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Asthma

Asthma occurs when the airways in your lungs (bronchial tubes) become inflamed and constricted. The muscles of the bronchial walls tighten, and your airways produce extra mucus that blocks your airways. Signs and symptoms of asthma range from minor wheezing to life-threatening asthma attacks.

Asthma can't be cured, but its symptoms can be controlled. Management includes avoiding asthma triggers and tracking your symptoms. You may need to regularly take long-term control medications to prevent flare-ups and short-term "rescue" medications to control symptoms once they start. Asthma that isn't under control can cause missed school and work or reduced productivity due to symptoms. Because in most people asthma changes over time, you'll need to work closely with your doctor to track your signs and symptoms and adjust your treatment as needed.

Signs and symptoms

Asthma signs and symptoms range from minor to severe, and vary from person to person. You may have mild symptoms such as infrequent wheezing, with occasional asthma attacks. Between episodes you may feel normal and have no trouble breathing. Or, you may have signs and symptoms such as coughing and wheezing all the time or have symptoms primarily at night or only during exercise.


  • Shortness of breath
  • Chest tightness or pain
  • Trouble sleeping caused by shortness of breath, coughing or wheezing
  • An audible whistling or wheezing sound when exhaling
  • Bouts of coughing or wheezing that are worsened by a respiratory virus such as a cold or the flu
Signs that your asthma is probably getting worse include:
  • An increase in the severity and frequency of asthma signs and symptoms
  • A fall in peak flow rates as measured by a peak flow meter, a simple device used to check how well your lungs are working
  • An increased need to use bronchodilators — medications that open up airways by relaxing the surrounding muscles
Work with your doctor to determine when you need to increase your medications or take other steps to treat symptoms of worsening asthma and get your asthma back under control. If your asthma keeps getting worse, you may need a trip to the emergency room. Your doctor can help you learn to recognize emergency signs and symptoms so you'll know when to get help.

Causes

It isn't clear why some people get asthma and others don't, but it's probably due to a combination of environmental and genetic (inherited) factors.
Asthma triggers are different from person to person. Exposure to various allergens and irritants can trigger signs and symptoms of asthma, including:
  • Airborne allergens, such as pollen, animal dander, mold, cockroaches and dust mites
  • Respiratory infections, such as the common cold
  • Physical activity (exercise-induced asthma)
  • Cold air
  • Air pollutants and irritants such as smoke
  • Certain medications, including beta blockers, aspirin and other nonsteroidal anti-inflammatory drugs
  • Strong emotions and stress
  • Sulfites, preservatives added to some perishable foods
  • Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up into your throat
  • Menstrual cycle in some women
  • Allergic reactions to foods such as peanuts or shellfish

Risk factors

Asthma is common, affecting millions of adults and children. A growing number of people are diagnosed with the condition each year, but it isn't clear why. A number of factors are thought to increase the chances of developing asthma. These include:
  • A family history of asthma
  • Frequent respiratory infections as a child
  • Exposure to secondhand smoke
  • Living in an urban area, especially if there's a lot of air pollution
  • Exposure to occupational triggers, such as chemicals used in farming, hairdressing and manufacturing
  • Low birth weight
  • Being overweight
 When to see your doctor

Three key circumstances may lead you to talk to your doctor about asthma:
  • If you think you have asthma. If you have frequent coughs that last more than a few days or any other signs or symptoms of asthma, see your doctor. Treating asthma early, especially in children, may prevent long-term lung damage and prevent worsening of the condition over time.
  • To monitor your asthma after diagnosis. If you know you have asthma, work with your doctor to keep it under control. Good asthma control not only helps you feel better on a daily basis, but also can prevent a life-threatening asthma attack.
  • If your asthma symptoms get worse. Contact your doctor right away if your medication doesn't work for you. Asthma changes over time, and you'll need periodic adjustments to your treatment to manage your symptoms. Don't try to solve the problem by taking more medication without consulting your doctor. Overusing asthma medication can cause side effects and may even make your asthma worse.
Severe asthma attacks
Severe asthma attacks can be life-threatening and require emergency treatment. If your asthma isn't getting better with quick-relief medications, seek emergency help right away. Work with your doctor ahead of time to determine what to do when your signs and symptoms worsen — and when you need emergency treatment. Signs of an asthma attack that needs emergency treatment include:
  • Rapid worsening of shortness of breath or wheezing
  • No improvement even after using short-acting bronchodilators
  • Shortness of breath with minimal activity
 Tests and diagnosis

Diagnosing asthma can be difficult. Signs and symptoms can range from mild to severe and are often similar to those of other conditions, including emphysema, early congestive heart failure or vocal cord problems. In children, it can be hard to differentiate asthma from wheezy bronchitis, pneumonia or reactive airway disease.
In order to rule out other possible conditions, your doctor will do a physical exam and ask you questions about your signs and symptoms and about any other health problems. You may also be given lung (pulmonary) function tests to determine how much air moves in and out as you breathe.

Tests to measure lung function include:
  • Spirometry. This test measures the narrowing of your bronchial tubes by checking how much air you can exhale after a deep breath, and how fast you can breathe out.
  • Peak flow. A peak flow meter is a simple device that can be used at home to help detect subtle changes before you notice symptoms. If the readings are lower than usual, it's a sign your asthma may be about to flare up. Your doctor will give you instructions on how to track and deal with low readings.
Lung function tests often are done before and after taking a bronchodilator to open your airways. If your lung function improves with use of a bronchodilator, it's likely you have asthma.
Other diagnostic tests to diagnose asthma include:
  • Methacholine bronchial challenge. If you have asthma, inhaling a known asthma trigger called methacholine will cause mild constriction of your airways. A positive methacholine test supports a diagnosis of asthma. This test may be used if your initial lung function test is normal.
  • Nitric oxide test. This test is sometimes used to diagnose and monitor asthma. It measures the amount of a gas called nitric oxide you have in your breath. If your airways are inflamed — a sign of asthma — you may have higher than normal levels of nitric oxide. This test isn't widely available.
How asthma is classified
To classify your asthma severity, your doctor will evaluate your answers to questions about symptoms (such as how often you have asthma attacks and how bad they are), along with the results of your physical exam and diagnostic tests. Determining the severity level of your asthma will help your doctor choose the best treatment for you. Asthma severity often changes over time, requiring an adjustment to treatment.

Asthma is classified into four general categories:

Asthma classification Signs and symptoms
Mild intermittent Mild symptoms up to two days a week and up to two nights a month
Mild persistent Symptoms more than twice a week, but no more than once in a single day
Moderate persistentSymptoms once a day and more than one night a week
Severe persistent Symptoms throughout the day on most days and frequently at night


Complications

Asthma may cause a number of complications, including:
  • Emergency room visits and hospitalizations for severe asthma attacks
  • Permanent narrowing of the bronchial tubes (airway remodeling)
  • Side effects from long-term use of some medications used to stabilize severe asthma
Treatment

Treatment for asthma generally involves avoiding the things that trigger your asthma attacks and taking one or more asthma medications. Treatment varies from person to person.
  • Most people with persistent asthma use a combination of long-term control medications and quick-relief medications, taken with a hand-held inhaler.
  • If your asthma symptoms are triggered by airborne allergens, such as pollen or pet dander, you may also need allergy treatment.
  • You may need to try a few different medications before you find what works best.
  • Because asthma changes over time, you will need to work with your doctor to monitor your symptoms and learn how to make needed adjustments.
Medications used to treat asthma include long-term control medications, quick-relief (rescue) medications and medications to treat allergies. The right medication for you depends on your age and symptoms, and what seems to work best to keep your asthma under control.

Long-term control medications
In most cases, these medications need to be taken every day. Types of long-term control medications include:
  • Inhaled corticosteroids such as fluticasone (Flovent Diskus), budesonide (Pulmicort), triamcinolone (Azmacort), flunisolide (Aerobid), beclomethasone (Qvar) and others. These medications reduce airway inflammation and are the most commonly used long-term asthma medication. Unlike oral corticosteroids, these medications are considered relatively low risk for long-term corticosteroid side effects. You may need to use these medications for several days to weeks before they reach their maximum benefit.
  • Long-acting beta-2 agonists (LABAs) such as salmeterol (Serevent Diskus) and formoterol (Foradil Aerolizer). These inhaled medications, called long-acting bronchodilators, open the airways and reduce inflammation. They are often used to treat persistent asthma in combination with inhaled corticosteroids. Long-acting bronchodilators should not be used for quick relief of asthma symptoms.
  • Leukotriene modifiers such as montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo CR). These inhaled medications work by opening airways, reducing inflammation and decreasing mucus production.
  • Cromolyn and nedocromil (Tilade). These inhaled medications reduce asthma signs and symptoms by decreasing allergic reactions. They're considered a second choice to inhaled corticosteroids, and need to be taken three or four times a day.
  • Theophylline, a daily pill that opens your airways (bronchodilator). It relaxes the muscles around the airways.
Quick-relief medications
Also called rescue medications, you use quick-relief medications as needed for rapid, short-term relief of symptoms during an asthma attack, or before exercise, if your doctor recommends it. Only use these medications as often as your doctor tells you to. If you need to use these medications too often, you probably need to adjust your long-term control medication. Keep a record of how many puffs you use each day. Types of quick-relief medications include:
  • Short-acting beta-2 agonists, such as albuterol. These inhaled medications, called bronchodilators, ease breathing by temporarily relaxing airway muscles. They act within minutes, and effects last four to six hours.
  • Ipratropium (Atrovent). Your doctor might prescribe this inhaled anticholinergic for the immediate relief of your symptoms. Like other bronchodilators, ipratropium relaxes the airways, making it easier to breathe. Ipratropium is mostly used for emphysema and chronic bronchitis.
  • Oral and intravenous corticosteroids to treat acute asthma attacks or very severe asthma. Examples include prednisone and methylprednisolone. These medications relieve airway inflammation. They may cause serious side effects when used long term, so they're only used to treat severe asthma symptoms.
Medications for allergy-induced asthma. These decrease your body's sensitivity to a particular allergen or prevent your immune system from reacting to allergens. Allergy treatments for asthma include:
  • Immunotherapy. Allergy-desensitization shots (immunotherapy) are generally given once a week for a few months, then once a month for a period of three to five years. Over time, they gradually reduce your immune system reaction to specific allergens.
  • Anti-IgE monoclonal antibodies, such as omalizumab (Xolair). This medication reduces your immune system's reaction to allergens. Xolair is delivered by injection every two to four weeks.
Albuterol inhaler changes: Know what to expect
The Food and Drug Administration (FDA) has required that metered-dose albuterol inhalers that use chlorofluorocarbon (CFC) propellent be replaced with hydrofluoroalkane (HFA) inhalers by the end of 2008. HFA inhalers work as well as CFC inhalers and are as safe, but they don't harm the ozone layer. If you're used to using a CFC inhaler, talk to your doctor about making the switch to an HFA inhaler. There are a few differences you should know about:
  • Your HFA inhaler may have a different taste and feel from your older CFC inhaler.
  • HFA inhalers have a less forceful spray than the older CFC inhalers. Make sure you know how to use your inhaler correctly - otherwise, you may not get the full dose of medication with each spray.
  • HFA inhalers are more costly than the older, generic albuterol CFC inhalers.
  • HFA inhalers should be cleaned with water every week.
Treatment by severity for better control: A stepwise approach
Treatment based on asthma control can help you manage your asthma. Asthma treatment should be flexible and based on changes in symptoms, which should be assessed thoroughly each time you see your doctor. Then, treatment can be adjusted accordingly.
For example, if your asthma is well controlled, your doctor may prescribe less medicine. If your asthma is not well controlled or getting worse, your doctor may increase your medication and recommend more frequent visits.

Prevention

Working together, you and your doctor can design a step-by-step plan for living with your condition and preventing asthma attacks.
  • Develop a written asthma plan. With your doctor and health care team, write a detailed plan for taking maintenance medications and managing an acute attack. Then be sure to follow your plan. Asthma is an ongoing condition that needs regular monitoring and treatment. Taking control of your treatment can make you feel more in control of your life in general.
  • Identify and avoid asthma triggers. A number of outdoor allergens and irritants — ranging from pollen and mold to cold air and air pollution — can trigger asthma attacks. Find out what causes or worsens your asthma, and take steps to avoid those triggers.
  • Monitor your breathing. You may learn to recognize warning signs of an impending attack, such as slight coughing, wheezing or shortness of breath. But because your lung function may decrease before you notice any signs or symptoms, regularly measure your peak airflow with a home peak flow meter.
  • Identify and treat attacks early. If you act quickly, you're less likely to have a severe attack. You also won't need as much medication to control your symptoms. When your peak flow measurements decrease and alert you to an impending attack, take your medication as instructed and immediately stop any activity that may have triggered the attack. If your symptoms don't improve, get medical help as directed in your action plan.
  • Don't let up on your medication program. Just because your asthma seems to be improving, don't change anything without first talking to your doctor. It's a good idea to bring your medications with you to each doctor visit, so your doctor can double-check that you're using your medications correctly and taking the right dose.
 Lifestyle

Although many people with asthma rely on medications to relieve symptoms and control inflammation, you can do several things on your own to maintain overall health and lessen the possibility of attacks.
Avoid your triggers
Taking steps to reduce your exposure to things that trigger asthma symptoms is a key part of asthma control. Here are some things that may help:
  • Use your air conditioner. Air conditioning helps reduce the amount of airborne pollen from trees, grasses and weeds that finds its way indoors. Air conditioning also lowers indoor humidity and can reduce your exposure to dust mites. If you don't have air conditioning, try to keep your windows closed during pollen season.
  • Decontaminate your decor. Minimize dust that may aggravate nighttime symptoms by replacing certain items in your bedroom. For example, encase pillows, mattresses and box springs in dust-proof covers. Remove carpeting and install hardwood or linoleum flooring. Use washable curtains and blinds.
  • Maintain optimal humidity. Keep humidity low in your home and office. If you live in a damp climate, talk to your doctor about using a dehumidifier.
  • Keep indoor air clean. Have a utility company check your air conditioner and furnace once a year. Change the filters in your furnace and air conditioner according to the manufacturer's instructions. Also consider installing a small-particle filter in your ventilation system. If you use a humidifier, change the water daily.
  • Reduce pet dander. If you're allergic to dander, avoid pets with fur or feathers. Having pets regularly bathed or groomed also may reduce the amount of dander in your surroundings.
  • Clean regularly. Clean your home at least once a week. If you're likely to stir up dust, wear a mask or have someone else do the cleaning.
  • If it's cold out, cover your face. If your asthma is worsened by cold, dry air, wearing a face mask can help.
Stay healthy
Taking care of yourself and treating other conditions linked to asthma will help keep your asthma under control. A few things you can do include:
  • Exercise. Having asthma doesn't mean you have to be less active. Treatment can prevent asthma attacks and control symptoms during activity. Regular exercise can strengthen your heart and lungs, which helps relieve asthma symptoms. Aim for 30 minutes of exercise on most days. If you've been inactive, start slowly and try to gradually increase your activity over time.
  • Maintain a healthy weight. Being overweight can worsen asthma symptoms, and it puts you at higher risk of other health problems.
  • Control heartburn and gastroesophageal reflux disease (GERD). It's possible that the acid reflux that causes heartburn may damage lung airways and worsen asthma symptoms. If you have frequent or constant heartburn, talk to your doctor about treatment options. You may need treatment for GERD before your asthma symptoms improve.
 Coping

Asthma can be challenging and stressful. You may sometimes become frustrated, angry or depressed because you need to cut back on your usual activities to avoid environmental triggers. You may also feel hampered or embarrassed by the symptoms of the disease and by complicated management routines. Children in particular may be reluctant to use an inhaler in front of their peers.
But asthma doesn't have to be a limiting condition. The best way to overcome anxiety and a feeling of helplessness is to understand your condition and take control of your treatment. Here are some suggestions that may help:
  • Identify the things that trigger your symptoms. This can be one of the most important ways to take control of your life. Also take peak flow measurements regularly and follow your action plan for using medications and managing attacks.
  • Pace yourself. Take breaks between tasks and avoid activities that make your symptoms worse.
  • Make a daily to-do list. This may help you avoid feeling overwhelmed. Reward yourself for accomplishing simple goals.
  • Talk to others with your condition. Chat rooms and message boards on the Internet or support groups in your area can connect you with people facing similar challenges and let you know you're not alone.
  • If your child has asthma, be encouraging. Focus attention on the things your child can do, not on the things he or she can't. Involve teachers, school nurses, coaches, friends and relatives in helping your child manage asthma.

Rheumatoid arthritis

Rheumatoid arthritis is a chronic inflammatory disorder that most typically affects the small joints in your hands and feet. Unlike the wear-and-tear damage of osteoarthritis, rheumatoid arthritis affects the lining of your joints, causing a painful swelling that can eventually result in bone erosion and joint deformity.
An autoimmune disorder, rheumatoid arthritis occurs when your immune system mistakenly attacks your own body's tissues. In addition to causing joint problems, rheumatoid arthritis can also affect your whole body with fevers and fatigue.
Rheumatoid arthritis is two to three times more common in women than in men and generally occurs between the ages of 40 and 60. While there's no cure for rheumatoid arthritis, treatment options have expanded greatly in the past few decades.

Signs and symptoms of rheumatoid arthritis may include:
  • Joint pain
  • Joint swelling
  • Joints that are tender to the touch
  • Red and puffy hands
  • Firm bumps of tissue under the skin on your arms (rheumatoid nodules)
  • Fatigue
  • Morning stiffness that may last for hours
  • Fever
  • Weight loss
Smaller joints affected first
Early rheumatoid arthritis tends to affect your smaller joints first — the joints in your wrists, hands, ankles and feet. As the disease progresses, your shoulders, elbows, knees, hips, jaw and neck also can become involved. In most cases, symptoms occur symmetrically — in the same joints on both sides of your body.

Symptoms may come and go
Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go. Periods of increased disease activity — called flare-ups or flares — alternate with periods of relative remission, during which the swelling, pain, difficulty sleeping and weakness fade or disappear.

When to see a doctor
Make an appointment with your doctor if you have persistent discomfort and swelling in multiple joints on both sides of your body.


Rheumatoid arthritis occurs when your immune system attacks the synovium, the lining of the membranes that surround your joints. The resulting inflammation thickens the synovium, which can eventually invade and destroy the cartilage and bone within the joint. The tendons and ligaments that hold the joint together weaken and stretch. Gradually, the joint loses its shape and alignment.

Doctors don't know what starts this process, although a genetic component appears likely. While your genes don't actually cause rheumatoid arthritis, they can make you more susceptible to environmental factors — such as infection with certain viruses and bacteria — that may trigger the disease.

Factors that may increase your risk of rheumatoid arthritis include:
  • Sex. Women are more likely to develop rheumatoid arthritis than men are.
  • Age. Rheumatoid arthritis can occur at any age, but it most commonly begins between the ages of 40 and 60.
  • Family history. If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease. Doctors don't believe you can directly inherit rheumatoid arthritis. Instead, it's believed that you can inherit a predisposition to rheumatoid arthritis.
  • Smoking. Smoking cigarettes increases your risk of rheumatoid arthritis. Quitting can reduce your risk.
Rheumatoid arthritis causes joint damage that can be both debilitating and disfiguring. Damage to your joints may make it difficult or impossible to go about your daily activities. You may find at first that tasks take more energy to accomplish. With time you may find you are no longer able to do them at all. Newer treatments may stop joint damage or prevent it so that you can continue the activities you enjoy. 

Evaluation

While you might first discuss your symptoms with your family doctor, he or she may refer you to a rheumatologist — a doctor who specializes in the treatment of arthritis and other inflammatory conditions — for further evaluation.

What you can do
Write a list that includes:
  • Detailed descriptions of your symptoms, including when they started and if anything makes them better or worse
  • Information about medical problems you've had in the past
  • Information about the medical problems of your parents or siblings
  • All the medications and dietary supplements you take
  • Questions you want to ask the doctor
What to expect from your doctor
During the physical exam, your doctor will check your joints for swelling, redness and warmth. He or she will also check your reflexes and muscle strength.

In addition to the physical exam, your doctor might order imaging and laboratory tests to help determine the cause of your signs and symptoms. Rheumatoid arthritis can be difficult to diagnose in its early stages because its early signs and symptoms mimic those of many other diseases. And no one test or physical finding confirms the diagnosis.

Blood tests
People with rheumatoid arthritis tend to have an elevated erythrocyte sedimentation rate (ESR, or sed rate), which indicates the presence of an inflammatory process in the body. Other common blood tests look for rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies.

X-rays
Your doctor may recommend X-rays to help track the progression of rheumatoid arthritis in your joints over time.


There is no cure for rheumatoid arthritis. Medications can reduce inflammation in your joints in order to relieve pain and prevent or slow joint damage. Occupational and physical therapy can teach you how to protect your joints. If your joints are severely damaged by rheumatoid arthritis, surgery may be necessary.

Medications
Many drugs used to treat rheumatoid arthritis have potentially serious side effects. Doctors typically prescribe medications with the fewest side effects first. You may need stronger drugs or a combination of drugs as your disease progresses.
  • NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve). Stronger versions of these NSAIDs and others are available by prescription. Side effects may include ringing in your ears, increased bruising, gastric ulcers, heart problems, stomach bleeding, and liver and kidney damage.
  • Steroids. Corticosteroid medications, such as prednisone and methylprednisolone (Medrol), reduce inflammation and pain and slow joint damage. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a round face and diabetes. Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication.
  • Disease-modifying antirheumatic drugs (DMARDs). These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. Common DMARDs include methotrexate (Rheumatrex, Trexall), leflunomide (Arava), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine) and minocycline (Dynacin, Minocin). Side effects vary but may include liver damage, bone marrow suppression and severe lung infections.
  • Immunosuppressants. These medications act to tame your immune system, which is out of control in rheumatoid arthritis. Examples include azathioprine (Imuran, Azasan), cyclosporine (Neoral, Sandimmune, Gengraf) and cyclophosphamide (Cytoxan). These medications can increase your susceptibility to infection.
  • TNF-alpha inhibitors. Tumor necrosis factor-alpha (TNF-alpha) is an inflammatory substance produced by your body. TNF-alpha inhibitors can help reduce pain, morning stiffness, and tender or swollen joints — usually within one or two weeks after treatment begins. Examples include etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira). Potential side effects include injection site irritation, congestive heart failure, blood disorders, lymphoma, demyelinating diseases and increased risk of infection.
  • Other drugs. Several other rheumatoid arthritis drugs target a variety of inflammatory substances produced by your body. These drugs include anakinra (Kineret), abatacept (Orencia) and rituximab (Rituxan). Potential side effects include injection site reactions, decreased white blood cell counts, headache and an increase in upper respiratory infections.
Therapy
An occupational therapist can help you find different ways to approach everyday tasks in order to take stress off your painful joints. For instance, if your fingers are sore, pick up an object using your forearms. Lean into a glass door to force it open, rather than pushing on the door with sore arms.
Assistive devices can make it easier to go about your day without stressing your painful joints. For instance, using specially designed gripping and grabbing tools may make it easier to work in the kitchen if you have pain in your fingers. Try a cane to help you get around. Your doctor or occupational therapist may have ideas about what sorts of assistive devices may be helpful to you. Catalogs and medical supply stores also may be places to look for ideas.

Surgery
If medications fail to prevent or slow joint damage, you and your doctor may consider surgery to repair damaged joints. Surgery may help restore your ability to use your joint. It can also reduce pain and correct deformities. Rheumatoid arthritis surgery may involve one or more of the following procedures:
  • Total joint replacement (arthroplasty). During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a prosthesis made of metal and plastic.
  • Tendon repair. Inflammation and joint damage may cause tendons around your joint to loosen or rupture. Your surgeon may be able to repair the tendons around your joint.
  • Removal of the joint lining (synovectomy). If the lining around your joint (synovium) is inflamed and causing pain, your surgeon may recommend removing the lining of the joint.
  • Joint fusion (arthrodesis). Surgically fusing a joint may be recommended to stabilize or realign a joint and for pain relief when a joint replacement isn't an option.
Surgery carries a risk of bleeding, infection and pain. Discuss the benefits and risks with your doctor.

Self-care Measures

You can take steps to care for your body if you have rheumatoid arthritis. These self-care measures, when used along with your rheumatoid arthritis medications, can help you manage your signs and symptoms.

Exercise regularly
Gentle exercise can help strengthen the muscles around your joints, and it can help fight fatigue you might feel. Check with your doctor before you start exercising. If you're just getting started, begin by taking a walk. Try swimming or gentle water aerobics. Public pools and health clubs in your area may offer classes.
Avoid exercising tender, injured or severely inflamed joints. If you feel new joint pain, stop. New pain that lasts more than two hours after you exercise probably means you've overdone it. If pain persists for more than a few days, call your doctor.
Apply heat or cold
Heat can help ease your pain and relax tense, painful muscles. One of the easiest and most effective ways to apply heat is to take a hot shower or bath for 15 minutes. Other options include using a hot pack or an electric heating pad set on its lowest setting.
Cold may dull the sensation of pain. Cold also has a numbing effect and decreases muscle spasms. Don't use cold treatments if you have poor circulation or numbness. Techniques may include using cold packs, soaking the affected joints in cold water and ice massage.
Many people with rheumatoid arthritis find relief by soaking their aching joints in warm water for four minutes and then in cool water for a minute. Repeat the cycle for a half-hour, ending with a warm-water soak.
Relax
Find ways to cope with pain by reducing stress in your life. Techniques such as hypnosis, guided imagery, deep breathing and muscle relaxation can all be used to control pain.

Complementary medications

Some common complementary and alternative treatments that have shown promise for rheumatoid arthritis include:
  • Thunder god vine. Preparations made from the peeled root of this plant are used in traditional Chinese medicine to treat inflammatory and autoimmune diseases. Studies indicate that it may be helpful in treating rheumatoid arthritis. Side effects include diarrhea, menstrual changes and hair loss.
  • Plant oils. The seeds of evening primrose, borage and black currant contain a type of fatty acid that may help with rheumatoid arthritis pain and morning stiffness. Side effects may include nausea, diarrhea and gas. Some plant oils can cause liver damage or interfere with medications, so check with your doctor first.
  • Fish oil. Some preliminary studies have found that fish oil supplements may reduce rheumatoid arthritis pain and stiffness. Side effects can include nausea, belching and a fishy taste in the mouth. Fish oil can interfere with medications, so check with your doctor first.
  • Tai chi. This movement therapy involves gentle exercises and stretches combined with deep breathing. Many people use tai chi to relieve stress in their lives. Small studies have found that tai chi may reduce rheumatoid arthritis pain. When led by a knowledgeable instructor, tai chi is safe. But don't do any moves that cause pain.

MSM for arthritis pain: Is it safe?

Few studies have examined the long-term effects of the dietary supplement called methylsulfonylmethane (MSM). One study suggested that it's safe to take MSM for up to 12 weeks. But further research is needed to assess its safety for long-term use.
There's no conclusive evidence that MSM is effective in reducing arthritis pain. Two small studies have suggested that MSM may reduce joint pain in people with osteoarthritis. Side effects of MSM may include stomach upset, diarrhea and headache.
Although there is great interest in using MSM to treat a variety of conditions, including arthritis, more research is needed to determine its potential benefits and risks.


Coping and support

The degree to which rheumatoid arthritis affects your daily activities depends in part on how well you cope with the disease. Talk to your doctor or nurse about strategies for coping. With time you'll find what strategies work best for you. In the meantime, try to:
  • Take control. With your doctor, make a plan for managing your arthritis. This will help you feel in charge of your disease. Studies show that people who take control of their treatment and actively manage their arthritis experience less pain and make fewer visits to the doctor.
  • Know your limits. Rest when you're tired. Rheumatoid arthritis can make you prone to fatigue and muscle weakness. A rest or short nap that doesn't interfere with nighttime sleep may help.
  • Connect with others. Keep your family aware of how you're feeling. They may be worried about you but might not feel comfortable asking about your pain. Find a family member or friend you can talk to when you're feeling especially overwhelmed. Also connect with other people who have rheumatoid arthritis — whether through a support group in your community or online.
  • Take time for yourself. It's easy to get busy and not take time for yourself. Find time for what you like, whether it's time to write in a journal, go for a walk or listen to music. Use this time to relieve stress and reflect on your feelings.
Remember, you don't have to make all of these changes at once. By gradually incorporating these methods into your day-to-day activities, you're more likely to stick with them.
Keep an open mind about how you do everyday tasks. You might have to change some old habits, but the reward is that your joints may cause you less pain.


Joint protection: Tips for managing rheumatoid arthritis pain

To avoid unnecessary joint strain and increased rheumatoid arthritis pain, consider these tips for protecting your joints.
Move each joint through its full pain-free range of motion at least once a day
This will help you maintain the active motion of your joints. The amount you're able to move each joint without pain may vary from day to day — take care not to overdo it. Keep movements slow and gentle — forcing a motion past the point of a tolerable stretch can damage your joints.
Learn to understand and respect your rheumatoid arthritis pain
Understand the difference between the general discomfort of rheumatoid arthritis and the pain from overusing a joint. By noting when an activity causes joint pain, you can then avoid repeating that movement or think of ways that you can modify the task. Pain that lasts more than an hour after an activity may indicate that the activity was too stressful. Remember that you're more likely to damage your joints when they're painful and swollen.
Be careful how you use your hands
You use your fingers in many ways during your day-to-day activities. You can perform most tasks in easier ways that put less deforming forces on your joints.
  • Avoid positions that push your other fingers toward your little finger. For instance, avoid tasks that require forceful or prolonged gripping or pinching. Finger motions should be in the direction of your thumb whenever possible. For example, when opening jars use a gripping aid and direct the force through the palm of your hand rather than just through your fingers. There are several types of jar opening devices available.
  • Avoid making a tight fist. Use tools with thick or ergonomically designed handles, which make the tools easier to hold.
  • Avoid prolonged pinching items between your thumb and your fingers. Hold a book, plate or mug in the palms of your hands. If you're reading for long periods, use a book holder. Instead of a clutch-style purse, select one with a shoulder strap.
Use good body mechanics
The way you position your body largely affects how much strain you put on your joints. Proper body mechanics allow you to use your body more efficiently and conserve energy.
  • When you're sitting, the proper height for a work surface is 2 inches below your bent elbow. Make sure you have good back and foot support when you sit. Your forearms and upper legs should be well supported, resting level with the floor.
  • If you type at a keyboard for long periods and your chair doesn't have arms, consider using wrist or forearm supports. An angled work surface for reading and writing is easier on your neck.
  • When you're standing, the height of your work surface should enable you to work comfortably without stooping.
  • Increase the height of your chair to decrease stress on your hips and knees as you get up and down.
  • To pick up items from the floor, stoop by bending your knees and hips. Or sit in a chair and bend over.
  • Carry heavy objects close to your chest, supporting the weight on your forearms.
  • Maintain good posture when standing or sitting. Poor posture causes uneven weight distribution and may strain your ligaments and muscles.
Use the strongest joint available for the job
Save your smaller, weaker joints for the specific jobs that only they can accomplish. Throughout the day, favor large joints. For example, carry objects with your palm open, distributing the weight equally over your forearm. Slide objects along a counter or workbench rather than lifting them. When opening cabinets or heavy doors, use a loop that you can pull with your wrist or forearm to decrease stress on your fingers.
Avoid keeping your joints in the same position for a prolonged period of time
Don't give your joints the chance to become stiff — keep them moving. When writing or doing handwork, release your grip every 10 to 15 minutes, or when your hand feels fatigued. On long car trips, get out of the car, stretch and move around at least every one or two hours. While watching television, get up and move around every half-hour.
Balance periods of rest and activity during the day
Effectively managing your workload throughout the day can help you avoid overworked joints. Take time to organize your daily tasks. Work at a steady, moderate pace and avoid rushing. Rest before you become fatigued or sore. Alternate light and moderate activities throughout the day. And take periodic stretch breaks.

Black Bean Hummus

Beans are full of fiber, which will keep you feeling full longer, and an inexpensive source of protein.
1 cup black beans, cooked, drained
1 clove garlic, minced
1/4 cup soft silken tofu
1½ tablespoons tahini
1 teaspoon ground cumin
1 teaspoon extra-virgin olive oil
Juice of 1 small lime
Dash of salt
Ground pepper, to taste
Sprinkle of ground paprika

Place the beans, garlic, tofu, tahini, cumin, oil, and lime juice in a food processor. Whirl until the mixture is smooth. Season to taste with salt and pepper.

Serve in a bowl, garnished with a sprinkle of paprika. Black Bean Hummus will keep for 4 to 5 days, tightly covered in the refrigerator.

Yield: 4 Servings

Per Serving
Calories: 111
Fat: 5 g
Carbohydrates: 12 g
Protein: 6 g

Toxins in Food and Medications to Avoid When You're Pregnant

The last thing you want to provide your baby with is an in-womb environment that resembles a landfill. And although your placenta does a fine job of filtering nutrients between mother and child, it's just not equipped to handle all of the things that we're seeing in today's diet and environment.

It lets everything through that's below a certain size. That means any toxins that make the size cut can get passed to the fetus, whether it's gunk from cigarettes, saturated and trans fats, alcohol or other nasty substances.

So you're wise to get rid of the most harmful toxins in your life as soon as you decide to get pregnant or once you find out you are. Major ones include:

Smoking, Alcohol and Drugs

  • Tobacco and secondhand smoke.
  • Alcohol.
  • Marijuana and other recreational drugs.
Chemicals
  • Spray paints and paint thinners—use latex paint instead.
  • BPA, or Bisphenol-A, commonly found in plastic water bottles. Look for the number 2 or 4 inside the triangle on the bottom of the bottle—but not 3, 6, 7, 8 or 9. A 1 is acceptable but not reusable.
  • Phthalates, found in composite dental fillings and also released when plastic is microwaved.
  • Fluorotelomers, which are in linings of microwave popcorn bags, and stain-resistant carpets and furniture.
  • PCBs, polychlorinated biphenyls, which are organic compounds in fish caught from polluted waterways.
  • Pesticides.
  • Heavy metals such as mercury and lead.
  • Organic solvents such as toluene, xylene, benzene, tetrachloroethylene, ethylene oxide, acetone, acetonitrile (in nail salons) and formaldehyde.
  • Anaesthetic gases.
  • Excess radiation and radon. So avoid X-rays and frequent long-haul flights, and splurge on a $10 radon kit. Leave it in the basement overnight to check if your house is leaking this dangerous gas from the soil.
Foods
  • Hot dogs, lunch meats and saturated fats. These contain nitrates and methylates, which unwind the DNA that's not supposed to be unwound.
  • Trans fats (e.g., any "partially hydrogenated" ingredients).
  • High-fructose corn syrup.
  • Sushi, undercooked meat, soft cheeses (like brie or gorgonzola) and unpasteurized cheese and milk.
Medications
  • Pain-killers: Ibuprofen (found in Advil and Motrin), naproxen (Aleve) and aspirin. Use acetaminophen (Tylenol) instead.
  • Acne medication: Accutane (isotretinoin).
  • Note: Don't stop any medications you're currently taking before talking to your doc. The issue of medicine is often a risk-versus-benefit decision. If you're at high risk of a complication by not taking your medication, you may very well be putting your baby in harms way by stopping.

Ways to Relieve Morning Sickness

A couple of things could be happening to make you feel so queasy. A vomiting center in your brain  is more sensitive, and your digestive tract is more relaxed, making it more likely that foods travel up as well as down. These factors, plus the heightened sense of smell you have during pregnancy, create a swirling GI storm that can make you sickened by the mere mention of food.

A lot of things can help you feel better, but that doesn't mean they all will. So, unfortunately, this is one of those areas in which you may have to experiment a bit to see what therapy may be best for your body.

Here are 15 things that have been shown to relieve the misery:

  • Keep 100 percent whole grain crackers by your bed. Eat a few as soon as you wake to get something in your stomach before you start moving around.
  • Eat a diet high in protein and complex carbohydrates.
  • Sip chicken broth to help you get some calories in along with the liquid.
  • Stick with cold foods—hot foods have a stronger smell, which can trigger queasiness.
  • Take a 6 mg vitamin of B6.
  • Eat leafy greens because they're rich in vitamin K, which seems to help.
  • Eat brown rice
  • Try acupuncture.
  • Wear acupressure wristbands to stimulate pressure points.
  • Brew fresh ginger root in a cup of tea, or take a 300 mg capsule.
  • Get light exercise.
  • Use a mouth rinse after vomiting and after each meal to keep your mouth fresh, reduce nausea and reduce the amount of tooth decay that can occur from the interaction of stomach acid with enamel.
  • Meditate to help control stress. Morning sickness is more common in women under a lot of stress.
  • Explore homeopathic remedies. They are hotly debated within the medical community but are unlikely to cause harm. Nux Vomica seems to help with nausea and irritability.
  • Consider meds. If your morning sickness is really bad, talk to your doc about prescription medications like scopolamine, promethazine, prochlorperazine and trimethobenzamide.

Sunday, February 21, 2010

Pregnancy Questions

Everyone tells me to take prenatal vitamins. Exactly which vitamins and minerals should be in them?

Below is a rundown of the optimal daily amounts of key nutrients that we recommend to support a healthy pregnancy and grow a healthy baby. Of course, taking prenatal vitamins doesn't give you a free pass to eat "whatever" for 40 weeks straight. Make your best effort to eat healthfully. Try these tasty recipes.

Vitamin A
Vitamin A aids in both cell development and brain growth, but this vitamin does have a drawback. There have been links between excessive amounts of vitamin A and an increased risk of birth defects, especially neural tube defects. (Be careful not to eat too many protein, breakfast or meal-replacement bars, each of which may have 100 percent of your daily value of vitamin A. Get into the habit of checking the FDA nutrition labels on everything you eat.)

Aim for this amount: Consume no more than 15,000 international units (IU) a day while pregnant or just before becoming pregnant.

Vitamin B6
Low levels of B6 are associated with a delay in the development of the baby's nervous system. Plus, inadequate amounts are also linked to problems for mom, such as morning sickness, preeclampsia and complications during delivery.

Aim for this amount: 3 milligrams (mg) twice a day.
Vitamin B9
Getting adequate amounts of this all-important prenatal nutrient—also known as folate—reduces the risk of specific birth defects, like spina bifida (an incomplete spinal cord). It also reduces your infant's cancer risk for the first 6 years of life.

Aim for this amount: At least 400 micrograms (mcg) from supplements, such as a prenatal folic acid vitamin pill, and a total of at least 800 mcg, including the amounts from food.

Calcium
A full-term baby accumulates 30 grams of calcium in bone mass, so a mom needs to make sure to get adequate amounts to maintain her own bone strength and get those necessary bone builders to the baby.

Aim for this amount: We recommend taking 600 mg of calcium citrate supplements twice a day, plus 200 mg of magnesium twice a day. Calcium without magnesium leads to constipation, so choose your combo carefully. Also, try to eat three or four servings of calcium-rich foods every day.

Iron
Because a mom transfers about 1,000 milligrams (mg) of iron to a growing baby and increases her total number of red blood cells by 20 to 30 percent, it's important to get adequate iron during pregnancy.

Aim for this amount: 20 mg twice a day.

DHA
The omega-3 fatty acid DHA (docosahexaenoic acid) is a major structural component in both your child's brain and your own. Fetuses are pretty assertive when it comes to taking omega-3 fatty acids for brain development, so you'll be depleted of those important neuron protectors unless you make a point of getting them through diet or supplements. DHA seems to help repair your brain cells or connections damaged by stress.

Aim for this amount: A minimum of 200 to 300 mg of DHA per day from fish, fortified foods or supplements is what we recommend for moms-to-be. Recent research indicates that 600 to 900 mg may be even better. More and more prenatal vitamins are including this important nutrient, but double-check to see if your vitamin does. If it doesn't, ask your doc whether you should take DHA supplements.

Zinc
Low levels of zinc have been shown to be related to increased birth defects, low birth weight, miscarriage and even behavior problems down the road.

Aim for this amount: 10 mg twice a day.

Other nutrients moms-to-be need

  • B1 (also called thiamin)—25 mg
  • B2 (also called riboflavin)—25 mg
  • B3 (also called niacin)—At least 30 mg
  • B5 (also called pantothenic acid)—At least 30 mg
  • B12—400 mcg twice a day
  • Biotin —300 mcg
  • C—400 mg twice a day (remember, it's water soluble, so you need two doses over the day)
  • D—600 IU twice a day
  • E—200 IU twice a day (or, preferably, 400 IU of mixed tocopherols)
  • Magnesium—200 mg three times a day; twice a day prior to pregnancy
  • Selenium—100 mcg twice a day

Weight-loss drugs: Can a prescription help you lose weight?

Weight-loss drugs can improve your health, if used in combination with a healthy diet and regular exercise. Find out if you could benefit from taking these medications. 

 

It's best to lose weight through a healthy diet and regular exercise. But if you're among those who struggle to lose weight and who have weight-related medical problems, weight-loss drugs may be able to help you.
You should know, however, that weight-loss drugs don't replace the need for changes in your eating habits or activity level. And although weight-loss drugs may sound like every dieter's dream, they aren't appropriate for everyone who's overweight.

Are you a candidate?

Prescription weight-loss drugs aren't intended for people who want to lose just a few pounds for cosmetic reasons. They're generally reserved for people who haven't been able to lose weight through diet and exercise, and who have health problems because of their weight.
Your doctor may consider weight-loss drugs for you if you have no contraindications and:
  • Your body mass index (BMI) is greater than 30
  • Your BMI is greater than 27 and you have a serious medical problem related to obesity, such as diabetes or high blood pressure

How well do weight-loss drugs work?

When combined with a low-calorie diet and regular exercise, weight-loss drugs produce an average weight loss of 5 to 10 percent of total body weight within a year, a typical initial goal for any weight-loss effort. Diet and exercise are responsible for part of this weight loss, and medications are responsible for part as well. It's been estimated that the two drugs approved for long-term use, orlistat (Xenical) and sibutramine (Meridia), can lead to weight loss of 5 to 11 pounds (2.3 to 5 kilograms) above and beyond that produced by diet and exercise alone after one year. Losing 5 to 10 percent of your total weight may not seem like much, but even modest weight loss can improve your health by:
  • Decreasing blood pressure
  • Decreasing lipid levels
  • Decreasing blood glucose levels
  • Increasing insulin sensitivity
It's important to keep in mind, however, that these medications may not work for everyone. And if they do work, their effects tend to level off after six months of use. You may need to take weight-loss medication for the rest of your life. When you stop taking these medications, you're likely to regain much or all of the weight you lost.

Most of the older prescription weight-loss drugs approved by the Food and Drug Administration (FDA) are approved for only short-term use — generally less than 12 weeks. Only orlistat and sibutramine have been approved by the FDA for long-term use. Orlistat is also available in a reduced-strength form without a prescription (Alli). Sibutramine and orlistat work in different ways and cause different side effects. Sibutramine changes your brain chemistry, making you feel full more quickly. Orlistat blocks the digestion and absorption of fat in your stomach and intestines. Unabsorbed fat is eliminated in the stool.

The table lists possible side effects for commonly used weight-loss drugs.

DrugPossible side effects
Diethylpropion (Amfepramone)Increased blood pressure and heart rate, insomnia, dizziness
Phentermine (adipex, duromine)Increased blood pressure and heart rate, insomnia, dizziness
Orlistat (Xenical)Intestinal cramps, gas, oily spotting
Sibutramine (Reductil)Increased blood pressure and heart rate

 Source: National Institute of Diabetes and Digestive and Kidney Diseases, 2010

Safety of weight-loss drugs

Before selecting a medication for you, your doctor will consider your health history, possible side effects and potential interaction of weight-loss drugs with other medications you're taking. With weight-loss drugs, there's an additional factor to consider. The drugs approved for long-term use haven't been around that long, which means that they may have long-term side effects that initial studies didn't uncover. For example, in 2009 the FDA announced it was conducting a safety review of sibutramine, which has been on the market since 1997, because of concerns about increased risk of heart attack and stroke in some people with have a history of heart disease. After reviewing the data, the FDA announced that sibutramine should not to be used in people with heart problems, such as:
  • Uncontrolled hypertension
  • History of angina or heart attack
  • History of stroke or transient ischemic attack
  • History of heart arrhythmias
  • History of congestive heart failure
  • History of peripheral arterial disease
Similarly, the FDA is reviewing the safety of orlistat because of reports of serious liver injury in people taking it. Although no definite association has been established at this time between orlistat and the risk of liver injury, people taking orlistat are advised to be alert to signs and symptoms that could indicate liver injury, such as weakness or fatigue, fever, jaundice, or brown urine. It's possible that the effect on the liver is due to increased weight in people who are using orlistat and not from the medication.

Factors to consider

You and your doctor need to carefully evaluate the potential benefits of taking a drug and weigh them against the possible long-term risks. Cost also is a consideration. Not all health insurance plans cover weight-loss prescription drugs. And some may require prior authorization before covering the expense. If you're unsure of your prescription coverage, contact your health insurance provider.
As you consider weight-loss drugs, make sure that you make every effort to exercise, change your eating habits and adjust any other lifestyle factors that have contributed to your excess weight. Weight-loss drugs aren't the easy answer to weight loss, but they can be a useful tool to help you make the necessary diet and lifestyle changes. These medications may also help with weight maintenance, especially if you continue exercising regularly. Keeping off the pounds you've lost, however, is an ongoing concern. And many people, despite their efforts, still regain the weight.




Over-the-counter weight-loss pills: Do they work?

The temptation to use over-the-counter weight-loss pills to lose weight fast is strong. But are these products safe and effective?

The appeal of losing weight quickly is hard to resist. But do weight-loss pills and products lighten anything but your wallet? And are they a safe option for weight loss? Here's a look at some over-the-counter weight-loss pills and what they will and won't do for you.
Over-the-counter (OTC) weight-loss pills: What you need to know

A number of weight-loss pills are available at your local drugstore, supermarket or health food store. Even more options are available online. Most haven't been proved effective, and some may be downright dangerous.

How can companies sell potentially unsafe products? Dietary supplements and weight-loss aids aren't subject to the same rigorous standards as are prescription drugs. Thus, they can be sold with limited proof of effectiveness or safety. Once a product is on the market, however, the Food and Drug Administration (FDA) monitors its safety and can take action to ban or recall dangerous products.

For this reason, it's important to do your homework if you're thinking about trying weight-loss pills. Read labels and talk with your doctor or pharmacist. Also check the FDA Web site for alerts about safety concerns and product recalls. The table shows common weight-loss pills and what the research shows about their effectiveness and safety.


ProductClaimEffectivenessSafety
Alli — OTC version of prescription drug orlistat (Xenical) Decreases absorption of dietary fatEffective; weight-loss amounts typically less for OTC versus prescriptionFDA investigating reports of liver injury
Bitter orangeIncreases calories burnedInsufficient reliable evidence to ratePossibly unsafe
Chitosan Blocks absorption of dietary fatInsufficient reliable evidence to ratePossibly safe
ChromiumIncreases calories burned, decreases appetite and builds muscleInsufficient reliable evidence to rateLikely safe
Conjugated linoleic acid (CLA)Reduces body fat and builds musclePossibly effectivePossibly safe
Country mallow (heartleaf)Decreases appetite and increases calories burnedInsufficient reliable evidence to rateLikely unsafe and banned by FDA
EphedraDecreases appetitePossibly effectiveLikely unsafe and banned by FDA
Green tea extractIncreases calorie and fat metabolism and decreases appetiteInsufficient reliable evidence to ratePossibly safe
Guar gumBlocks absorption of dietary fat and increases feeling of fullnessPossibly ineffective Likely safe
HoodiaDecreases appetiteInsufficient reliable evidence to rateInsufficient information

Sources: U.S. Food and Drug Administration, 2010; Natural Medicines Comprehensive Database, 2010

scent-based weight-loss products

How do weight-loss products such as Sensa, SlimScents and Aroma Patch work?

These scent-based weight-loss products deliver aromas that are supposed to reduce your appetite. Sensa is sprinkled on your food. SlimScents is sprayed in your nose before meals. The Aroma Patch is worn on your hand, wrist or chest.
Alan Hirsch, M.D., who developed Sensa, says proof of its effectiveness comes from a six-month study he conducted in which participants lost an average of 15 percent of their body weight. The makers of Aroma Patch and SlimScents point to another study by Dr. Hirsh to bolster their claims. That study, which was reported in a medical journal, showed that volunteers who used an aroma inhaler lost an average of 2 percent of their body weight over six months. Neither one of these studies looked at whether participants were able to maintain the weight loss.
So can these weight-loss products lead to significant, sustainable weight loss? The jury is still out on that question. Even the makers of these weight-loss products acknowledge that losing weight comes down to diet and exercise. It makes more sense, then, to skip the scents and focus on what's proven to work — reducing the calories you consume and increasing the calories you burn through exercise.

Include your doctor in your weight-loss plans

If you're considering trying weight-loss pills, be sure to talk with your doctor, especially if you have health problems or take prescription drugs. Why? For one thing, your doctor can provide support and advice on losing weight, and can monitor your progress. Just as important, your doctor can talk with you about possible side effects and what to watch out for.
In addition, your doctor can help determine if weight-loss pills are likely to interact with any prescription drugs you take. Many weight-loss pills contain multiple ingredients, such as herbs, botanicals, vitamins, minerals, and even caffeine or laxatives. If you take prescription drugs — or herbal or dietary supplements — adding weight-loss pills to the mix can be tricky.

Despite the hype, no quick fixes

The makers of weight-loss pills would like you to believe that their products will miraculously solve your weight problems. But keep in mind that even if you take a weight-loss pill, you still have to eat fewer calories than your body uses in order to lose weight. And even if these products help you lose weight initially, you will probably have to keep taking them to keep the weight off, which may not be practical or safe.
The reality is that there's no magic bullet for losing weight. The most effective way to lose weight and keep it off is through lifestyle changes: Eat healthy, low-calorie foods, watch portion sizes and be physically active. It's not magic, but it works.

Antibiotics: Misuse puts you and others at risk

Antibiotics can be lifesavers, but misuse has increased the number of drug-resistant germs. See how this affects you and what you can do to help prevent antibiotic resistance.

If you think antibiotic resistance isn't a problem or doesn't affect you, think again. A prominent example of the dangers of antibiotic resistance is the spread of MRSA — or methicillin-resistant Staphylococcus aureus. MRSA was once a concern only for people in the hospital, but a newer form of MRSA is causing infections in healthy people in the community.

Antibiotic resistance occurs when antibiotics no longer work against disease-causing bacteria. These infections are difficult to treat and can mean longer lasting illnesses, more doctor visits or extended hospital stays, and the need for more expensive and toxic medications. Some resistant infections can even cause death.

Although experts are working to develop new antibiotics and other treatments to keep pace with antibiotic-resistant strains of bacteria, infectious organisms adapt quickly. Antibiotic-resistant bacteria will continue to be a global health concern — and using antibiotics wisely is important for preventing their spread.
When is it appropriate to use antibiotics?

Antibiotics are effective against bacterial infections, certain fungal infections and some kinds of parasites. Antibiotics don't work against viruses. The chart shows common illnesses and whether they're caused by bacteria or viruses. Taking an antibiotic when you have a viral infection won't make you feel better — and can contribute to antibiotic resistance.
Bacterial infections

* Some ear infections
* Severe sinus infections
* Strep throat
* Urinary tract infections
* Many wound and skin infections

Viral infections

* Most ear infections
* Colds
* Influenza (flu)
* Most coughs
* Most sore throats
* Bronchitis
* Stomach flu (viral gastroenteritis)

Consequences of antibiotic misuse

If antibiotics are used too often for things they can't treat — like colds, flu or other viral infections — they become less effective against the bacteria they're intended to treat. Not taking antibiotics exactly as prescribed also leads to problems. For example, if you take an antibiotic for only a few days — instead of the full course — the antibiotic may wipe out some but not all of the bacteria. The surviving bacteria become more resistant and can be spread to other people. When bacteria become resistant to first line treatments, the risk of complications and death is increased. In the United States alone, thousands of people die each year of antibiotic-resistant infections they contracted in the hospital.

The failure of first line antibiotics also means that doctors have to resort to less conventional medications, many of which are more costly and associated with more serious side effects. For instance, the drugs needed to treat drug-resistant forms of tuberculosis (TB) are much more expensive than are the drugs used to treat nonresistant TB. The course of treatment is long — up to two years — and the side effects can be severe.

Other consequences are the increased costs associated with prolonged illnesses, including expenses for additional tests, treatments and hospitalization, and indirect costs such as lost income

What you can do to safeguard antibiotic effectiveness

Repeated and improper use of antibiotics is the primary cause of the increase in the number of drug-resistant bacteria. Here's what you can do to promote proper use of antibiotics:

* Understand when antibiotics should be used. Don't expect to take antibiotics every time you're sick. Antibiotics are effective in treating most bacterial infections, but they're not useful against viral infections, such as colds, acute bronchitis or the flu. And even some common bacterial ailments, such as mild ear infections, don't benefit much from antibiotics.
* Don't pressure your doctor for antibiotics if you have a viral illness. Instead, talk with your doctor about ways to relieve your symptoms — for instance, a saline nasal spray to clear a stuffy nose or a mixture of warm water, lemon and honey to temporarily soothe a sore throat.
* Take antibiotics exactly as prescribed. Follow your doctor's instructions when taking medication. Don't stop treatment a few days early because you're feeling better. Taking the full course of antibiotics is the only way to kill all of the harmful bacteria. A shortened course of antibiotics, on the other hand, often wipes out only the most vulnerable bacteria while allowing relatively resistant bacteria to survive.
* Never take antibiotics without a prescription. If you didn't complete a full course of antibiotics, you might be tempted to use the leftover medication the next time you get sick or to pass it along to someone else. But this isn't a good idea. For one thing, the antibiotic might not be appropriate for a future illness. And even if it is, you're not likely to have enough pills to combat the germs making you sick, which can lead to more resistant bacteria.
* Prevent the spread of germs. Good hygiene goes a long way in preventing infection. Wash your hands thoroughly with soap and water, especially after using the toilet, changing a diaper, or handling raw meat or poultry. Keep food preparation areas clean. Although antibacterial cleaners and soap are widely available, they aren't necessary. Plain soap and water work fine to kill germs in most settings.

Protect yourself and others

Antibiotic resistance is a global health problem. Nearly all significant bacterial infections in the world are becoming resistant to commonly used antibiotics. When you misuse antibiotics, you help create resistant microorganisms that can cause new and hard-to-treat infections. That's why the decisions you make about using antibiotics — unlike almost any other medicine you take — have far-reaching consequences. Be responsible in how you use antibiotics to protect your health and that of your family, neighbors and community.

Kidney stones

Kidney stones (renal lithiasis) are small, hard deposits that form inside your kidneys. Kidney stones are made of mineral and acid salts. Kidney stones have many causes. In one common scenario, kidney stones form when the urine becomes concentrated, allowing minerals to crystallize and stick together.

Passing kidney stones can be painful. The pain of a kidney stone typically starts in your side or back, just below your ribs, and moves to your lower abdomen and groin. The pain may change as the kidney stone moves through your urinary tract.

Kidney stones usually cause no permanent damage. Apart from pain medication and drinking lots of water, treatment is often unnecessary. However, treatment may help prevent recurrent kidney stones in people with increased risk.

A kidney stone may or may not cause signs and symptoms until it has moved into the ureter — the tube connecting the kidney and bladder. At that point, these signs and symptoms may occur:

* Severe pain in the side and back, below the ribs
* Pain that spreads to the lower abdomen and groin
* Pain on urination
* Pink, red or brown urine
* Nausea and vomiting
* Persistent urge to urinate
* Fever and chills if an infection is present

When to see a doctor
Make an appointment with your doctor if you have any signs and symptoms that worry you.

Seek immediate medical attention if you experience:

* Pain so severe that you can't sit still or find a comfortable position
* Pain accompanied by nausea and vomiting
* Pain accompanied by fever and chills

Kidney stones often have no definite, single cause. A number of factors, often in combination, create the conditions in which susceptible people develop kidney stones.

Kidney stones form when the components of urine — fluid and various minerals and acids — are out of balance. When this happens, your urine contains more crystal-forming substances, such as calcium, oxalate and uric acid, than the available fluid can dilute. At the same time, your urine may be short of substances that keep crystals from sticking together and becoming stones. This creates an environment in which kidney stones are more likely to form.

Types of kidney stones
Most kidney stones contain crystals of more than one type. Types of kidney stones include:

* Calcium stones. Most kidney stones are calcium stones, usually in the form of calcium oxalate. High oxalate levels can be found in some fruits and vegetables, as well as in nuts and chocolate. Your liver also produces oxalate. Dietary factors, high doses of vitamin D, intestinal bypass surgery and several different metabolic disorders can increase the concentration of calcium or oxalate in urine. Calcium stones may also occur in the form of calcium phosphate.
* Struvite stones. Struvite stones form in response to an infection, such as a urinary tract infection. Struvite stones can grow quickly and become quite large.
* Uric acid stones. Uric acid stones can form in people who are dehydrated, those who eat a high-protein diet and those with gout. Certain genetic factors and disorders of the blood-producing tissues also may predispose you to uric acid stones.
* Cystine stones. These stones represent only a small percentage of kidney stones. They form in people with a hereditary disorder that causes the kidneys to excrete excessive amounts of certain amino acids (cystinuria).
* Other stones. Other, rarer types of kidney stones can occur.

Knowing your type of kidney stone helps to understand what might have caused the stone to form and may give clues as to what you can do to reduce your risk of getting additional kidney stones.

Factors that increase your risk of developing kidney stones include:

* Family or personal history of kidney stones. If someone in your family has kidney stones, you're more likely to develop stones, too. And if you've already had one or more kidney stones, you're at increased risk of developing another.
* Being an adult. Kidney stones are most common in adults age 40 and older, though kidney stones may occur at any age.
* Being a man. Men are more likely to develop kidney stones.
* Dehydration. Not drinking enough water each day can increase your risk of kidney stones. People who live in warm climates and those who sweat a lot may need to drink more water than others.
* Certain diets. Eating a diet that's high-protein, high-sodium and high-sugar may increase your risk of some types of kidney stones.
* Being obese. High body mass index (BMI), increased waist size and weight gain have been linked to an increased risk of kidney stones.
* Digestive diseases and surgery. Gastric bypass surgery, inflammatory bowel disease or chronic diarrhea can cause changes in the digestive process that affect your absorption of calcium and increase the levels of stone-forming substances in your urine.
* Other medical conditions. Diseases and conditions that may increase your risk of kidney stones include renal tubular acidosis, cystinuria, hyperparathyroidism and certain urinary tract infections.
You're likely to start by first seeing your family doctor or a general practitioner if you think you have a kidney stone. Small kidney stones can be treated by your family doctor. But if you have a large kidney stone and experience severe pain or kidney problems, your doctor may refer you to a doctor who treats problems in the urinary tract (urologist).

Because appointments can be brief, and because there's often a lot to cover, it's a good idea to be well prepared. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

* Be aware of any pre-appointment restrictions. At the time you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet.
* Write down your symptoms, including any that may seem unrelated to the reason for which you scheduled the appointment.
* Write down key personal information, including major stresses or recent life changes.
* Make a list of all medications, as well as any vitamins or supplements, that you're taking.
* Take a family member or friend along, if possible. Sometimes it can be difficult to absorb all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
* Write down questions to ask your doctor.

Time with your doctor is limited, so preparing a list of questions will help you make the most of your appointment. List your questions from most important to least important in case time runs out. For kidney stones, some basic questions include:

* Do I have a kidney stone?
* What size is my kidney stone?
* Where is my kidney stone located in my urinary tract?
* What type of kidney stone do I have?
* Will I need medication to treat my kidney stone?
* Will I need surgery or another procedure to treat my kidney stone?
* What is the chance that I will develop another kidney stone?
* How can I prevent kidney stones in the future?
* I have these other health conditions. How can I best manage them together?
* Are there any restrictions that I need to follow?
* Should I see a specialist? What will that cost, and will my insurance cover it?
* Is there a generic alternative to the medicine you're prescribing me?
* Are there any brochures or other printed material that I can take with me? What Web sites do you recommend?
* What will determine whether I should plan for a follow-up visit?

In addition to the questions that you've prepared, don't hesitate to ask questions during your appointment any time that you don't understand something.

If your doctor suspects you have a kidney stone, you may undergo tests and procedures to diagnose your condition, such as:

* Blood tests. Blood tests may reveal excess calcium or uric acid in your blood. Blood tests allow your doctor to check for other medical conditions and to monitor the health of your kidneys.
* Urine tests. Tests of your urine, such as the 24-hour urine collection, may show that you're excreting too many stone-forming minerals or too few stone-inhibiting substances.
* Imaging tests. Imaging tests may show kidney stones in your urinary tract. Imaging tests may include computerized tomography (CT) or, less commonly, X-ray.
* Analysis of passed stones. You may be asked to urinate through a strainer designed to catch any stones you pass. That way, any stones can be collected for laboratory testing. A laboratory analysis will reveal the makeup of your kidney stones. Your doctor uses this information to determine what's causing your kidney stones and to formulate a plan to prevent future kidney stones.

Treatment for kidney stones varies, depending on the type of stone and the cause.

Treatment for small stones with minimal symptoms
Most kidney stones won't require invasive treatment. You may be able to pass a small stone by:

* Drinking water. Drinking as much as 2 to 3 quarts (1.9 to 2.8 liters) a day may help flush out your urinary system.
* Pain relievers. Passing a small stone can cause some discomfort. To relieve mild pain, your doctor may recommend pain relievers such as ibuprofen (Advil, Motrin, others), acetaminophen (Tylenol, others) or naproxen sodium (Aleve).

Treatment for larger stones and those that cause symptoms
Kidney stones that can't be treated with conservative measures — either because they're too large to pass on their own or because they cause bleeding, kidney damage or ongoing urinary tract infections — may require more invasive treatment. Procedures include:

*Using sound waves to break up stones. A procedure called extracorporeal shock wave lithotripsy uses sound waves to create strong vibrations called shock waves that break the stones into tiny pieces that are then passed in your urine. The procedure creates a loud noise and can cause moderate pain, so you may be under sedation or light anesthesia to make you comfortable. The specifics of your procedure may vary depending on the type of equipment your doctor uses.

Extracorporeal shock wave lithotripsy can cause blood in the urine, bruising on the back or abdomen, bleeding around the kidney and other adjacent organs, and discomfort as the stone fragments pass through the urinary tract.

* Surgery to remove very large stones in the kidney. A procedure called percutaneous nephrolithotomy involves surgically removing a kidney stone through a small incision in your back. This surgery may be recommended if extracorporeal shock wave lithotripsy has been unsuccessful or if your stone is very large.
* Using a scope to remove stones. To remove a stone in your ureter or kidney, your doctor may pass a thin lighted tube (ureteroscope) equipped with a camera through your urethra and bladder to your ureter. Your doctor maneuvers the ureteroscope to the stone. Once the stone is located, special tools can snare the stone or break it into pieces that will pass in your urine.
* Parathyroid gland surgery. Some calcium stones are caused by overactive parathyroid glands, which are located on the four corners of your thyroid gland, just below your Adam's apple. When these glands produce too much parathyroid hormone, your body's level of calcium can become too high, resulting in excessive excretion of calcium in your urine. This is sometimes caused by a small benign tumor in one of your four parathyroid glands. A surgeon can remove the tumor or the parathyroid glands.

Alternative medicine can't treat kidney stones. But, when combined with your doctor's advice, alternative treatments may help reduce your risk of kidney stones. Some evidence suggests these alternative kidney stone treatments may help:

* Tea. Drinking a cup of black tea or green tea each day could reduce the risk of kidney stones. One study in women found those that drank the most black tea had a slightly lower risk of kidney stones. The study was not rigorous and only involved women, so it doesn't provide strong evidence that drinking tea is helpful for all kidney stones. If you enjoy drinking tea, there may be a chance that continuing to drink tea can help reduce your risk of kidney stones. However, tea contains high oxalate levels. So if your urine has a high oxalate level, your doctor may advise against drinking tea.
* Lemon juice and orange juice. Theoretically, drinking lemon juice or orange juice could reduce the risk of kidney stones. The citric acid levels in lemon juice and orange juice could reduce calcium levels in your urine, leading to fewer calcium kidney stones. But no studies have proven this theory. If you enjoy drinking water flavored with lemon or drinking orange juice, you might find that this helps reduce your risk of kidney stones. But there is not enough evidence to suggest everyone should try this.

Lifestyle changes
You may reduce your risk of kidney stones if you:

* Drink water throughout the day. Drink more water throughout the day. For people with a history of kidney stones, doctors usually recommend passing about 2.6 quarts (2.5 liters) of urine a day. Your doctor may ask that you measure your urine output to ensure that you're drinking enough water. People who live in hot, dry climates and those who exercise frequently may need to drink even more water to produce enough urine.
* Eat fewer oxalate-rich foods. If you tend to form calcium oxalate stones, your doctor may recommend restricting foods rich in oxalates. These include rhubarb, beets, okra, spinach, Swiss chard, sweet potatoes, tea, chocolate and soy products.
* Choose a diet low in salt and animal protein. Reduce the amount of salt you eat and choose nonanimal protein sources, such as nuts and legumes. This may help reduce your chance of developing kidney stones.
* Continue eating calcium-rich foods, but use caution with calcium supplements. The calcium in the food you eat doesn't have an effect on your risk of kidney stones. Continue eating calcium-rich foods unless your doctor advises otherwise. Ask your doctor before taking calcium supplements, though, as these have been linked to an increased risk of kidney stones. You may reduce the risk by taking supplements with meals.

Ask your doctor for a referral to a dietitian who can help you plan meals that will help reduce your risk of kidney stones.

Medications
Medications can control the level of acidity or alkalinity in your urine and may be helpful in people who form certain kinds of stones. The type of medication your doctor prescribes will depend on the kind of kidney stones you have:

* Calcium stones. To help prevent calcium stones from forming, your doctor may prescribe a thiazide diuretic or a phosphate-containing preparation.
* Uric acid stones. Your doctor may prescribe allopurinol (Zyloprim, Aloprim) to reduce uric acid levels in your blood and urine and a medicine to keep your urine alkaline. In some cases, allopurinol and an alkalinizing agent may dissolve the uric acid stones.
* Struvite stones. To prevent struvite stones, your doctor may recommend strategies to keep your urine free of bacteria that cause infection. Long-term use of antibiotics in small doses may be useful to achieve this goal.
* Cystine stones. Cystine stones can be difficult to treat. Your doctor may prescribe certain medications to alkalinize the urine or to bind the cystine in the urine in addition to recommending an extremely high urine output.

Strawberry banana milkshake

Serves 2
Ingredients

6 frozen strawberries, chopped
1 medium banana
1/2 cup soy milk
1 cup fat-free vanilla frozen yogurt
2 fresh strawberries, sliced

Directions

In a blender, combine the frozen strawberries, banana, soy milk and frozen yogurt. Blend until smooth.

Pour into tall, frosty glasses and garnish each with fresh strawberry slices. Serve immediately.

Nutritional Analysis
(per serving)
Calories 175 Cholesterol 1 mg
Protein 7 g Sodium 61 mg
Carbohydrate 36 g Fiber 3 g
Total fat 2 g Potassium 545 mg
Saturated fat trace Calcium 151 mg
Monounsaturated fat 1 g

Friday, February 19, 2010

protein packed meals

Note: Use 12 to 16 ounces of meat or fish in recipes that don't specify amounts.



1. Chicken Braised in Soy Sauce and Lemon

Sauté, Cheap eat, Intermediate

Brown bone-in chicken pieces in a few tablespoons olive oil. Remove them and stir in some chopped garlic. Add the minced zest of a lemon, a pinch of cayenne, 2 tablespoons soy sauce, 1 teaspoon sugar, and 1/3 cup water; stir. Add the chicken, cover, and simmer. Turn the pieces once; the dish will be done in about 15 minutes. Add lemon juice and more soy sauce to taste.



2. Grilled Chicken with Pesto Sauce

Grill, Beginner

To make the pesto, puree 2 cups fresh basil, 1 garlic clove, a pinch of salt, 2 tablespoons pine nuts, 1/2 cup grated Parmesan, and 1/2 cup olive oil in a blender or food processor. Season 1 pound chicken cutlets with salt and pepper. Grill them, turning once, about 8 minutes total. Paint with pesto and serve.



3. Grilled Chicken Kebabs with Spicy Peanut Sauce

Spicy, Cheap eat, Intermediate

Cut boneless chicken thighs into 11/2" chunks. Shake on salt and pepper. Thread onto skewers and grill about 12 minutes. To make the sauce, combine the minced zest and juice of a lime, 1 tablespoon peanut oil, 1 tablespoon soy sauce, 2 tablespoons minced garlic, 2 tablespoons chopped cilantro, a pinch of cayenne, 2 tablespoons peanut butter, and 1 chopped onion.



4. Chicken with Citrus Sauce

Broil, Cheap eat, Intermediate

To make the sauce, warm the zest and juice of a lemon, plus the sections of another lemon, an orange, and a grapefruit, in a pan. Add 1/4 cup olive oil, 1 teaspoon fresh thyme leaves, 1/2 teaspoon minced garlic, a small minced onion, salt, and pepper. Rub boneless chicken with olive oil and sprinkle them with salt and pepper. Broil or grill. Serve with the citrus sauce.



5. Chicken Tikka with Yogurt Sauce

Grill, Intermediate

Cut boneless chicken into 1" chunks. Combine with 1/4 cup yogurt, 1/4 cup ground cashews, and a teaspoon each ground cardamom, ground coriander, minced ginger, and minced garlic. Remove from the marinade, and grill until it's brown and cooked through. To make the sauce, mix 1 cup yogurt with 1 teaspoon minced garlic and some lemon juice, salt, and pepper. Serve with the chicken.



6. Broiled Chicken Breasts with Cilantro and Lime

Broil, Spicy, Cheap eat, Intermediate

Combine 3 tablespoons peanut oil, 2 tablespoons chopped cilantro leaves, 1 tablespoon freshly squeezed lime juice, 1 tablespoon chopped shallot, 1/4 teaspoon cayenne, and some salt and pepper. Spread half in a pan and add the chicken; sprinkle with salt, pepper, and the remaining mixture. Broil until cooked through. Garnish with chopped cilantro and lime wedges.

7. Lamb Burger with Smoked Mozzarella

Grill, Cheap eat, Beginner

Cut 1/4 pound smoked mozzarella into 4 pieces. Divide a pound of ground lamb and form into patties around each one. Add salt and pepper. Grill or broil until the outsides feel very firm, about 3 or 4 minutes a side. Serve on toasted buns with whatever fixings you like.



8. Grilled Chicken with Wasabi Sauce

Grill, Spicy, Intermediate

Combine minced garlic, 1/2 cup rice vinegar, 2 tablespoons mirin (in the international aisle), 2 tablespoons soy sauce, 1 tablespoon minced fresh ginger, 1 teaspoon wasabi powder, and salt and pepper. Brush chicken with oil and grill. Warm the wasabi mixture and pour it on the chicken; garnish with chopped scallions and cilantro.



9. Herb-Roasted Chicken Cutlets

Bake, Beginner

Heat the oven to 325°F. Mix 1 tablespoon minced fresh tarragon, 1/4 cup chopped fresh dill, 1/2 cup chopped fresh parsley, and some salt and pepper. Place chicken in a baking dish with olive oil, herb mixture, and 1 cup chicken stock. Roast about 15 minutes. Serve with the sauce.



10. Sautéed Chicken with Warm Spices

Sauté, Spicy, Beginner

Heat 4 tablespoons peanut oil in a large skillet. Shake salt and pepper on chicken cutlets, then dredge them in flour with 1/2 teaspoon cayenne. Sauté the chicken, turning once, for about 6 minutes total. Remove from pan. Cook 1/2 cup minced onion until soft. Add 1 tablespoon minced fresh ginger, 1/8 teaspoon nutmeg, 1 teaspoon paprika, 1/4 teaspoon ground cinnamon, and 1 cup chicken stock; cook until reduced. Add chopped cilantro leaves and lime juice. Spoon the sauce over the chicken.



11. Chicken Caesar Salad

Grill, Cheap eat, Intermediate

Grill chicken cutlets. Rub a salad bowl with garlic. Beat 2 pasteurized eggs (available in the dairy case) with a fork; add 2 tablespoons lemon juice and 6 tablespoons olive oil. Stir in 2 tablespoons minced anchovies, a dash of Worcestershire, and some salt and pepper. Toss with romaine lettuce, and top with chicken and freshly grated Parmesan.



12. Mediterranean-Style Seafood Salad

Intermediate

Cut 1/2 pound any firm white fish into 1/2" chunks and drop them into boiling, salted water. After 30 seconds, add 8 ounces each scallops and peeled raw shrimp. Cover, remove from heat, let sit 10 minutes, and drain. Toss the seafood with 1/2 cup minced fresh parsley, 1 tablespoon capers, 1 minced shallot, salt, pepper, and 1/4 cup olive oil. Add lemon juice to taste and adjust the seasoning.



13. Grilled Cod with Basil Dipping Sauce

Grill, Intermediate

To make the sauce, combine 2 tablespoons water, 1 teaspoon minced garlic, 2 tablespoons soy sauce, 2 table-spoons rice vinegar, 1 tablespoon sugar, 1 Thai chili (seeded and thinly sliced), and 1/2 cup sliced fresh basil. Season 1 pound cod with salt and pepper. Cook, turning once. The fish will be done in 8 to 12 minutes, depending on thickness. Serve with the sauce.

14. Cobb Salad

Sauté, Intermediate

Cook 6 slices of bacon and 2 boneless chicken breasts; dice. Chop 1/2 red onion, a tomato, an avocado, and a hard-boiled egg. Top a bowl of lettuce with the meat, vegetables, egg, and 1/2 cup of crumbled blue cheese. Whisk together 2/3 cup olive oil, 1/3 cup sherry vinegar, a diced shallot, salt, pepper, and 1 teaspoon Dijon mustard. Dress, toss, and serve.



15. Shrimp with Olive Oil and Lots of Garlic

Sauté, Beginner

Warm 1/3 cup olive oil over low heat. Add 3 or 4 cloves sliced garlic and cook until golden. Raise the heat and add 11/2 pounds peeled raw shrimp. Season with salt and pepper, 1 teaspoon ground cumin, and 11/2 teaspoons hot paprika. Stir, turning shrimp once or twice, until pink, 5 to 10 minutes. Garnish with fresh parsley.



16. Kung Pao Shrimp

Sauté, Spicy, Beginner

Combine 1 tablespoon dry sherry or Shaoxing wine, 1/2 teaspoon cornstarch, and 11/2 pounds peeled raw shrimp. Heat 2 tablespoons canola oil and cook a few dried chili peppers until slightly blackened. Mince 2 cloves garlic and add to the shrimp mixture along with 1 teaspoon minced ginger. Cook about 3 minutes. Reduce the heat. Add 1 teaspoon sugar and 3 tablespoons soy sauce. Cook 5 minutes. Remove from the heat, stir in 1 teaspoon sesame oil and a chopped scallion, and garnish with roasted, chopped peanuts.



17. Grilled Shrimp Salad with Chili and Basil

Grill, Spicy, Beginner

Grill raw shrimp until firm. Toss 4 cups salad greens with 1 cup torn Thai basil leaves, 1/4 cup minced red onion, and 1 diced cucumber. Whisk together the juice of 2 limes, 1 tablespoon fish sauce, 1/8 teaspoon red-pepper flakes, 1/2 teaspoon sugar, and 1 tablespoon water. Toss with greens and vegetables. Lay shrimp on top and serve.



18. Oven-Fried Fish Fillets

Bake, Beginner

Preheat the oven to 450°F. Soak fish fillets in 11/2 cups milk, then drain and dredge in bread crumbs seasoned with salt and pepper. Put 2 tablespoons oil in the bottom of a baking pan. Add the fillets and drizzle with a little oil. Bake 8 to 15 minutes until done. Serve with lemon wedges.



19. Pan-Cooked Salmon with Miso Carrot Sauce

Sauté, Intermediate

For the sauce, combine 1/4 cup peanut oil, 1/4 cup rice vinegar, 3 tablespoons mild/sweet miso, 1 tablespoon dark sesame oil, 2 carrots, and 1 inch fresh peeled ginger in a food processor. Process until chunky-smooth. Add salt and pepper. Heat 2 tablespoons oil in a pan. Sprinkle 1 pound salmon with salt and pepper. Cook 4 minutes, turn, and cook until done. Serve with the sauce.



20. Red Snapper Meunière

Sauté, Beginner

Heat olive oil. Sprinkle fish fillets with salt and pepper; dredge in flour. Cook until they brown, about 3 minutes; turn. Cook second side 2 to 4 minutes, until firm to the touch. Drizzle with lemon juice, olive oil, and minced parsley.

21. Grilled Swordfish with Fruit Salsa

Grill, Spicy, Beginner

For the salsa, mix 1/2" chunks papaya, mango, pineapple, and/or watermelon with 1/2 cup each diced pepper (any color) and red onion, 2 tablespoons minced chilies, 1/4 cup chopped cilantro, 1 tablespoon olive oil, 3 tablespoons lime juice, and some salt. Sprinkle swordfish with salt and pepper. Grill 5 minutes, turn, and cook until done. Serve with salsa and lime wedges.



22. Squid with Chilies and Greens

Sauté, Spicy Cheap eat, Expert

Separate tentacles from bodies of 11/2 pounds squid. Slice bodies into rings and cut tentacles in half. Strip leaves from mustard or dandelion greens and chop enough to fill 2 or 3 cups. Heat 3 tablespoons oil. Cook 1 chopped jalapeño and 1 tablespoon chopped garlic for 15 seconds. Add greens and cook until wilted, about 2 minutes. Add squid and a pinch of salt; cook until opaque. Serve with rice.



23. Stir-Fried Shrimp with Cashews

Sauté, Intermediate

Combine 11/2 pounds peeled raw shrimp, 1/2 teaspoon sugar, 1 tablespoon soy sauce, 1 sliced garlic clove, and 1 teaspoon each salt and sesame oil. Chop 1 pound bok choy, separating stems from leaves. Heat some peanut oil and cook the shrimp mixture for about 2 minutes; remove. Add 1 tablespoon minced ginger, 1/2 cup cashews, and the bok choy stems. Cook until brown. Add the greens and 1 cup water or sake. Cook until most of the liquid evaporates. Return the shrimp to the pan and add 1/4 cup minced scallions, 1 teaspoon sugar, and 1 tablespoon soy sauce. Cook 1 minute and serve.



24. Poached Monkfish

Intermediate

Melt 3 tablespoons butter in a saucepan. Add 2 diced carrots, 2 diced onions, 2 diced celery stalks, 1 minced garlic clove, salt, and pepper. Cook until vegetables wilt, about 8 minutes. Place two 6-ounce monkfish fillets atop vegetables, and add 2 cups any stock. Bring to a boil, cover, and remove from heat. Let sit about 10 minutes before serving.



25. Vietnamese-Style Steak

Grill, Beginner

In a food processor, combine 1 tablespoon fish sauce, 1 teaspoon pepper, 1 teaspoon sugar, 1 small, seeded Thai chili, 2 tablespoons lime juice, 2 cloves garlic, 2 chopped shallots, 1/2 cup chopped mint or Thai basil, 1/2 cup chopped cilantro, and salt. Pulse until finely chopped. Grill steak, and serve it sliced on greens with the sauce.



26. Garlicky Shrimp Fajitas with Guacamole

Sauté, Intermediate

Cook 2 cloves minced garlic in oil until fragrant. Add 1 pound peeled shrimp; sprinkle with salt and pepper and cook until no longer pink, about 3 minutes. Mash an avocado with 2 tablespoons minced shallot or onion, 1 teaspoon garlic, 1 teaspoon diced chili, a squeeze of lemon juice, salt, and pepper. Serve the shrimp and guacamole with heated flour tortillas.



27. Grilled Tuna Steak with Corn and Tomato Relish

Grill, Intermediate

To make the relish, heat 1 teaspoon olive oil in a skillet. Cook kernels from 4 ears of corn until lightly browned, about 2 minutes. Add 2 chopped tomatoes, some salt and pepper, 1 teaspoon ground cumin, and 1/4 teaspoon cayenne. Cook 30 seconds and remove from heat. Sprinkle tuna with salt and pepper. Grill, turning once, to desired doneness. Serve with the relish.


28. Grilled Beef Salad with Mint

Grill, Spicy, Intermediate

Cook 1 pound beef tenderloin to medium rare, about 10 minutes. Toss 4 cups lettuce with 1 cup torn mint leaves, 1/4 cup minced red onion, and 1 diced cucumber. Whisk together the juice of 2 limes, 1 tablespoon soy sauce, 1/8 teaspoon cayenne, and 1 tablespoon water. Slice beef thinly; add juices to the dressing. Serve sliced beef over salad; drizzle with dressing.



29. Stir-Fried Spicy Beef

Sauté, Cheap eat, Beginner

Slice 1 pound flank steak thinly across the grain into bite-sized pieces. Chop 1/2 cup basil; mix with beef. Cook 11/2 tablespoons minced garlic in 1 tablespoon peanut oil until slightly brown. Add beef-basil mixture and 1/4 tablespoon red-pepper flakes, and cook for 2 minutes. Add 1 tablespoon soy sauce and the juice of 1/2 lime. Serve.



30. Sautéed Calf's Liver

Sauté, Cheap eat, Beginner

Calf's liver is the poor man's foie gras, except it's actually good for you, so eat up. Cut 1 pound calf's liver into 3/4"-thick slices. Heat 2 tablespoons butter. Sprinkle liver with salt and pep- per and dredge in flour. Cook 2 minutes or so, turn, and cook until done. Serve with parsley and lemon.



31. Teriyaki Wings

Grill, Cheap eat, Beginner

Mix 1/3 cup soy sauce, 1/3 cup sake or sweet white wine, 1/3 cup mirin, and 2 tablespoons sugar in a pan. Boil until thickened. Grill chicken wings until cooked through, basting with mix and turning every 2 or 3 minutes. Serve.



32. Edamame with Ground Pork

Sauté, Intermediate

In 2 tablespoons olive oil, cook 8 ounces ground pork until brown and crisp. Remove pork from the pan and pour off all but 2 tablespoons fat. Cook a chopped onion and 1 tablespoon minced garlic until soft, about 3 minutes. Add 1 teaspoon ground cumin and 11/2 cups chopped tomatoes, and cook 10 minutes. Stir in 2 cups shelled edamame and cook until tender (about 8 minutes). Return pork to the pan, season with salt and pepper, and garnish with cilantro.



33. Sautéed Pork Medallions with Lemon and Parsley

Sauté, Cheap Eat, Beginner

Cut 1 pound pork tenderloin into 1/2"-thick slices and pound to 1/4" thickness. Heat 1/4 cup olive oil in a pan. Dredge medallions in flour seasoned with salt and pepper. Cook, turning once, a total of 5 minutes or less. Remove. Pour off fat, add 1/2 cup dry white wine, and cook until wine is almost evaporated. Add lemon juice and some capers. Spoon sauce over the meat. Serve with parsley and lemon wedges.



34. Thai-Style Stir-Fried Pork

Sauté, Cheap eat, Beginner

Cut 1 pound pork shoulder into bite-sized pieces. Cook in 1 tablespoon peanut oil until no longer pink, about 3 minutes. Remove. Cook 11/2 tablespoons minced garlic for 10 seconds. Add 1 pound chopped spinach, and cook until just wilted. Add the pork, 2 tablespoons Thai fish sauce, and the juice of 1/2 lime. Stir and serve.

35. Grilled Chicken, Sausage, and Vegetable Skewers

Grill, Cheap eat, Beginner

Cut boneless chicken and your favorite sausage into 1" chunks. Cut an eggplant into 1" cubes and two bell peppers into 2" pieces. Slice a lemon into eighths. Thread everything onto skewers, alternating ingredients, and sprinkle with salt and pepper. Grill 10 to 15 minutes. Squeeze the hot lemon over all.



36. Broiled Lamb Chops with Swiss Chard

Broil, Intermediate

Sprinkle two lamb chops with salt and pepper. Broil, turning once, less than 10 minutes total. Chop 1 pound Swiss chard, separating stems from leaves. Heat 2 tablespoons olive oil in a small pot, stir in stems, and cook until softened. Add leaves, cover, and steam for a few minutes. Add salt and pepper. Serve lamb with a mound of greens and some lemon wedges.



37. Lamb Medallions with Shallots, Tarragon, and Red Wine

Sauté, Beginner

Cut 1 pound lamb loin into 3/4"-thick rounds and sprinkle with salt and pepper. Heat 1 tablespoon butter in a pan and cook lamb until both sides are browned, 4 to 5 minutes. Remove lamb. Add 1 tablespoon minced shallots; cook 2 minutes. Add 1 teaspoon minced tarragon and 1/2 cup red wine; reduce liquid by half. Stir in 1 tablespoon butter and any lamb juices from under the resting meat. Serve lamb with the sauce.



38. Lamb Kebabs with Peppers and Yogurt

Grill, Intermediate

Combine 1 tablespoon olive oil, 2 tablespoons lemon juice, 2 tablespoons chopped parsley, 1 teaspoon minced garlic, and salt and pepper to taste. Cut 1 pound boneless lamb into 2" chunks, 2 bell peppers into 11/2" chunks, and 6 medium onions into quarters. Thread on skewers, alter-nating ingredients. Brush with marinade, and grill until done, turning two or three times. Mix 1 cup yogurt with 1 teaspoon minced garlic, juice of 1 lemon, salt, and pepper. Serve with the kebabs.



39. White Beans with Cabbage and Ham

Sauté, Cheap eat, Intermediate

In boiling, salted water, cook 3 cups chopped cabbage until tender; drain. Heat 2 tablespoons olive oil. Cook 2 cups chopped leeks and 1 chopped celery stalk until softened, about 5 minutes. Add 2 sprigs thyme, 1/2 cup chopped ham, 1 cup chicken stock, 3 cups drained cannellini beans, and the cabbage. Season with salt and pepper. Cook until heated through. Serve with grated Parmesan.



40. Miso-Grilled Pork Tenderloin

Grill, Beginner

Rub a pork tenderloin with 1/4 cup white, yellow, or red miso paste. Grill, browning all sides, until almost cooked through but slightly pink in the center, about 10 to 15 minutes. Let sit 10 minutes. Cut into 1/2-inch-thick slices and serve.



41. Chorizo and Beans

Sauté, Cheap eat, Beginner

Cut about 1/2 pound chorizo into chunks and bury it in a pot filled with 4 cups cannellini beans, along with a dried chili pepper or red-pepper flakes to taste. Warm through on a stove over medium heat, about 10 minutes, adjust seasoning, and serve.



42. Roasted Sausage with Rosemary and Lemon

Bake, Cheap eat, Beginner

Preheat the oven to 450°F. Lay sweet Italian sausage links on 4 rosemary sprigs in a pan. Prick sausages with a thin knife. Roast for about 15 minutes, turning once or twice. Top the sausage with 1/4" slices from 3 lemons, peeled. Bake until cooked through, about 10 minutes. Serve with lemon.

43. Veal Cutlets with Rosemary and Parmesan

Sauté, Intermediate

Combine 1/2 cup freshly grated Parmesan, 1/2 cup bread crumbs, 1 tablespoon minced fresh rosemary, and salt and pepper. Heat 1/4 cup olive oil. Dredge 1/4" veal cutlets in crumb mixture. Cook, turning once, until browned, less than 5 minutes total. Serve with lemon quarters.



44. Veal Scallopine

Sauté, Intermediate

Sprinkle salt, pepper, and 1/4 cup lemon juice over four 1/4" veal cutlets. Heat 3 tablespoons olive oil. Dredge veal in flour; cook 1 to 2 minutes on each side, until browned. Remove veal. Add a sliced lemon, 1 cup dry white wine, and 1/2 cup chicken stock. Bring to a boil; cook until thickened. Return the veal to pan, coat with the sauce, and heat through. Add some capers; serve.



45. Bean-and-Cheese Burger

Sauté, Cheap eat, Beginner

In a food processor, combine 2 cups drained beans (white, black, or red, or chickpeas), a quartered onion, 1/2 cup rolled oats, 1/2 cup grated mozzarella cheese, 1 tablespoon chili powder, an egg, salt and pepper. Pulse until chunky, adding liquid to get the mix to hold together. Shape into patties. Heat oil. Cook until browned on one side, about 5 minutes; turn. Cook other side until firm and browned.



46. Pasta Carbonara

Sauté, Cheap eat, Beginner

Fry 4 ounces of bacon (about 8 strips), then drain and chop. Beat together 2 eggs and 1 cup grated Parmesan. Cook 1 pound spaghetti in salted boiling water until tender but firm. Drain pasta and toss with the egg mixture. (Don't worry, residual heat from the pasta will cook the eggs.) Add bacon and lots of fresh cracked pepper.



47. Pan-Roasted Swordfish with Pea Puree

Bake, Expert

Preheat the oven to 500°F. On the stovetop, boil 2 cups peas until tender. Puree peas with 1 tablespoon minced ginger. Add water or cream until the mixture is the consistency of yogurt. Heat 2 tablespoons olive oil in an ovenproof skillet. Add swordfish steaks, salt, and pepper. Cook until browned, 3 to 5 minutes; turn. Cook in the oven 5 to 10 minutes. Reheat pea mixture with 2 tablespoons butter and serve with the fish.



48. Baked Eggs with Spinach

Bake, Cheap eat, Beginner

Preheat the oven to 350°F. In boiling, salted water, cook 2 pounds spinach for 1 minute. Drain, cool, squeeze, and chop. Heat 3 tablespoons butter in a baking dish, add spinach, and toss to coat. Spread spinach out, making 8 nests. Crack 1 egg into each. Top with salt, pepper, Parmesan, and bread crumbs. Bake 15 to 20 minutes or until yolks are just set and whites solidified.



49. Smoked Salmon Scramble

Sauté, Beginner

Whisk together 4 eggs, 2 tablespoons milk or cream, and salt and pepper. Heat 2 tablespoons butter until foamy. Add eggs and reduce heat. Push eggs from the pan edges to the center, stirring frequently but gently. Add 1/2 cup flaked smoked salmon. Remove eggs from the heat when just set. Garnish with sour cream.



50. Black-Bean and Beer Soup

Sauté, Cheap eat, Beginner

In 2 tablespoons hot oil, cook a chopped onion until softened, about 5 minutes. Add 1 tablespoon minced garlic and 2 teaspoons ground cumin cook another minute. Add 3 cups canned black beans (drained), 1 can beer, and salt and pepper. Bring to a boil, reduce the heat, and cook for 10 minutes, stirring occasionally. Puree half the soup and add it back to the pot. Add fresh lime juice and serve.