A Healthy lifestyle can reduce YOUR risk of stroke

How you can decrease your risk of stroke

As a neurologist, I see on a daily basis how devastating and debilitating a stroke can be. Unfortunately, the effects are typically irreversible. Therefore, prevention is of great importance. Controllable risk factors for stroke include hypertension, diabetes, high cholesterol, and smoking.   Thus, living a healthy lifestyle, which potentially would improve those risk factors, could decrease your risk for stroke.

Researchers in a recent study analyzed the combined effect of five factors that typically are associated with living a healthy lifestyle to see if living a healthy lifestyle would indeed decrease the risk of stroke. The 5 factors studied and recommended for a healthy lifestyle include: having a healthy diet, i.e., eating within the top 50% of a recommended foods, modest alcohol consumption (not greater than 3-9 drinks per week), not smoking, 40 minutes of being physically active per day and BMI of <25 kg/m2

The study found that women who had all 5 factors of healthy lifestyle compared with women with none had a 62% lower risk of ischemic stroke. All 5 components of the low risk lifestyle were inversely associated with the risk of ischemic stroke. The risk of stroke steadily decreased with each additional healthy lifestyle factor.

Once again research documents the importance of exercise as a part of a healthy lifestyle AND prevention of a devastating stroke. If you wish to add exercise to decrease your risk of a stroke but don’t know where to start, I would love to help you.


Dr Deb

Works Cited

Larsson, S. C. (2014). Healthy diet and lifestyle and risk of stroke in a prospective cohort of women. Neurology , 83, 1699-1704.



Non-Caloric Sweeteners

Non-Caloric Sweeteners,

Friend or Foe?


More and more people have turned to non-caloric sweeteners, in attempts to lose weight or at least, help prevent further weight gains. Questions have been raised about whether or not we are, instead, doing our bodies a disservice?

1.  Can non-caloric sweeteners cause weight gain?

Counterintuitive to what we might think, there is evidence that the use of non-caloric sweeteners may actually be associated with weight gain.  This was first shown in the San Antonio Heart Study. This study-documented weight changes over a 7-8 year period in people who drank beverages sweetened with non-caloric sweeteners compared to those who did not.  They found that those who drank on average 21 beverages sweetened with non-caloric sweeteners per week had about double the risk of being obese.  This was true regardless of the weight of the person at the start of the study.

Another study published in the January 2013 issue of the journal Appetite, found similar findings in rats. In this12 week study rats were fed plain yogurt sweetened with aspartame, saccharin, or sugar in addition to their regular rat chow.  What they found was that the rats that were given either saccharin or aspartame in their yogurt had an increased weight gain compared to rats that were given only sucrose in their yogurt.

2.  Can non-caloric sweeteners increase you risk for type 2 diabetes?

There have been multiple studies that have shown that the consumption of beverages sweetened with non-caloric sweeteners increased the risk for type 2 diabetes compared to non-consumers of beverages sweetened with non-caloric sweeteners.  This was seen even in participants who were of normal weight at baseline.

3.  Can non-caloric sweeteners cause an increase your appetite?

It is unclear why non-caloric sweeteners would cause weight gain and/or increase your risk for diabetes.  One of the theories is that non-caloric sweeteners are felt to increase your appetite.  Experiments have found that the sweet taste, regardless of its caloric content, increases your appetite.  Real sugar tells your brain that it has received enough calories, thus activating satiety signaling and telling your body that you are full.  Non-caloric sweeteners stimulate your appetite by the sweet taste, but your body keeps waiting for the calories to come. When the calories do not come, the sensations of hunger remain.

4.  Are non-caloric sweeteners associated with any side effects?

a. Sucralose (Splenda): has been shown to trigger migraine headaches. It has also showed to increase the incidence of inflammatory bowel diseases possibly due to the decrease in the amount of beneficial gut bacteria as the result of Sucralose consumption.

b.  Saccharin (Sweet’N Low):  has been reported to cause cancers at very high doses.  Between the years 1981 and 2000 the FDA required labeling to warn about possible carcinogenic effects.  Those warnings have since been removed.

c.  Aspartame (NutraSweet and Equal): has possible side effects including dizziness, headaches, GI issues and mood changes.

Aspartame is broken down into phenylalanine (50%), aspartic acid (40%) and methanol (10%) in the body. The excess of phenylalanine from the breakdown of aspartame blocks the transport of important amino acids in the brain contributing to reduced levels of dopamine and serotonin.  Aspartic acid is the precursor to an excitatory amino acid glutamate.  Increased amounts of this and other excitatory amino acids results in increased free radical formations, increased oxidative stress and increased inflammation in the brain. This results in cell death.  These alterations seen are similar to those occurring in neurodegenerative diseases such as Alzheimer’s disease.  Increased inflammation also linked to diseases such as fibromyalgia and other chronic pain syndromes.

It has also been reported that, if stored too long in high temperatures and in a pH above 6, aspartame produces a carcinogenic metabolite – diketopiperazine.  This breakdown product has been reported to cause tumors in the brain including gliomas, medulloblastomas, and meningiomas.

5.  Do ALL non-caloric sweeteners have potential side effects?

Stevia is a natural non-caloric sweetener that is isolated from the plant Stevia Rebaudiana Bertoni.  So far no negative side effects have been reported with its use. Additionally, a study has found that participants who consumed products made with Stevia had lower total caloric intake compared to those consuming sucrose.  Consumption of stevia also lowered postprandial insulin and glucose levels compared to consumption of aspartame and sucrose.

The FDA and most industry-funded studies endorse the safety of these additives. I however have formed my opinion based on these and other studies that I have read.  Based on these studies I have come to the realization that non-caloric sweeteners may not be the best things to be putting into our bodies but if I were going to reach for one maybe a better alternative would be Stevia.


Anton, S. E. (2010). Effects of stevia, aspartame, and sucrose on food intake, satiety, and postprandial glucose and insulin levels. Appetite , 55, 37-43.

Fowler, S. P. (2008). Fueling the Obesity Epidemic? Artificially Sweetened Beverage Use and Long-tem Weight Gain. Obesity , 16 (8), 1894-1900.

Rycerz, K. e. (2013). Effects of aspartame metabolites on astrocytes and neurons. Folia Neuropathologica , 51 (1), 10-17.

Shankar, P. P. (2013). Non-nutritive sweeteners: Review and update. Nutrition , 29, 1293-1299.

Swithers, S. (2013). Artifical sweeteners produce the counterintuitive effect of inducing metabolic derangements. Trends in Endocrinology and Metabolism , 24 (9), 431-441.


5 Things You Should Question About Your Migraines

 5 Things you should question your Doctor about your Migraines

Here are 5 things that American Headache Society task force recommends to help physicians and patients make wise decisions about the most appropriate migraine care.

1.  There is no need to preform neuroimaging studies when you have stable migraine headaches.  This is based on the fact that there is numerous evidence-based guidelines have shown that the risk of intracranial disease is not elevated in people with migraine headaches.   A migraine diagnoses however needs to be made based on the International Classification of Headache Disorders criteria to avoid missing patients with more serious headache.

2. If you are going to get neuroimaging, make sure you get a MRI instead of CT scan, except in emergency setting.  A MRI is more sensitive than CT scan for the detection of many of the secondary causes of headache.  CT scan should only be obtained in the emergency setting when hemorrhage or acute stroke is suspected.

3.  Do not get surgical deactivation of migraine trigger points outside of a clinical trial.  The value of the form of ‘migraine surgery’ is still under question with limit evidence that it is effective or safe.  Long term side effects from these types of procedures are also unknown.
4.  Do not take opioids or butalbital containing medications as first line treatment for your migraines.  These medications  can impair alertness,  produce dependence or addiction.  They may worsen your headaches by increasing the frequency of your headaches and may make your headaches harder to treat.  These medications may also produce heightened sensitivity to pain.

5.  Do not use prolonged or frequent use of over the counter medication for your migraines.  Over the counter medications (OTC) can be used for occasional headaches if they work reliably without side effects.   Frequent use (especially of the caffeine containing medications) can lead to an increase in headache frequency/medication overuse headaches.   Overuse of Acetaminophen containing medications can cause liver damage.   Overuse of non-steroidal anti-inflammatory drugs can lead to gastrointestinal bleeding.  Thus it is recommended that you do not take OTC more than 2 days a week.



Loder E, Weizenbaum E, Frischberg B, Siberstein S.  Choosing Wisely in Headache Medicine: The American Headache Society’s List of Five Things Physicians and Patients Should Question. Headache. 2013:53:1651-1659.

Moran, M. From the American Headache Society: ‘Choosing Wisely’ in Headache Medicine: The American Headache Society’s List of Five Things Physicians and Patients Should Question about Migraine. Neurology Today. 2014:14.


stroke cut

Stroke Prevention Made Simple

 Stroke Prevention

It just starts with one simple step


I was recently at a stroke prevention talk for physicians and medical students. The speaker started the talk by asking the audience several questions.  The first was; “If you had a stroke, how many of you would want to be on a treatment program to prevent a second one?”  Everyone’s hand shot up.  The second question was; “If you haven’t had a stroke how many of you would want to be on a treatment program to prevent a stroke in the first place?” Again everyone’s hand went up.

Next she asked;  “How many of you currently do these things: exercise regularly, on average greater than 150 hours a week; maintain a healthy diet and weight; don’t smoke; limit alcohol intake; maintain normal blood pressure, sugars and cholesterol?”  After this question only a few hands went up.   The audience appeared embarrassed.  They knew that doing these few things is indeed the best treatment program to prevent strokes, and they were not practicing what they preached to their patients.

Just like the doctors in the audience, most people know that they need to have a healthy life style, which includes regular exercise, not smoking and healthy eating. Unfortunately, many of us, doctors included, do not start these simple preventive measures until it is too late, after we already start to have problems.

We as a society are too much into instant gratification, ‘we want it now’ mentality. Darren Hardy talks about this in his book, The Compound Effect.  In this book he states that if we knew that eating unhealthy foods like a Big Mac would cause us to have a stroke at that instant we would not eat that Big Mac.  The problem is that since you do not have a stroke at that instant we keep on eating the unhealthy foods.  Unfortunately, there is a negative affect; it is just delayed.  Over time these unhealthy habits of eating fatty food, lack of regular exercise, and smoking leads to narrowing of the blood vessels (atherosclerosis), high blood pressure and diabetes.  Having these conditions then increase your risk for stroke.

Stroke is the 4th leading cause of death and the leading cause of disability in the United States.

A stroke occurs when the blood supply to the brain is blocked or interrupted.  This results in damage to that area of brain tissue.   Typically, this causes a sudden onset of symptoms including weakness or numbness to one side of the body, problems talking, visual changes, lack of control of movements or dizziness.

What causes this lack of blood flow to the brain?  It can be caused by a narrowing of the blood vessels in the brain from the build up of the fatty deposits (atherosclerosis).  Those small arteries in the brain can also be narrowed by vasoconstriction from high blood pressure.  The other main cause of blockage is from clots that break off of atherosclerotic plagues from the neck, or from blood clots from the heart that travels through the brain’s blood vessels until it reaches vessels too small to let it pass.

stroke picture

What are the main controllable risk factors for stroke?

  • High blood pressure
  • Heart disease
  • High cholesterol levels (specifically, high LDL or “bad” cholesterol)
  • Obesity
  • Type 2 diabetes
  • Smoking

The best defense against having a stroke is controlling these risk factors.  This is not done by taking a pill but instead by starting these simple healthy behaviors of what the American Heart Association describe as  “Life’s simple 7”:

  1. Get active or exercise
  2. Control cholesterol
  3. Eat better
  4. Manage blood pressure
  5. Lose weight
  6. Reduce blood sugar
  7. Stop smoking

I know that this seems like a lot to do all at once.  So just take one step at a time.  A good first step is to start by exercising 30 minutes, 5 days a week.  This one simple activity can have a positive compounding effect over time. Regular exercise will then help with some of the other risk factors by lowering your blood pressure and help you lose weight.  The changes in weight will not start the first time you exercise but if you continue it, the weight loss benefits will come and hopefully will decrease your risk for a stroke.

We all have a choice, do you want to choose a simple action (regular exercise) that can improve your health or one that can have a negative affect (eating that big mac).

If you are ready to start to do all you can to prevent that stroke let me know. I would love to help you get fit for your brain!


Tai Chi for Fibromyalgia

tc fibro

Tai Chi for Fibromyalgia

People who have fibromyalgia live in considerable amount of pain.  They are aerobically unfit, have poor muscle strength, limited flexibility, and have impaired physical performance.  Studies have shown that exercise would benefit all of those symptoms.   Despite knowing that exercise is beneficial, most people who have fibromyalgia do not participate in a regular exercise program.

Why is it that people who have fibromyalgia do not exercise? It is not because people with fibromyalgia cannot be active, since about 2% of competitive sport players have fibromyalgia.  As a Neurologist the two most common reasons that I hear for the lack of exercise is #1 they are too fatigued and #2 they have too much pain.  (I will talk more about how to treat the fatigue in another post in the future).

People who live with fibromyalgia experience a chronic cycle of pain.  They complain of pain, which causes increased muscle tension, which along with increased stress causes limited activity.  This, then, causes increases fatigue, depression, muscle stiffness, and thus pain.  The best way to break this pain-tension cycle is to start moving.  Unfortunately, patients with fibromyalgia are often reluctant to engage in physical activity due to the fear that the one thing that may help the most may instead exacerbate their pain.

chronic pain_cycle

For this reason I typically recommend people who have fibromyalgia to start with either a warm water-based exercise program or a mind–body forms of exercise such as yoga or Tai Chi. I will discuss  Tai Chi.

Tai Chi is a mind-body practice that originated in China as a gentle form of martial arts.  It combines meditation with slow, gentle, graceful movements, as well as deep breathing and relaxation.  It has been found to have therapeutic benefits in patients with rheumatoid arthritis, osteoarthritis, and more recently fibromyalgia.

Based on the fact that Tai Chi is beneficial in patients with arthritis and other musculoskeletal disorders there have been several studies, which looked at the use of Tai Chi in patients with fibromyalgia. Basically all the studies show that the Tai Chi participants had significantly improvement in their measurements of pain, quality of life, improved sleep, and decreased fatigue and depression compared to the control group. Thus the Fibromyalgia pain cycle is broken.  Functional mobility and balance also improved which means less falls and injuries.  Tai Chi is also well tolerated meaning it did not produce major exercise related symptoms flares.

The major problem is finding a Tai Chi class.   Typically Tai Chi classes are most readily found at senior centers, and are only rarely found at your local gym.  If you can’t find Tai Chi classes near you then a great alternative is Tai Cheng.

tai ch

Tai Cheng is a 12 week home Tai Chi based exercise program developed by Dr. Mark Cheng.  Dr. Cheng drew on his 3-decade experience in Tai Chi, his PhD in Chinese medicine and acupuncture, and expertise with physical therapy-based corrective exercises to develop Tai Cheng.

Tai Cheng uses fluid, graceful movements, which improve your balance and coordination while increasing range of motion and flexibility.  The goals of regular practice of Tai Cheng as a home exercise program is to increase movement, decrease stiffness and improve strength.  When this happens, pain is decreased and one can begin to move out of the chronic pain cycle seen with Fibromyalgia and so many other chronic pain conditions.






Fibromyalgia is chronic musculoskeletal pain condition that, unfortunately, it is much too common (reported in nearly 5 million people in the US). It is characterized by widespread muscle and joint pain.

Patients with fibromyalgia complain of aches and pain all over their bodies. They often complain of fatigue — even on arising from sleep. Even if the sleep all night, people with fibromyalgia do not get good restorative sleep, causing them not to feel rested in the morning. Depression, cognitive dysfunction or “fibro fog”, migraine headaches, irritable bowel syndrome and other pain symptoms are commonly seen in patients with fibromyalgia.

The cause of fibromyalgia is unknown. The prevailing theory is that is due to an abnormal pain processing in the central nervous system resulting in hyperexcitability. This hyperexcitability results in a hypersensitivity to stimuli to both things that are usually painful but also things that should not cause pain.

There is no cure for fibromyalgia.  Nor is there any specific treatment that that will address all of the fibromyalgia symptoms. Instead, the mainstay of treatment has always been control of symptoms and pain with medicines.

Based on more than 100 published studies regular exercise is more commonly being recommended in the management of fibromyalgia. The studies have shown a benefit with exercise training in patients with fibromyalgia. Basically, those who participated in an exercise program were more likely to have reduced levels of pain, fatigue, depression, and have an improved quality of life and physical fitness.

For the best treatment efficacy the treatment of fibromyalgia should include a combination of both traditional and alternative treatments. Specifically a combination of medication, exercise and behavioral techniques should be used.


Works Cited:

Blotman, E. N. (2010). Aeorbic exercise in fibromyalgia: a practical review. Rheumatology International (30), 1143-1150.
Busche, A. J. (2011). Exercise Therapy for Fibromyalgia. Current Pain Headache Report (15), 358-367.
Randy Neblett, M. L. (2012, June). Fibromyalgia: An Overview of Etiology and Treatment Options. Practical Pain Management , 21-26.


Migraine Headaches

 What are migraines and how can I prevent them?

As a Neurologist with a specialty in Headache Medicine;  This is what I tell patients with migraine headaches

What are migraines?  Migraines are a primary headache disorder of recurrent attacks of moderate to severe pain.  The pain is often described as a throbbing or a pulsing pain which is typically located on one side of the head.  This can be accompanied by light and noise sensitivity, upset stomach, and visual changes (aura).  Migraines may present in different ways and maybe misdiagnosed by as tension headaches or sinus headaches.

What causes migraines? For many years it was believed that migraine attacks were due to changes in the blood vessels in the brain.  It is now believed that migraines are probably genetically induced hypersensitivity of the neurons in the central nervous system. This results in the brain neurons being more sensitive to their environment and thus has a lower threshold for developing a headache. Hormones, foods, noises, smells, lights, and stress all play a part in causing headaches.

How are migraines diagnosed? Migraines are diagnosed clinically by talking with your doctor. There are no x-rays or blood tests that will diagnose migraines. Generally, no tests are needed when migraine is suspected.

Who gets Migraines? Migraines affect 12 % of the U.S. population. Men and women of any age can get migraine headaches. However, migraines are most common in women in their teens to menopause.  Migraines often run in families.

Why did I get migraines? Every person has a headache threshold.  For a lucky few, it may take a sledgehammer to give them even a mild headache.  However for those with frequent headaches, something as simple as a missed meal may lower their headache threshold enough to start a disabling migraine.  Everyone has different migraine triggers to increase their headache threshold. The way I like to describe migraine is to think of it like a cup; once the cup is full = migraine.  Some people start with a cup that is already almost full and only one other trigger such as hormonal issue can make the cup full and thus trigger a migraine.  Other people have very little in the cup to begin with so it takes multiple triggers before the cup is full, and thus harder to trigger a migraine.

What are some common migraine triggers?

  1.     Sleep pattern changes, either too much or too little
  2.     Increased stress in everyday life
  3.     Menstrual cycles or hormonal changes (for women)
  4.     Weather changes/fronts
  5.     Foods; There a lot of foods that has been reported to trigger migraines in some people.  Some of the most commonly reported causes include
    1. Caffeine
    2.  Aspartame
    3.  MSG from Chinese food
    4.   Nitrates and nitrites
    5.   Red wines and alcohol
  6.  Dehydration

For more information on migraine triggers see recent blog post on triggers.

Conservative ways to prevent/decrease migraines:

  1. Get good restorative sleep; try to wake up and go to sleep at about the same time every day.  If you snore please seek medical evaluation and treatment for this, it may be sign of obstructive sleep apnea which can cause headaches, and also other medical problems such as high blood pressure, heart attack, and strokes.
  2. Stress reduction; obviously it is hard to get rid of all the stress in your life, but you need to find ways to better deal with the stress.  Such as: talking about problems, relaxation, messages, and exercise.
  3. Make exercise a routine part of your life.  Migraine may worsen when you exercise with a headache.  Recent studies however show that participants who routinely exercise had a decrease in the frequency and severity of their migraines.  I recommend exercising 5-6 times a week.  Exercise also help to decrease other migraine triggers such as anxiety and stress. It can improve sleep, decrease weight, increases natural pain reducing chemicals, and increases natural endorphins (feel good chemicals) in the brain.  For more information see “Exercise to prevent your migraines” post.
  4. Practice relaxation exercises on a daily basis. Whether it is through biofeedback, deep breathing, mediation, guided relaxation, cognitive-behavioral treatment, yoga, or Tai Chi, these practices can help decrease the hyperexcitation of the brain, thus decreasing likelihood of getting a migraine, help you deal with the migraine better, and help you deal with other outside stressors.
  5. Weight loss: Obesity is associated with an increase in frequency of migraines in people with migraines.  It is unclear why, some feel it is due to the higher levels of inflammation in the body.
  6. Hydration:  Drink at least eight 8 ounces of water daily, this may need to be increased in the summer months, if exercise regularly, or drink dehydrating fluids such as caffeine or alcohol.
  7. Limit or stop drinking caffeine: If suddenly stop drinking caffeine may get caffeine withdraw headache.  If must drink caffeine try to drink less than two servings a day.
  8. Eat regularly: do not skip meals, especially breakfast. I also recommend eating smaller more frequent meals.  (See addition information in “Migraine Diet” blog)
  9.  Maintain a headache diary: this helps you keep track of any possible triggers (lack of sleep, food, hormones, stress) that might have trigger but also shows if migraine frequency is improving or worsening.

Medical treatment for migrainesThere are medications that can decrease the frequency of your migraines and also medication to take when you have a migraine.  For more information please discuss with your Neurologist.

This site is purely informative and should not be considered medical advice. It is not intended to be used to diagnosis or treat any disease.  Please consult your physician before starting any fitness program or new supplement.