiled water (coffee, tea) or bottled water (double check the sealing)

  • Avoid tap water and anything mixed with water or ice

Traveler’s Diarrhea

This is probably the most common travel-related health problem for our jet setters.   It usually occurs within the first 14 days of travel, especially if it is caused by bacteria (such as E. coli).  It’s defined as having three or more loose stools in an 8-hour period or four or more loose stools in a 24-hour period plus other symptoms like stomach cramps, nausea, etc.  Sexy, we know.  Typically, traveler’s diarrhea is self-limiting (i.e. goes away on its own) and will last 3-5 days.  So how do you prevent it?  Standard food and water precautions should suffice.  For the hypochondriacs in the room, antibiotics such as TMP/SMX (Bactrim), or ciprofloxacin and levofloxacin can be used.  However, because many diarrheas go away without medication, using an over-the-counter medicine like Loperamide (Imodium) which slows down your overactive bowels should suffice for mild to moderate diarrhea.


People usually contract typhoid fever from food and water contaminated with the bacteria, Salmonella typhi.  Typhoid vaccines are 60-70% effective against this critter and can be administered as a pill or an injection.  The pill form provides 5 years of immunity and needs to be completed 7-10 days before departure.  Alternatively, The injection is a single dose that lasts for 2 years and needs to be given 14 days prior to departure.  Note: the pill form needs to be taken every other day (three doses total) and the pill causes mild gastric discomfort (i.e. an upset stomach for a few days).

Hepatitis A

Hepatitis A isn’t nearly as famous as Hepatitis B but is a virus you will definitely want to avoid during your next trip.  Hep A is transmitted via contaminated food and water and person-to-person.  Morbidity increases with age and reports show 2% mortality in those greater than 40 years of age.  Countries like South America, Mexico, China, India, Africa, and even Greenland have an elevated prevalence of Hep A.  Vaccines are very effective and well tolerated and should be administered 2-4 weeks prior to departure.


This is an acute viral infection that typically involves the gastrointestinal tract.  At the end of 2007, areas of polio risk included Sub-Saharan Africa, Southeast Asia, and the Middle East.  Food, water hygiene and vaccinations remain the best defenses against this infection.

Diseases you can catch via Person-to-Person contact (watch out snugglers!)

Hepatitis B and C

Hepatitis B is transmitted via blood, saliva and sexual contact.  Hepatitis C is transmitted via blood.  There is an excellent vaccine for Hepatitis B but there is currently NO vaccine to prevent Hepatitis C.  You Hep B vaccine options include two interchangeable Hep B vaccines and a combination Hep A and B vaccine.  Since the Hep B vaccine consists of three shots given at 0,1, and 6 month intervals, plan ahead so that you’re fully vaccinated by the time you leave for your trip.


This is an acute bacterial infection that is spread by respiratory droplets (i.e. saliva and those tiny drops of water that fly everywhere when you sneeze), close personal contact, and nasal secretions.  Saudi Arabia, where Meningitis is common, requires a vaccine for those who travel to Mecca during the Hajj pilgrimage.  Additionally, the “Meningitis Belt” includes Sub-Saharan Africa and Asia wher risk is especially high during the dry season (Dec-June).  There are two vaccines available, both of which take 7-10 days to take effect.


TB is a bacterial respiratory disease spread by airborne respiratory droplets.  Risks to travelers include areas highly endemic with TB such as Sub-Saharan Africa, Russia, and Asia.  The vaccine is given at birth in many developing countries but not used in the U.S. due to variable efficacy.  However, it’s important to get screened either via the PPD skin test or chest x-ray from your provider.

Vector-Borne Illnesses (i.e. disease you get from critters)

Although vampire movies are all the rage right now, mosquitoes are unmatched in their ability to suck blood and transmit diseases (only they’re not as good looking).  Enter the insect repellent arms race!  The most common types of insect repellants are:

•    DEET

•    Picaridin

•    Oil of Lemon Eucalyptus

•    Soybean oil

•    Citronella

(Bold = CDC Recommended)

DEET is considered the most effective insect repellant by the CDC.  Two important variables with repellents are Protection and Retention Time, both of which are concentration dependent (10-35% formulations provide adequate protection for 3-6 hours while 50-100% formulations increase protection time by 1 additional hour).  At the same time, more is not always better.  Using too much DEET in high concentrations can lead to DEET toxicity in the form of skin irritation, allergies and, in rare cases, encephalopathy (brain swelling) and seizures.  Another important tip is to avoid products that contain both DEET and sunscreen because the DEET can decrease the effectiveness of the sunscreen.  Therefore, you should apply sunscreen FIRST followed by DEET 1-2 hours later.  Yes, we realize this is a huge pain…but not nearly as bad as malaria.  Travelers can also use Permethrin spray (another insecticide) that can be applied to clothes and lasts for 2 weeks or 2 washings (whichever comes first depending on your personal hygiene).


There are currently 500 million cases worldwide and 1 million deaths reported annually as a result of malaria.  Clinically, there is a 10-14 day incubation period followed by fever, malaise (i.e. you feel like poop), headaches, chills, diarrhea and sweats.  The risk of malaria after 1 month of travel with no preventive medications are as follows:

•    Oceania                                           1:5

•    Africa                                               1:50

•    S. Asia                                              1:250

•    SE Asia                                            1:2,500

•    Mexico and Central America      1:10,000

There are a ton of options for malaria-preventing medications depending on the species of mosquito in the region you visit.   The drugs are categorized as Chloroquine-sensitive P. vivax malaria, Chloroquine-resistant P. falciparum malaria (CRPF), and Mefloquine-resistant P. falciparum malaria (MRPF).  There are many choices within each category and your physician will choose the best option for you based on your current medical history (pregnant, psychiatric disorders, drug interactions, etc.) and your travel itinerary.

Dengue Fever & Chikungunya

This virus is the result of a marriage between an African virus and an Asian mosquito.  It can be self-limiting and is associated with fever and joint/muscle pain that lasts for 2-3 weeks.  It is also associated with a 30% mortality rate (not a good thing).  Unfortunately, there is NO vaccine and NO treatment available so the best way to prevent this disease is by using DEET and/or Permethrin.  Countries with a notable risk of Dengue Fever include Mexico, South America, Sub-Saharan Africa, India, and Southeast Asia.

Yellow Fever

Prevalent in countries including Brazil, Peru, Colombia, and the entire Sub-Saharan region of Africa, this viral disease is transmitted via mosquitoes (surprise, surprise).  The incubation period is usually 3-6 days and symptoms range from subclinical (i.e. you don’t ever notice it) to severe (i.e. multiple organ system failure).  There are roughly 200,000 cases per year, 30,000 of which are fatal, leading to a mortality rate of 15% annually.  Each dose of the Yellow Fever vaccine lasts for 10 years and needs to be administered 10 days before entering the country of risk.

Japanese Encephalitis

This virus is extremely rare.  You are at risk if you spend extensive amounts of time in a rural outdoor setting in the evening (we told you it was rare).  Incubation is typically 4-14 days and is associated with fever, chills, headache, nausea, vomiting, and neurological symptoms.  Of note, 30% of encephalitis cases are fatal but encephalitis is rare in most parts of the world (except for countries in Southeast Asia such as Indonesia).  A 2-dose vaccine is available that needs to be administered 28 days apart, so plan accordingly if traveling to a destination that has a high risk of Japanese Encephalitis both seasonal or year round.

Okay, I’ve consulted my provider and received the necessary vaccines for my trip, does that mean I’m done?

The answer is almost, but not quite!  Avoiding/preventing infection is a big part of staying healthy while traveling but not the only health aspect to be mindful of.  It’s important to pack a few basics for your trip including:

  • Water – Your body has an uncanny ability to lose water while traveling.  The air (completely lacking moisture) on airplanes dries you out before you even set foot on foreign soil.  Once you arrive at your destination, you’ll notice that many parts of the word are extremely hot.  You can sweat multiple liters of fluid each day, all of which need to be replaced.  Make sure to drink plenty of water (as well as electrolytes) to stay hydrated during your adventure.  While traveling, bottled or purified water is always your safest bet.

  • Sunscreen – As we all know our skin protects against heat, sunlight and infection, however, we need to protect our skin from skin cancer, aging, wrinkles, pigment discoloration, sunburn and heat rash.  The SPF on a sunscreen measures a product’s ability to screen or block UVB rays and is calculated based on the smallest dose of UV radiation (measured in hours) which causes erythema (i.e. inflammation in your skin affectionately known as sunburn).  The FDA does not like labeling sunscreen above SPF 30+ because there is not much protective benefit beyond that level.  The factors to take into consideration when choosing a sunscreen include the amount you need, broad or full spectrum, water resistance and formulation.  There are two types of sunscreen – chemical absorbers and physical blockers.  Chemical sunscreens have active ingredients that absorb, filter and reduce UV radiation penetration (examples include PABA, cinnamates, salicylates and octocrylene) and their strength is measured in SPF.  Physical blockers such as titanium oxide or zinc oxide reflect or scatter the sun’s UVR and are not measured by SPF.

  • Insect Repellant – Another option besides DEET or Permethrin is Picaridin, which is equally as effective as 20% DEET and is non-greasy and odorless.  For those who prefer more natural products, 30% Oil of Lemon Eucalyptus (PMD) is equivalent to 20% DEET but requires more frequent application.

  • Mosquito Net (if applicable)

  • Anti-Diarrheal Medications – Other than rehydration, over-the-counter agents such Loperamide (Imodium) work fast to absolve diarrhea symptoms by minimizing loose stools and stomach cramps (it works like brakes on runaway bowels).  Bismuth Subsalicylate (Pepto-Bismol) can also be used as an antidiarrheal, antimicrobial and a mucosal protective agent, however, it can interact with certain antibiotics including Ciprofloxacin (such as for Traveler’s Diarrhea), and should be avoided in pregnant women.

  • Pain Medications – Non-steroidal Anti-Inflammatory Drugs (NSAIDs) like Ibuprofen or Naproxen can not only help decrease generalized pain but it can also decrease erythema or sunburns.  Other agents that can be used for sunburns include aloe vera and vitamin E creams and gels.

  • Allergy Medications – Pack some Diphenhydramine (Benadryl) or a non-drowsy alternative like Loratidine (Claritin) or Cetirizine (Zyrtec) in case you develop allergy symptoms such as watery/itchy eyes, runny nose, rash, or hives due to exotic foods or flowers.

  • First Aid Kit – Most pharmacies sell pre-made kits you can easily purchase that include antibiotic creams (Polysporin and Neomycin), band-aids, gauze and alcohol wipes.

  • Water Disinfectants & Hand Sanitizers

There are many resources available to travelers (for example, the CDC website,, which can be very useful and informative for important travel information.  It’s always better to be safe rather than sorry before hitting the road.  The last thing anyone wants is to end up in a hospital instead of showing off his or her cool tan lines.  An ounce of prevention goes along way when traveling.  As always, remember to seek professional medical advice before starting any new treatment.  Happy travels!


1.    Shoreland’s Medical Reference Guide

2.    Shoreland’s Travel and Routine Immunizations (“Blue Book”)

3.    Shoreland’s Travax/EnCompass

4.    TravelCare©

5.    Tropimed© by Astral, Switzerland

6.    CDC Health Information for International Travel (“Yellow Book”) – 2009

7.    World Health Organization (WHO). International Travel and Health – most current edition

8.    Rose S. and Keystone J.S. International Travel Health Guide. December 2005

9.    Dawood, R. (2002). Traveler’s Health: How to Stay Healthy Abroad (4th ed.).

10.    DuPont, H.L., & Steffen, R. (Eds.). (2000). Textbook of Travel Medicine and Health (2nd ed.).

11.    Jong, E. & McMullen, R. (2003). The Travel and Tropical Medicine Handbook (3rd ed.).

12.    Keystone, J.S., Kozarsky, P.E., Freedman, D.O., Nothdurft, H.D. (Eds.). (2008). Travel Medicine

13.    Leggat, P.A., & Goldsmid, J.M. (Eds.). (2002). Primer of Travel Medicine (3rd ed.). Brisbane: ACTM Publications.

14.    Steffen R., DuPont H.L., & Wilder-Smith, A. (Eds.). (2003). Manual of Travel Medicine and Health (2nd ed.).


05 2010

Breaking the Obesity Cycle

by G. John Mullen, DPT 2011 |

The United States is the most obese nation in the world. Awesome…well done, America. 30.6% of Americans are believed to be obese, 6% higher than the next country, ironically, our Americanized neighbor… Mexico (3)! It is estimated 50% of Hispanics born since 2000 will become diabetic. Mississippi currently holds the crown as the fattest state in the fattest union and has been for the past 5 years, with obesity estimated at 32.5%3. Mississippi also holds the award for fattest children at 44.4% of 10-17 year olds (3). Five states have a current adult obesity percentage over 30%3. To top it off, obesity rates have more than tripled in the past 30 years! These obesity rates are out of control and are a huge weight on the United States budget. On the other end of the spectrum, Colorado is the thinnest state in the union with an obesity rate of 18.9% and is the only state with an obesity rate under 20% (3).  The take home message: America has a weight problem.

Where is all this weight coming from?

The cause of obesity is relatively simple: weight gain occurs when caloric intake exceeds caloric expenditure. Despite the simplistic nature of obesity, weight maintenance and loss are thought of as difficult or impossible tasks. Roughly 25% of American adults report no leisure time activity and 60% report activity levels less than the value shown to reduce their risk of disease (5). No wonder we’re overweight! To add insult to injury, overweight individuals are more inclined to be inactive, with 33% of men and 41% of women reporting inactivity (5). At the same time, roughly 50% of women set a New Year’s resolution to lose weight2. We, as a society, acknowledge the problem and are committing to fixing it each January 1st but seem to fail over the course of the year.

What does it take to lose weight?

Federal guidelines suggest a minimum of 150 minutes a week of moderate-intensity exercise to obtain “substantial health benefits” (4). These health benefits are not associated with weight management, but rather with lowering rates of chronic disease. A recent publication in the Journal of American Medical Association followed 34,079 healthy US women from 1992-2007 studying their activity level and associated weight gains/losses. This study concluded that (amongst women consuming a “normal” diet) physical activity was associated with less weight gain (5 lbs) in women with a BMI lower than 25. The “activity level” was defined as 60 minutes of daily moderate-intensity activity for the duration of the study (4). However, only 45% of women in America are estimated to have a BMI of 25 or less. This study does a great job looking at activity level for weight management, but does not tell us about the volume of exercise necessary for weight loss.

Weight Loss vs. Weight Management

The Harvard study discussed above looked at women with an average age of 54.2 years with no medical complications (cardiovascular disease, cancer, etc.) (4). Women with a BMI of 25 were able to maintain their weight within 5 pounds of their weight at the beginning of the study if they exercised with moderate-intensity activity for 60 minutes a day throughout the study. Moderate-intensity exercise includes bicycling, callisthenics and fast walking (~3.0 MPH or 55-69% of maximal heart rate). However, these same protocols were not successful for weight management in females over a BMI of 25, which constitutes more than half of Americans! This research suggests that overweight or obese women need to change one of the two variables associated with weight management: decrease caloric consumption or increase caloric expenditure. The most important piece of a weight management program is consistency. As stated, many New Year’s resolutions include weight loss goals (fitness centers see an exponential membership increase during January), but the volume of people in the gym returns to normal within a month. The intent is correct but the execution falls short. There are many theories for this. We believe that lack of interest and enjoyment plays a huge role in the gym attrition rate between January and March. If someone does not like riding a stationary while bike watching CNN report another Earthquake in a third world country or another vandalism case by their neighborhood, then it is highly unlikely they will exercise consistently. If we don’t like it and we don’t have to do it, we don’t do it. It’s called human volition. The American view of exercise needs to shift dramatically from a chore to a hobby. The Harvard study used METS (metabolic equivalent) to assess activity level and determined a total of 14 MET hours per week or 3 MET hours a day was sufficient in weight management for women with a BMI of 25 or less. As stated, activities with a 3 MET or higher rating include biking, fast walking, etc. 3+ MET activities also includes various hobbies not typically viewed as exercise: canoeing/kayaking, dancing, ice/roller skating, hiking, gardening and racquetball to name a few (full list of activities with their MET ratings). If you perform these activities at a more rapid pace (really start cruising with that paddle!) these activities can reach the upper echelon of METS. The take home message: Make exercise fun. If you don’t, you’ll quit. If you do, you can potentially burn more calories than you would boring yourself to death on a stationary bike watching Larry King.

Weight loss is a tougher nut to crack and is often person-dependent. Common sense makes it sound as simple as increasing caloric expenditure, but exercising greater than one hour a day is unrealistic for many and leads to failed goals and the aforementioned NYE resolution abandonment. Often times, physical activity is not sufficient in weight loss due to the multivariable nature and complexity of the problem. Many of these issues are related to diet.

Diet is the number one contributor to weight loss. Here are a few simple tips for those trying to lose weight (be sure to stay tuned for more from our staff dietitian):

  • Do not limit yourself to strict caloric restriction diets. The math is complicated and the stress at each meal is unnerving. This approach is hard to consistently maintain leading to failed goals and disappointment. Strict diets can decrease metabolism making the body more likely to gain weight once the diet is discontinued. Instead, monitor diet and decrease consumption of high caloric foods. For example, you can eat four bananas or one McDonald’s double cheeseburger…they have the same number of calories. We guarantee that eating four bananas will be just as filling as a double cheeseburger and the four bananas cost less and have more vitamins than the McDonald’s double cheeseburger.

  • Monitor drink consumption. Energy drinks, frappuccinos, etc. contain high quantities of unfilling calories. Replace these high calorie, high cost options with….water! Simple and effective.

  • Prepare your own food and eat foods that require some work. When was the last time you ate an uncooked carrot? It takes a while to consume and requires a lot of chewing. Increasing the amount of chewing can trick the mind regarding the amount of food being consumed, decreasing hunger.

These three tips are easy to perform and are, most importantly, cost efficient. Some additional factors affecting your ability to lose weight include:

  • Sleep: Inadequate sleep impairs hormones (ghrelin and leptin) that regulate hunger and satisfaction following food consumption. One study found people who slept less than 8 hours a night had lower levels of leptin (controlling satisfication) and higher levels of ghrelin (controlling hunger) AND higher levels of body fat (1).

  • Stress: Cortisol is a hormone produced in response to stress. Cortisol release causes insulin release resulting in increased hunger. The take home message: Relax! You can use multiple stress reduction techniques including deep breathing, meditation, visual imagery, and exercise. Take your pick.

We all know that weight management is an issue in America as obesity rates continue to rise. An undeniably effective approach to weight loss is exercise. The goals is a calorie expenditure > calorie intake. Remember that exercise should be a hobby and not a chore! Find activities you enjoy and stick with them. Set realistic goals that target three areas: appearance, health and consistency. If exercise alone does not achieve your weight goals, diet, sleep and stress can also be manipulated to make your weight goals a reality.

Questions? E-mail John:


  1. Bouchez C. How Sleep Affects Your Weight. 2007.

  2. Losing Weight Is One Of The Most Popular New Year’s Resolutions. Medical News Today. 2005.

  3. F as in Fat 2009 – Trust for America’s Health. 2009.

  4. Lee I, Djoussé L, Sesso H, Wang L, Buring J. Physical activity and weight gain prevention. JAMA. Mar 2010;303(12):1173-1179.

  5. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Kaplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA JAM Aabbr. Journal of the American Medical Association 2001;256:1 195-1200.


05 2010

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