Category Archives: Heart Health

COVID AND YOUR HEART

February is Heart Health Month

 

Each year the American Heart Association designates February as Heart Health Month to raise awareness and encourage health style changes to lower risks. Heart disease caused by narrowed coronary arteries has been the major cause of death in both women and men around the world for decades. This year, rising Covid-19 deaths will skew statistics and within this high death rate are many who have underlying coronary artery disease.

Covid-19 typically impacts the respiratory system but may progress to other body parts including the heart. Older people who developed heart disease over a lifetime are at increased risk when infected with the SARS-CoV-2 coronavirus that causes COVID-19 illness. But the virus can also attack young healthy hearts.

Some survivors with no underlying heart disease who did not require hospitalization still developed heart complications. Heart muscle inflammation (myocarditis) and heart failure (decreased pumping ability) occur in some. Heart failure results in shortness of breath, ankle swelling and decreased exercise tolerance.

A Mount Sinai Health Systems study of 3,000 patients hospitalized with COVID-19 showed a high number with heart injury. Thirty-six percent showed elevated troponin levels indicating heart muscle damage. Rising blood troponin correlated with a higher risk of death. Even patients with mild heart muscle injury had a 75% higher risk of death than those with normal troponin levels.

Most people who test positive for COVID-19 experience mild symptoms, require no hospitalization, and experience a full recovery. Systemic effects from the infection are variable but include blood clotting disorders and nervous system involvement. An overwhelming immune response, called a “cytokine storm” results in cellular damage and shock in some patients. But many older people with chronic diseases such as diabetes, kidney and lung problems have complicated courses. Reduced oxygenation that can be severe may evolve to irreversible lung damage.

Post COVID weakness and exhaustion require a cardiac workup. It is important to seek medical attention for chest pressure, shortness of breath, and palpitations (irregular heartbeat). If your heart rate is abnormally slow, fast, or irregular, make an appointment to see your doctor.

 

The workup will involve the following: a history of your symptoms, underlying risks such as diabetes, high blood pressure, known heart disease, medication list, and activity level prior to COVID-19 infection. Common evaluations include physical exam, chest X-ray, ECG, and an echocardiogram.

Contact the American Heart Association for general heart health guidance and follow CDC recommendations for protection during the pandemic. For personal safety and the safety of others, masks and social distancing are essential. Consult your healthcare provider or local health department to register for a vaccination as soon as possible. Follow safety precautions and always wear a mask when you leave your home.

Lower stress with education. Know your risks and take action.

American Heart Association

CDC COVID information

Save lives and protect your heart.

Lipstick Logic Sisters Betty and Bev

 Amazon link

HEART HEALTH

 Over the month of February, known as Heart Month, you may have heard a lot about the importance of having a healthy heart. We want to offer some quick tips and access to websites and a book designed to help you improve not only your heart health, but your overall health as well.

Heart disease remains the number one cause of death for both men and women. Go Red for Women is an American Heart Association’s (AHA) platform presented to improve health. AHA’s website is an excellent source of valuable information: https://www.goredforwomen.org/

Make 2020 your year to live a healthier life for your heart’s sake.

Develop A Personalized Plan

To improve your health and outlook on life, make a commitment to eat healthy and find an exercise that works for you, one you can do daily. Get plenty of sleep, limit your alcohol intake, choose happy active friends, and find activities you enjoy.

Move More

A 30-minute walk each day with six minutes of cardio-exercise will increase your endurance to enjoy all activities and prolong your life. https://www.nytimes.com/2020/02/18/well/move/in-6-minutes-you-can-be-done-with-your-workout.html

Eat Healthy and Less

The Mediterranean diet has proven to help people lose weight, keep it off, plus reduce their chance of having a heart attack, stroke, or developing type 2 diabetes. It is a healthful approach to eating for men and women for all ages.

A Mediterranean diet consists of fish and seafood, poultry, eggs, low-fat dairy like yogurt, Vegetable Tray-1vegetables, fruits, whole grains, beans, nuts and seeds, and olive oil. For a sample meal plan and beginner’s guide to the Mediterranean diet, check out this website:  https://www.healthline.com/nutrition/mediterranean-diet-meal-plan

 Mediterranean 5:2 Diet

In 2012, weight expert, Dr. Michael Mosley introduced the Mediterranean 5:2 diet – an eating plan where you reduce your calorie intake to 800 or fewer calories two days a week. It is best to split those days, say Monday and Thursday. Splitting the days helps you maintain an even metabolic rate while dieting. On the other “regular” five days, you eat a diet consisting of fish, poultry, dairy, vegetables, fruits, whole grains, beans, nuts and seeds, and olive oil – a healthy Mediterranean Diet.

Calculate Your Calorie Needs

Below is a website that will help you calculate how many calories you need per day to reach your desired weight.

https://www.healthline.com/nutrition/how-many-calories-per-day

Handbook on Heart Health

Your Heart Book Cover- Final 1For more in-depth information about heart health, Dr. Betty Kuffel, MD, Fellow of theAmerican College of Physicians, has published Your Heart, Prevent and Reverse Heart Disease in Men, Women and Children. This handbook is available for purchase on Amazon.

https://www.amazon.com/Betty-Kuffel/e/B07XFQPLFX

Challenge yourself

Start your customized program today. Adopt healthier eating and exercise habits that will pay dividends in 2020 and beyond. If you are on medications or have health risks, be sure to discuss diet and exercise with your health practitioner. Your heart and body will thank you.

Betty Kuffel, MD and Bev Erickson

5:2 Mediterranean Diet

Your Heart – Prevent & Reverse Heart Disease in Women, Men & Children

The 5:2 Eating Plan

Your Heart Book Cover- Final 1

♥ If you look to the future in defeat and say to yourself there is no way I can lose 20, 30, 50 or 100 pounds. Ask yourself this: Can I cut back my calories one day each week? How about cutting back two days a week?

On the 5/2 Plan you eat about 500 calories one day, then eat a regular healthy Mediterranean cuisine or plant-based cuisine the next one or two days, then you eat only 500 calories the next day, resume regular eating the rest of the week and repeat this ongoing. Your overall calorie intake drops gradually and you lose weight.

In 2012, Dr. Michael J. Mosley shared his concept of eating less than your usual intake for two non-consecutive days a week. With this plan, you reduce your calorie intake significantly but it is not as mentally challenging as setting out to sharply curtail eating for the indefinite future. His concept is to have men eat about 600 calories and women about 500 calories on two non-consecutive low calorie days.

Dr. Mosley’s examples of food choices on the low-intake days are: two eggs and lean meat with water, tea or black coffee; a second meal of grilled fish or meat, with vegetables. You can make breakfast healthier by throwing out the yolks and eating a side of non-processed protein choices, such as a heap of steamed veggies. (Veggies high in protein include broccoli, mushrooms, soybean sprouts, tomatoes and onions, to name a few.)

Although fasting has been advocated for decades in many groups, harsh diets often fail miserably because metabolic changes related to starvation trigger the body to store up calories and as soon as you begin eating normally, you regain weight.

To be effective and long-lasting, the manner of eating must be sustainable. It must be a way of life — something you can do for the rest of your life. If you have a lot of weight to lose, this would be a life-changing method of gaining control of your eating and reducing weight. To review: one pound = 3500 calories. If your normal intake is 2500 calories/day and you eat 500 calories two days/week, your weight loss each week would be more than one pound. This is approximately 4-5 pounds per month and 48-60 pounds in a year. In addition, if you choose lower calorie foods, less fat and sugar, you may lose more. Most people find this plan easy to follow for long periods.

Animal studies examining the effects of fasting have shown heart benefit with reduced blood pressure and lower cholesterol levels. Intermittent fasting also lowered diabetes development in lab animals.

Because Dr. Mosley’s unique concept of marked calorie reduction for two out of five days lacked scientific evidence to support the process in reduction of heart disease and diabetes in humans, I was hesitant to include it in this evidence-based book. However, as I was writing this portion of the book a very exciting scientific review in the British Journal of Diabetes and Vascular Disease was published!

An Aston University team in the UK, led by Dr. James E.P. Brown evaluated various approaches to intermittent fasting, looking for any evidence of advantage for its use in treating Type 2 diabetes. In their review, they found intermittent fasting was just as effective, possibly even more effective, than daily calorie restriction and calorie counting. Other favorable findings: markedly low calorie days (not true fasting) can reduce inflammation, reduce both glucose and lipids, and reduce blood pressure.

True fasting lowers metabolic rate and making it harder to burn fat and lose weight. Reduced metabolic rate is protective in a prolonged starvation state and impacts the ability of people today to lose weight. Researchers believe the gene pool of those who were able to survive periods of starvation has been retained in today’s population. Examples are the American Indians and many Polynesian cultures that are experiencing obesity and Type 2 diabetes epidemics.

Their bodies evolved to become efficient in saving calories for harsh times. The problem today is, food is plentiful and the ability to efficiently save the energy in fat stores has become detrimental instead of life-saving.

In the 5/2 plan, eating less on two non-consecutive days is unlikely to lower your metabolic rate and trigger the starvation response. For example, choose Monday and Thursday as your low calorie days and add daily exercise to your weight loss plan, Exercise is an essential component to health improvement and longer life.

Pregnant women and people with Type 1 diabetes should not fast.

If you are interested in the 5/2 diet, check with your physician and obtain guidance regarding your medications during the low calorie days, especially if you are a Type 2 diabetic taking medications to lower blood glucose. Monitor blood glucose carefully and avoid readings that are too low.

There are many studies showing great benefit by delaying Type 2 diabetes, reversing glucose elevations and reducing insulin resistance with weight loss. Dr. Brown and his team are preparing clinical trials to evaluate the 5/2 dietary format as interventions in various clinical settings.

An excerpt from: Your Heart – Prevent & Reverse Heart Disease in Women, Men & Children

Betty and Bev

Your Heart Book Cover- Final 1

Your Heart

 

♥ Protect Your Heart ♥

February is American Heart Month

Cardiovascular disease is the number one killer of women and men. February is a great time to review your health history and explore actions to reduce risks for dying of heart disease and stroke. Heart risk factors and actions:

♥ Tobacco use and cessation

♥ High blood pressure identification and treatment

♥ Cholesterol abnormalities paired with dietary modification and statin use when needed

♥ Low activity levels counteracted with exercise prescriptions

♥ Alcohol consumption history and limitation of use

♥ Heredity factors and recommended interventions

To help you take control and make 2018 a healthier year, we are offering our book free on February 13, 14 & 15. In just two-hundred pages, Your Heart will give you the science behind the disease, some actions to improve your health and common interventions that could save your life or the life of a loved one. This includes information on the Mediterranean 5/2 diet, a safe and easy way to reduce weight and maintain a healthy weight for life.

YOUR HEART –

Prevent & Reverse Heart Disease in Women Men & Children

♥ FREE FEBRUARY 13, 14 & 15♥ 

HAPPY VALENTINE’S DAY

BETTY and BEV

Easy Weight Loss or Maintenance

Mediterranean 5/2 Eating Plan

The Five/Two Diet
As a method of weight loss and weight control, this easy solution of five/two pertains to a 7 day eating plan. Once you have reached your ideal weight, you transition to healthy baseline calorie intake every day. If you gain a pound, then you can transition back to the 5/2 plan. This is how it works:

• For 5 days a week, you eat a healthy diet based primarily on fruits, vegetables, a few nuts, a little olive oil, limiting pasta or rice to twice a week. Add limited whole grains to the mix, with low-fat meat, including salmon or other similar fish. Mirror your food selections with the Mediterranean diet like people who live along the southern Italian coast and Greek islands. Eating primarily fresh fruits, vegetables, and little saturated fat, they tend to live longer, in better health and with lower heart disease.

• For two days a week, eat very few calories, only 500-600. The two days must not be consecutive. Instead separate them such as Monday and Thursday.

Why not do the low calorie days together? Harsh calorie restriction can trigger what researchers call the starvation response. With starvation, the body revs up to store calories by lowering the metabolic rate and packing on calories when food becomes available. It is a natural process to maintain life.

Even though the two low calorie days are not true fasting, if they are consecutive such as Monday and Tuesday, your metabolic rate may be affected. Separating the days, combined with daily exercise such as walking is known to increase metabolic rate andkabob veg calorie burn. — And, with exercise, you are unlikely to stimulate a starvation response. In fact, with a marked reduction in calorie intake and consistent exercise, you will lose weight.

British physician Michael Mosley, described the 5/2 diet in his book FastDiet in 2012. In a follow up study done at the Aston University in the UK, they found intermittent fasting (very low calorie days) more effective than daily calorie restriction and calorie counting.

Favorable findings included:
• Reduced weight
• Reduced inflammation
• Reduced blood glucose
• Reduced lipids (cholesterol)
• Reduced blood pressure

True fasting (consuming no nutrition) has been shown to lower weight, prolong life, lower blood glucose and lower cholesterol levels. However, fasting also lowers metabolic rate, something you do not want, because your body becomes very efficient at storing excess calories and weight returns.

Eating two low calorie days per week is usually safe for Type 2 diabetics. Those taking medications and insulin must consult their medical provider for advice and to help manage medication dosages when reducing calorie intake. In the end, with weight loss, some Type 2 diabetics can reduce or stop some of their medications. Or, for those with borderline glucose elevations, weight loss and the drug Metformin, may help ward off the development of full-blown Type 2 diabetes. Without interventions, most people with borderline elevation of blood glucose will evolve to Type 2 diabetes within ten years.

Pay special attention to your daily intake:
• Choose fruits over sweets for desserts.
• Exercise portion control. Avoid second helpings. Wait 30 minutes and see if you are really still hungry.
• Do your best to prepare low calorie meals such as turkey breast instead of hot wings or steak.
• Forget potatoes, pasta, gravy, cheese sauce and fattening salad dressing.
• If you are preparing meals, serve light calorie recipes and fruit for dessert.
• Take time to exercise

Note: If you are, pregnant, breast feeding or a Type 1 diabetic, following a Mediterranean-type cuisine is healthy but do not follow the very low calorie day recommendations. However, this is a heart-healthy approach for those with high blood pressure and heart disease, even those who have had bypass and stent procedures.
Betty Kuffel, MD & Bev Erickson

PROTECT YOUR HEART

Fewer people are dying from heart attacks. Education, healthy changes in lifestyle and diet have made dramatic improvements. Additional life-saving interventions include rapid treatments to open closing vessels interrupting heart attacks. Dilation and placement of stents open a closing vessel and returns blood flow to the heart muscle before damage occurs. We have made strides in reducing heart deaths in recent years, but cardiovascular disease remains the number one killer of both men and women.

The key to heart health is early action to alter contributing factors. If you recognize worrisome chests symptoms seek healthcare immediately. Call 9-1-1.

Take control of your health through education and action. Basic actions:

  • Exercise – Thirty minutes of exercise a day contributes to improved health
  • Eat Right – Cut calories by reducing fat, sugar and portion sizes
  • Drink – Water, coffee or tea. Stop drinking diet and sugared sodas.
  • Read – Learn how to improve your health and take control
  • Visit a health practitioner: Know your numbers for blood pressure, cholesterol and glucose

National Wear Red Day is Friday February 3, 2017

The American Heart Association started the Go Red for Women national movement to improve education helping women learn their risks and take action. I wrote Your Heart- Prevent & Reverse Heart Disease in Women, Men and Children to provide a concise reference with broad information on heart health, diet, exercise with details to take action. Heart disease the #1 killer of women causes 1:3 deaths each year.

Your Heart – Prevent & Reverse Heart Disease in Women, Men & Children

Your Heart Book Cover- Final FINAL

Your Heart Book on Amazon

Price reduction: Kindle $2.99, Paperback $9.99

https://www.goredforwomen.org/

https://yourheartbook.com

Improve Your Health

Springtime Weight Loss & Health Goals

KONICA MINOLTA DIGITAL CAMERAThe doldrums of winter have passed. With shorter nights and warmer days, the grass is greener, flowers are blooming and the birds are singing. It’s spring!

If you are an outdoor winter sports enthusiast, you may be fit and at your ideal weight. But, if icy weather kept you indoors and sedentary, you may have added a pound or two. If so, this is the time to get started on a healthy routine. Forget spring cleaning, instead, dust off your shoes and take a walk.

Before you begin, hop on the scale and record your weight. Use the baseline to track your progress to better health. According to the National Institutes of Health, excess weight can put you at risk for a multitude of health problems. Cardiovascular problems are at the top of the list, including heart attacks, strokes and high blood pressure. Close behind are: Type 2 diabetes, unhealthy pregnancies, sleep apnea and even some types of cancer.

Now that you have your weight, you need see where you are based on accepted parameters using the Body Mass Index (BMI) categories of weight:
• Normal = 18.5-24.9Scale, Tennis Shoes, Calculator
• Overweight = 25-29.9
• Obesity = 30 or higher

So, how do we measure BMI? The easiest way is to go to: BMI Calculator
Input your numbers and the internet program will give you the value.

If you like math and you’d rather calculate your BMI, you need your weight, height, a metric conversion multiplier and a calculator to square your answer and divide. It’s Easy – follow the steps below:

1. Multiply your weight in pounds by 0.45. Ex: 125 pounds x .45 = 56.25 kg

2. Multiply your height in inches by 0.025. Ex: 63” x .025 = 1.575 m

3. Square the answer from step 2. Example: 1.575 x 1.575 = 2.4806

4. Divide Step 1 answer by Step 3 answer. Example:56.25 divided by 2.480625 = 22.7 BMI

• If your BMI is normal, exercise is still important.
• If the BMI is elevated, get started on the Mediterranean 5/2 eating plan combined with walking at least 30 minutes a day plan to drop the unwanted pounds.

Go to: Your Heart, our other blog, to find details regarding both Mediterranean food choices and guideline for the plan of eating two low calorie days per week – allowing easy weight reduction.
Losing just 5 to 10 percent of your body weight may lower your chances of developing heart disease? If you weigh 200 pounds, this means losing as little as 10 pounds could prolong your life. Weight loss benefits include:
• Improved energy, sleep, sex life and self-image
• Lower blood pressure, lower cholesterol and lowered risk of heart attack
• Reduced cancer risk
• Fewer aches and pains
• Reduced risk of dementia
Spring Forward. Put on your tennis shoes and start walking. Listen for the sweet sounds of returning birds. Watch for spring flowers and pussy willow buds. Take a dog for a walk. Ask a friend to join you.

Lift your spirits and improve your health.

Betty Kuffel MD and Bev EricksonTall Grass

Lipstick Logic

Your Heart Book Cover- Final FINALMore information about heart health and losing weight can be found in our book: YOUR HEART

The Benefits of Daily Exercise after Menopause

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Women experience menopause with lost ovarian function due to aging or surgical removal. Loss of estrogen in the postmenopausal state affects the body in both obvious and subtle ways. Obvious effects are hot flushes, thinning hair and skin wrinkling, but there are many more silent harmful effects.

Early menopause contributes to osteoporosis. Gradual weakening of bones occurs without the estrogen stimulus to calcium metabolism and bone strength. Further bone loss may evolve to fractures and disability.

We also know the effectiveness of high-density-lipoprotein (HDL), the “good” blood fat, is reduced without estrogen effect. This transporter molecule is responsible for removing cholesterol buildup in arteries. HDL particles without the effect of estrogen are less efficient and the risk for heart attacks increases in women following menopause. Postmenopausal women can offset some of this effect by eating healthy and staying active. Statin medication to modify abnormal blood lipids may also be needed.

A study reported at the North American Menopause Society stated women after menopausal tend to weigh more, have larger waist lines, and a higher percentage of body fat than younger more active premenopausal women. Sedentary behavior correlated with a larger waist size – no surprise. But their findings showed regular exercise brought benefit to both pre- and post-menopausal women. When women increased their daily exercise – energy, mobility, and bone density all improved, along with reduction in waist size. Increased activity and weight control can also reduce the risk of developing Type 2 diabetes.

Last year, a journal of the American Association for Cancer Research reported a four year study examining women who walked the equivalent of thirty minutes per day had a lower risk of invasive breast cancer. The exact mechanism is unknown, but we do know exercise carries many positive benefits. Researchers stressed the benefit of lowered risk of invasive breast cancer was lost when exercise stopped — so daily exercise is key.

Walking daily can become a positive routine and is as important to overall health as brushing your teeth. Dogs love to walk. Our dogs provide encouragement to take a hike even in the rain. If you don’t have a dog, find a friend to join you. Exercise and social relationships correlate with happiness and longer life. Find a route that makes you smile and take a daily walk.

Some good advice from Dr. Seuss:
You have brains in your head.
You have feet in your shoes.
You can steer yourself in any direction you choose.

20151018_142608Betty and Bev

I’ll Drink to That!

Some water flowing in high mountain streams is pristine enough to drink without the need of additives to kill or filter out disease-causing microbes. But, in many places on planet earth, water clean enough for consumption is in short supply. In California and other drought-ridden locations, plants and animals are dying due to insufficient water. In many areas around the world, dysentery from drinking contaminated water is prevalent and life-threatening.

We take water purity for granted in the US where chlorinated water pours from our taps. But, during much of the past 10,000 years, before the availability of pure water, the only safe liquid to drink contained alcohol. Today, we see alcohol through many lenses, with both good and bad views.

Alcohol is the metabolic byproduct of the natural process of fermentation that occurs when yeasts metabolize sugars. In the Middle Ages, alcohol was called “the water of life,” aqua vitae. They learned to make wine from grapes, and beer from fermented grain. People of all ages, including children, drank alcoholic beverages as their primary consumable liquid. The alcohol destroyed many microbes causing disease and made it safer to drink than water. The processes for making wine and beer are simple. Today, many people make them for fun. Microbreweries have sprung up everywhere. There are many suppliers, even health food stores carry the products.

All alcohols are not consumable. Some can cause blindness and death. Disinfectant alcohol is applied to surfaces of the body prior to medical procedures, and is the primary ingredient in liquid hand purifiers. Windshield cleaners spew various colored fluids containing alcohol. There are many industrial uses.

20150626_195841The drinkable form is ethyl alcohol. It is used in celebratory toasts, paired with elegant dining, and has been shown to contribute to cardiovascular health. Undisciplined drinking carries health risks and tragedy. Alcohol is a sedative drug and a toxin. Excessive consumption contributes to loss of mental function, also causing addiction and liver failure. Alcohol has become a common social drink and a problem for many who drink to excess.

Our next blog will review a new powdered alcohol product called palcohol. Additional blogs will provide information on health and social issues related to alcohol consumption, common early signs of problematic drinking, and will discuss blood alcohol determinations.

Here’s to safe drinking, designated drivers, and moderation in all things.

Betty and Bev

Broken Heart Syndrome

Takotsubo Cardiomyopathy

Losing a loved one, the sudden stress of receiving bad news, intense fear or domestic violence can break your heart. But this isn’t in the emotional sense we usually think about. There is an acute heart problem seen primarily in women of menopausal age in which the heart weakens in the face of sudden stress. The main pumping chamber of the heart balloons instead of contracts. Resulting chest pain and shortness of breath are symptoms indistinguishable from a heart attack.

The electrocardiogram shows classic ST segment elevation found in heart attacks. In addition, there is often a small sharp rise in troponin, a heart injury blood marker. In a typical heart attack caused by a blocked coronary artery, the damaged heart muscle cells leak troponin, but usually in larger amounts.

If an angiogram determines there is a blocked artery the cardiologist will likely place a stent. But in the broken heart syndrome known as Takotsubo Cardiomyopathy, instead of finding blockage, the coronary arteries are clear — the results indicate a failing heart with an odd shape. It looks like an octopus trap (a tako-tsubo).

 

The actual cause of this disorder is not known but is likely related to a surge of stress hormones that stun the heart and prevent normal muscle contraction. Takotsubo is usually seen in older estrogen-deficient menopausal women. However, younger women who lack estrogen because of surgical menopause from ovary removal are also at risk. Animal studies show estrogen appears to protect the heart in stress states.

There are no treatments shown to reverse Takotsubo. Doctors usually order common heart failure medications including beta blockers (to reduce heart rate and blood pressure), ACE inhibitors (to dilate arteries making it easier for the heart to pump) and diuretics (to remove excess fluid). It isn’t known if continuing the drugs can prevent a recurrence, but within two months, most patients fully recover. A few women are left with reduced heart function, and occasionally abnormal heart rhythms occur.

Women in this age group may also have underlying heart disease requiring medical management unrelated to the sudden stress state. Like men, women develop blockage of the major coronary arteries.

Another heart problem most often seen in women involves only small heart arteries. The large coronary arteries are clear but tiny arteriolar vessels are diseased. Microvascular disease is serious. It can lead to heart attacks and heart failure. A treadmill in combination with continuous monitoring, followed by echocardiogram to check heart function will show abnormalities. Microvascular disease is also treated medically.

Techniques used to help reduce stress hormone surges include: progressive muscle relaxation, exercise, yoga, avoiding alcohol and caffeine. Controlling anxiety is not easy and counseling may be necessary.

 

Lipstick Logic
Betty Kuffel, MD