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Scot: Many people take fish oil for a lot of different reasons. Some of the benefits, well, there's a lot of mays in front of these benefits. May support heart health, may help treat certain medical conditions, may aid in weight loss and the list goes on and on. However, we might be able to take the may off of one of those. Dr. Tom Miller is an internal medicine doctor here at University of Utah Health.

What might we possibly be able to remove the may from, as to what fish oil helps with?

Dr. Miller: Well, it's interesting. Let's start with a little bit of history. Some time ago, probably back in the '60s, maybe '50s, we understood that the native population up above the Arctic Circle, Innuits had low rates of heart disease, and it was postulated that perhaps their high diet in fish contributed to this.

Now, Arctic fish have high levels of omega-3. The idea was that if you took omega-3s, you might have less heart disease, lower incidents of stroke. This went on for a number of years, in fact a couple of decades, and it was never really very clear whether omega-3 supplements actually made a difference.

But in the last year there have been a couple of landmark studies that have employed the large number of patients required to sort this out. And it does appear for people who have high triglyceride levels and have some type of event, like heart attacks or they have coronary artery disease or they might have had a stroke, that omega-3s supplemented to their diet will prevent and lower the risk of a second event.

The exact number that they came out with in this trial is 25% reduction if you were to take four grams a day. Now that's a higher dose than most people take. Most people take one to two grams a day as a supplement. I think what needs to be determined going forward is what would be the adequate dose for those who have had an event versus those who've never had that event. Should they just take a one gram, standard daily dose, or should it be more? We don't quite know that yet.

And then, secondly, there seems to be less evidence that's it beneficial in people who have never had an event.

So it does appear for the first time that we have some pretty reliable evidence, especially in people who have had cardiovascular events and high triglycerides, that the addition of omega-3 to the diet can lower the risk of a second event.

Scot: If they take a four gram dose. Dosage is important. That was the question.

Dr. Miller: That was the study that was done on four grams. Is that the optimal dose? I don't think we know just yet, but at least we have signposts that tell us that this is going to be beneficial.

Scot: Is this something you should talk to your physician about, or if you know that you fall into this category, should you just go ahead and start taking a four gram dose?

Dr. Miller: I think it would be wise to talk to your physician, because you also want to have the rest of your metabolic profile tuned up. So you want to make sure your other cholesterol subgroups are taken care of. And that's why people are on statins for preventing secondary events of coronary disease. And then, if you high triglycerides, which statins don't treat, then it might be wise for you to start omega-3.

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Interviewer: Your annual prostate exam. Is it still something that you should have done every year, or can you skip it? We'll find out next on The Scope.

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Interviewer: Dr. Tom Miller, so, at one point, I know that every year that they said you should get a prostate exam if you're after over 50 years old. Do you have to still do that anymore, or is there a better way?

Dr. Miller: Well, aside from the prostate exam being the brunt of many, many jokes over the year, the answer now is generally no. The guidelines no longer suggest doing a prostate exam to screen for colon cancer. It was done in the past because the number of prostate cancers were picked up on digital screening, but we've no evidence that finding those cancers on exam actually leads to better outcomes, that is cures for prostate cancer. We do recommend the standard screening with PSA. That's still something that should be done at the age of 50 in average-risk men, and perhaps screening should start earlier for men who have a history of prostate cancer in their family. The digital exam is pretty much gone by the way, so.

Interviewer: All right. So, just to clarify, because I mean this is a bit of a paradigm change for me. It feels a little weird like . . .

Dr. Miller: Well, most men would tell you that.

Interviewer: Yes, I don't mean in that way, but it feels a little strange that we're saying now you don't need to do the rubber glove and the whole thing, that there's actually an alternative test you're talking about. Tell me more about that test.

Dr. Miller: Well, basically, the PSA test has been around for some time now since the mid-80s, and it was used in conjunction with the digital exam. More recently, the guidelines have de-emphasized the need to do a digital exam to check for prostate cancer. And, again, the reason for that is that we may not . . . if we find prostate cancer, it will be advanced and it may not change the outcome of the disease. Whereas testing with PSA, which is a blood test, can find cancer early enough to cure the cancer.

Interviewer: Got you. So it's just a blood draw that would start after the age of 50, earlier, if you have a family history?

Dr. Miller: Average comers starting at the age of 50.

Interviewer: Yes. So, as somebody who's approaching 50, is that something I can request from my doctor? Or what does the evidence say about getting it much before 50 if I don't have a family history?

Dr. Miller: Basically, there's not a lot of good evidence that getting tested before the age of 50 with PSA is useful unless you have certain risk factors, family history, strong family history.

Interviewer: Got you. But after 50, if the doctor, if your physician's not suggesting it, then that's something you should be sure that you're suggesting to them.

Dr. Miller: Correct. So if you do have a complaint, so if you have a complaint where you have dysuria, pain with urination, a digital exam would be something that a physician would do. I don't want to point out that we don't do the digital exam. We do the digital exam when there's a reason to do it.

Interviewer: Got you, and there's some symptoms or something going.

Dr. Miller: Exactly. Interviewer: Got you. So, otherwise, ask for that PSA. It's completely . . . it's even more effective.

Dr. Miller: Correct.

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Interviewer: So, when it comes to opioids and being prescribed opioid painkillers, do most doctors at this point in time all operate from a similar paradigm when it comes to whether they should prescribe them, whether they should not prescribe them to a particular patient? Or do patients still need to kind of have a working knowledge of opioid pain pills? Because they scare me. I hear some of these stories and they sound a little frightening.

Dr. Miller: Well, as you know, the news is out that opioids are very addictive. The statistic is something like 80% of current heroin abusers had started out on prescription opioids. And so we have a track record in this country now over the last 30 years of overprescribing opioid narcotics for the treatment of pain, and that has led unfortunately to an increase in deaths from opioids and heroin use and other bad things.

So, in answer to your question, there is not a policy about prescribing opioids that applies to all physicians. And, more importantly, we're not yet all completely on the same page about how to use and treat people with opioid painkillers.

Interviewer: Yeah. So, to some extent, the consumer, the healthcare consumer should have a working knowledge. And as somebody that might find myself in the healthcare system, how would I know whether or not it's appropriate for me if all doctors aren't operating from the same paradigm as of yet? And why is that? Why aren't they? Is it just because the information hasn't caught up to everybody yet?

Dr. Miller: I think that's part of it. They're individual prescribing practices, and some physicians don't prescribe opioids very commonly while others do. And presumably, the ones that are now prescribing opioid for pain and do quite a bit of that are well versed in how to use that, setting up contracts with their patients on how to take opioids and when to report in and when to get their refills and so forth.

So there is a spectrum of understanding of how to prescribe opioids. It starts back with medical student training and then residency training. We have not had what I would consider to be top-of-the-mark training in opioid use throughout our medical training, and that's changing over time.

Interviewer: Gotcha. Just takes a little time for that to kind of roll out, yeah.

Dr. Miller: It takes time.

Interviewer: So, back to my original question. I asked somebody who might find themselves in the healthcare system and now I'm trying to determine, "Is this really the right course of action for me or not?" how would I make that informed decision?

Dr. Miller: That's a great question. It starts with a question. So asking your physician how your pain can be best controlled is the way to start. What is the best way that you, meaning the physician, think that your pain should be treated? How do we do that?

In general, it depends on the type of procedure you're having or the pain you're experiencing. And the plan is really to start slow and use non-opioid substances or drugs, like non-steroidal anti-inflammatories like aspirin or ibuprofen or Tylenol, or other modalities, like massage or other physical therapy efforts.

Interviewer: Which I've read, and people might find this hard to believe actually can be just as effective if not more effective than opioids for chronic pain, those types of things.

Dr. Miller: That's true. Yeah, I think we were under the misassumption that opioids treated all types of pain pretty easily as a public, and that's not true. There are many other ways to treat pain. Acupuncture is another way that works well for some patients.

But again, you have to assess the severity of the problem, the potential severity of the pain. So if you have an open abdominal procedure where the muscles of the wall of the abdomen are cut, you're very likely going to have some pretty intense pain for a while.

And then you work with the physician to decide how much pain medicine you need and for how long. So, in general, shorter courses are preferred. And you don't want to be taking large amounts of opioids for a long period of time for a problem that is healing itself.

So, again, you start with questions. You start with, "What is the best way to treat the pain you might anticipate that I will have? What is your standard of practice?" or "I have this particular pain. What do you think the best way for me to have it treated is?" And then listen carefully to what they tell you.

If it starts off with a conversation that seems unclear or moves very quickly to opioid narcotics, then you might want to ask more questions about why are we starting with that particular medication rather than something that's potentially less addictive.

Interviewer: If we were to try to draw a visual path, I have the feeling that opioids might be prescribed for chronic pain, which is long, ongoing pain, like severe back pain that you're suffering from, or it could be pain that you might experience during a surgical procedure. Those would be the two different paths possibly?

Dr. Miller: Right. So there's chronic pain, pain that you can expect to have for weeks and months and perhaps years.

Interviewer: Yeah. And those are the types of things that some of these other modalities, as you said, massage, acupuncture, physical therapy, exercise could possibly mitigate and would be a better option.

Dr. Miller: Correct. At least trying that initially or working through that without using opioids initially would be a good point.

Some of the illnesses that we've gotten away from prescribing opioids would be things like migraine headaches, fibromyalgia, types of pain that are chronic, that don't really have a well-understood initiating cause or a cause that we think is going to heal over time, or pain that is episodic. If you treat that with opioids, sometimes that leads to a higher rate of addiction.

Interviewer: Gotcha. And in a surgical procedure, say I'm going to go into a surgical procedure and my physician says, "Yeah, this is going to be pretty intense for a couple of days. I'm going to recommend opioids." They're saying it right away, but they're also saying it's only going to be for a couple of days possibly. Should I be frightened of that?

Dr. Miller: No, you should not. I think most surgeons now are very well aware of the amount of narcotics that they're going to need for the particular duration of healing that you're going to experience.

If you're getting a month's worth of narcotics for a procedure that you might expect to be out of the hospital for in several days, then that is probably too much, and you could just say, "How many days do you think I'll be needing to take these medicines?" And then you might ask to say, "Look, why don't you just give me a week or two weeks or whatever you think is best for this particular healing period?"

Interviewer: Read an interesting article. The surgical department here actually did a study that found out that, as of right now, prescribing of opioid-based painkillers after a procedure is . . . they don't take the individual into consideration. Everybody would get them whereas they felt that they should talk to each patient to try to figure out what would be appropriate for that patient.

Dr. Miller: Correct. So what that study or that . . . it's not a study, but what that approach shows is just what you and I are talking about, that every patient has an individual need for the way their pain is treated and that depends on the procedure. So it depends on the type of the procedure, the length of the incision, the area of the procedure, and then the assumed time of healing.

So laparoscopic procedures, where they make very small incisions, are likely to heal quite a bit faster and would need less pain control and possibly could be managed without narcotics. Larger procedures, possibly longer periods of time, a week to two weeks, where they might need opioids. Again, it's quite individual.

And this is another thing. The science is not well worked out in terms of why one person's pain requires more and different types of analgesics than others. It's not known yet. So everybody is a little bit different.

Interviewer: And I think that brings up an important point too, that another way that people get into trouble is they are prescribed to take a certain amount over a certain time and they're like, "Well, I know my body and I don't normally react, so I'm going to take two instead of one." And with Tylenol, it's probably not a good idea, but with opioids, it's a really bad idea to start changing that dosage.

Dr. Miller: Yes. Again, we're not entirely clear why some people start on a path and then become rapidly addicted to opioids and seek opioids for the pain relief. It's not quite clear. Some people can be on opioids for some time and stop and it's not a problem. We don't really understand that completely.

Interviewer: But maybe not a gamble worth taking if you think you could . . .

Dr. Miller: Well, yeah. What we know now, given the evidence of the '90s and the last decade, is there was too much opioid prescribing, and it did lead to higher rates of addiction. So, obviously, the more opioids that are out there that people are taking for longer periods of time or perhaps in higher doses leads to higher rates of addiction.

Interviewer: So the important takeaway from this, it sounds like, is if you're finding yourself in position where that is a recommended way to deal with your pain from a physician, to start having a conversation. Because not having that conversation and just perhaps taking those pills could lead to a place you don't want to be.

Dr. Miller: That's correct, or it could lead you to have excess opioids at home, whatever type or form you have, and somebody else could maybe use that and that would lead to some problems down the road for them.

Interviewer: What about a resource if somebody wants to read a little bit more? The CDC? Is that a good place to go to learn more? Or National Institutes of Health?

Dr. Miller: CDC has guidelines, and we've actually repurposed the guidelines in our community clinic group as a training tool and an education tool for physicians in our community clinic group to read and learn from. So the CDC would be a good place to start.

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Interviewer: Gout. What causes it, what can you do to prevent it, and what can you do if it's so unbearable and nothing seems to work? Dr. Tom Miller, I'm going to make a quick confession here. My father had gout. I don't think it was ever anything too bad. He just had some minor flare ups. But I'm concerned could I get gout because I hear there is a big genetic component to it.

Dr. Miller: There is in fact, and you may indeed be predisposed to gout. So the question is, where did your father first have his gout attack?

Interviewer: I don't even remember. Like his feet maybe.

Dr. Miller: You know they used to call it podagra, the big toe. That was where people usually developed gout attacks. In the old days, you'll see pictures of sort of portly men in 17th century English garb with their foot up on a pedestal. And they have a bright red toe in the painting. And that's classic podagra, that's gouty inflammation of the first toe.

Interviewer: Which interesting side note, I actually did read about that. It was known as like a disease of royalty because only the royalty could afford to get a disease like that, that could keep them, you know, not be able to move for two or three days.

Dr. Miller: Right. So gout is essentially an overproduction of uric acid that crystallizes in the joints. And the reason that you would sometimes get a higher concentration of uric acid is that you would take in large amounts of protein. So if the wealthy person was on a big meat diet from that hunt that they were just on, and they were portly to begin with, and they were washing it down with their favorite port, or Bordeaux, that was sort of push them over the limit and they would then develop crystals in their joints. And that would cause the intense pain and inflammation, redness, swelling.

Interviewer: Yeah. Not a lot of fun, though. I hear that there are varying levels of pain caused by gout. Do you in the medical community define what those levels are?

Dr. Miller: Well, generally speaking, when someone has an attack, we call an acute attack, gouty attack, it's very painful. Because what happens imagine all of a sudden you have crystals deposit in your joints. And that sets up an inflammatory reaction where you have all the mediators of inflammation focusing in on those crystals to try to eat them, if you will. That causes tremendous pain, redness, infusion of blood into that area, and it is very painful. And you'll read some of these descriptions about people who have gout, gouty attacks, and they can't even put a sheet over that toe. It's so painful.

Interviewer: Yeah, and it can go to other joints too, right?

Dr. Miller: It is.

Interviewer: Is that the differentiation between somebody who is mildly suffering and really suffering?

Dr. Miller: Right. So someone who has recurrent gout attacks and they don't always have to start in the extremities in the big toe, for instance. They can start in the knees and the other large joints as well. So some people are predisposed to have high uric acid levels and those are the folks will develop multiple joints with inflammation due to the crystallization of uric acid.

Interviewer: And it is genetically caused, it's not necessarily . . .

Dr. Miller: You are predisposed by genetics so you have a higher likelihood of developing gout if you have family members who have had gout.

Interviewer: And then the things you eat can cause those flare ups to be worse if you're predisposed.

Dr. Miller: You can, you can. Now sometimes, it's not fair to say that, you know, a person that does everything right won't get gout, because they will. They'll have a very strong predisposition for it. And in fact, on a on a diet, a low purine diet, they may still develop gout. But for some, you know, weight control, cutting back on the high protein intake, those kinds of things may moderate the attacks, the number of attacks. The frequency. But nowadays, we have medicines for these things that are actually very effective.

Interviewer: Is that in lieu of controlling your diet or is controlling your diet kind of the first step?

Dr. Miller: Of course, we would do both. Now, I will tell you that if someone has an acute flare of gout, that we treat that with medicine. We don't wait for that to go away because resolution can take quite a while. And we generally don't screen for high uric acid levels. So someone who develops gout then we get after them with diet, but we also treat that initial attack with medication because it resolves much more quickly.

Interviewer: And at what point does it become a little bit more elevated?

Dr. Miller: In terms of recurrence, you mean?

Interviewer: Yeah.

Dr. Miller: Well, again, what you do is you treat the acute attack, it goes away, and you wait and then you check the uric acid levels. And if they are significantly elevated, you may put that person on chronic therapy to suppress the level of uric acid. There are over execrators and under execrators of uric acid. So that is to say some people produce more uric acid because of their metabolism than others and some people under excrete it in the urine. And so, there are two mechanisms and you can attack either one with medications long term to prevent recurrent attacks. Generally, if someone has one attack, you'll treat that acutely, and then you'll follow up and see how they're doing. So I wouldn't rush to put somebody on chronic therapy.

Interviewer: And how many people end up going on chronic therapy because I have to talked to people since I found out my dad has it that they suffer quite often in a lot of joints.

Dr. Miller: Anyone who joins anyone who has more than a couple of attacks in the setting of watching their protein intake and diet probably could use, you know, some suppressive therapy. That is therapy to reduce the level of uric acid and if you reduce the level of uric acid, you reduce the risk of crystallization in the joints.

Interviewer: And what about somebody that treatments don't seem to be working? I have talked to a couple people that they seem to suffer from it and it doesn't seem like the medication's working, the diet's working. What could possibly be going on in those situations?

Dr. Miller: Those are complicated cases, and sometimes they occur in the setting of people who have gout and deformative joints. So the crystallization sets up in the joints and because of the abnormalities in the joints, they continue to be predisposed to the attacks. Those require the care of a rheumatologist long term to monitor how they're doing and to . . . there are different treatments. But yes, there are some people that have recurrent attacks and they need special treatment and usually we'll send them to the specialist.

Interviewer: So if somebody is suffering from gout, it sounds like it's very painful and they're probably, they're going to seek out some help to alleviate pain.

Dr. Miller: It's quite painful. They will seek out some help. And I would say to those that are listening that if it happens in the large toe, it becomes red and inflamed and you're over 30, you probably should think about gout. It's a possibility there's an infection there so you don't want to you know, could be an infection other than a gouty attack but that's unless you've had trauma to the toe or the feet. That would be less likely

Interviewer: Come and see a primary care physician. They can generally treat it if it becomes more complicated than a rheumatologist

Dr. Miller: Correct.

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Interviewer: All right. Here's a scenario, Dr. Miller. A patient comes to you because of a runny nose, sneezing, watery eyes, itchy throat. Okay? So you suspect seasonal allergies. What do you do to help them? Maybe I should back up. Are those the symptoms of allergies? Did we hit all of them?

Dr. Miller: Oh, yeah. Absolutely. So runny nose, sneezing, itchy eyes, itchy ears, itchy back of the throat, postnasal drip. Basically, these are, and especially the time of year, so if it's fall and spring when you have a lot of pollen.

Interviewer: That's like bingo.

Dr. Miller: Yeah. Ragweed in the fall, things like that.

Interviewer: Gotcha.

Dr. Miller: People get allergies.

Interviewer: Can you differentiate those symptoms from a cold, generally?

Dr. Miller: Yes. Generally, you can. A cold gives you the scratchy, uncomfortable feeling. You'll have some of the same symptoms, like postnasal drip, but you tend not to get that itchy eyes and itchy nose. And it just feels uncomfortable. Most people can differentiate between an upper respiratory infection versus allergies.

Interviewer: Yeah, I feel that I'm an allergy sufferer. I feel like I can usually when it comes on. So we've hit the signs, right? Those are some of the signs that you're suffering from some sort of a seasonal allergy from your environment.

Dr. Miller: Well, the other thing is you look and you can see the pollen counts, like in the spring and fall, you'll see when they start to go up that more and more people have problems with allergies.

Interviewer: And you see a lot of this sort of thing?

Dr. Miller: We do.

Interviewer: Okay.

Dr. Miller: We do quite a bit.

Interviewer: So, since you see a lot of it, you probably have a routine that you go through to help that patient if they're sick and tired of suffering?

Dr. Miller: Yeah. First of all, you have to make the diagnosis and so you listen to the history. So, just as we were talking about, if they come with those symptoms, it's the right time of year. Yes. You can say these are seasonal allergies and then you begin to talk about treatment. Avoidance is the best treatment. So, if you can stay out of the open where you have a lot of high . . . or you have a high pollen count, stay away from it if that's possible. Many times it's not possible, but that's the best thing.

Also, for people who are out working in the yard or they're out exercising or mowing the lawn, if they start to exhibit symptoms because the antigens from all these pollens, these particles are on their skin, which trigger the allergic reaction, you should go home, change your clothes, take a shower, wash it off, clean off the antigens.

Interviewer: All right.

Dr. Miller: That'll be the first thing to do.

Interviewer: So avoid it if you have to be out in it. Clean it off as soon as is feasible. What about putting one of those masks on?

Dr. Miller: Right. So you'll see gardeners wear those masks sometimes.

Interviewer: They're effective.

Dr. Miller: They are effective. They're partly effective. They're not a 100% effective, but they're better than just breathing in the particles, which will trigger allergic reactions in a lot of people, especially in high amounts like you might expect you would see in gardeners, lawn care people.

Interviewer: Okay. So can allergies possibly get worse over time if I don't do something about them?

Dr. Miller: In fact, they do. So some people will start out, especially when you're younger and you'll have some issues and they can tend to be worse over time as your body becomes more sensitized and produces a more aggressive allergic reaction every time you're exposed to them.

Interviewer: And that's regardless of I do something or not because aren't most treatments revolving around giving you symptom relief? Like there's no cure for allergies.

Dr. Miller: There isn't a cure per se. Although if you end up having desensitization shots, they many times will help reduce the burden of the allergic reaction and sometimes eliminates it completely. And people have very serious allergic reactions due to pollens and other particulates and you can't get away from the triggers. Sometimes these allergy shots which they start them in a low dose and then they increased the dose over time so that your immune system just becomes used to it. That's the theory behind it. That can actually be pretty helpful. So, in that sense, for some people, yes. The treatment can make it go away.

Interviewer: But I think I jumped ahead a little bit, because as a kid I got a lot of shots. I didn't find a lot of success personally with those, although people do. I ignored my symptoms for many, many years, and finally I got so bad I went to a doctor again and the doctor said, "Well, shots is really down the d in treatment options at this point."

Dr. Miller: Down the road. That's right.

Interviewer: There's a lot of stuff you can do before that. So what are some of those things that you would do then?

Dr. Miller: Well, interestingly, there are a number of medications now that are very effective for people who have mild to moderate symptoms of allergic reaction to pollens and particulates. And basically, you can use antihistamines, which are a pill that you take by mouth. And there's a couple of kinds. The older antihistamines have some side effects. They can make people sleepy, drowsy, fatigued. They tend to work pretty well. That is they suppress the itching and the sneezing and the itchy throat and those types of things. But they have a newer class of antihistamines that's non-sedating, and they work pretty well in suppressing the symptoms, and they don't give you that massive fatigue that some people get taking the older antihistamines.

Interviewer: And that's in a pill form?

Dr. Miller: That is in a pill form.

Interviewer: Okay.

Dr. Miller: The other thing that we've moved to, especially for sneezing and rhinitis that most people get with these allergies are nasal sprays, very mild doses of steroids in nasal sprays. And you spray that in on a daily basis, and it basically just cools down the lining of the sinuses and it's pretty effective for preventing sneezing and itching and scratchy throat, that kind of thing. They also have similar drops for the eyes for people who struggle with itching eyes during allergy season.

Interviewer: It didn't occur to me, but so like the nasal sprays, that's what I use. I've had great success with them.

Dr. Miller: They work pretty darn well for most people.

Interviewer: But something you just said earlier intrigued me. It's mainly for the sneezing symptom and maybe some of the itching?

Dr. Miller: Correct. It doesn't really work for the eyes. And so that's the nasal spray that you're talking about. So they make drops. They contain some of the same medicine and you can use those.

Interviewer: And the pills, do they take care of all of the symptoms, the antihistamine pills?

Dr. Miller: Yes. They do.

Interviewer: Okay.

Dr. Miller: So during allergy season for people with moderate symptoms, you'll find that they get relief both with the nasal spray and the oral antihistamine, especially the non-sedating antihistamine on a daily basis. So they just lacquer up, if you will, during that season.

And then also again, trying to stay away from the triggers. This is especially true for people who have allergies to pets. We haven't talked about that yet, but some people are allergic to cats, although they like to scratch the cat when the cat comes by and then the immediately they rub their eyes and all of a sudden they're going crazy. So the key there is avoidance. And for some people, unfortunately, they discover that they are allergic to pets, and in severe cases, they have to send the pet to a relative or somebody else. And that's unfortunate. That's really hard to do when people are attached to their pets. So the next best thing is you wash your hands after you pet the animal. But you have dander around the house and that sets people off.

Interviewer: We talked about some nasal histamines. Do you need to start taking those like, say, my allergies are going to kick in when the grass starts growing. For any of these actually, do I need to start ramping up, or do I just take it as soon as I need it?

Dr. Miller: That's a good question. So, basically, if you're anticipating a spell of allergy coming on with a particular season or if you're going to be out gardening, it's a good idea to get ahead of that a day or two before you head out.

Interviewer: Oh, so just a day or two?

Dr. Miller: Well, especially if you're going to be exposing yourself to high pollen counts. So starting the antihistamines two days before, a day before and then definitely starting the nasal spray probably maybe three, four days before because it does take a few days for the medicine to become maximally effective.

Interviewer: So, for me and my cat allergy and my mother-in-law who has cats, three or four days before I go for a visit that's what I want to do?

Dr. Miller: Either that or . . . well, I won't say don't visit because that's probably not a possibility or have a neutral space that you can visit her where the cats don't come with her.

Interviewer: Sure. That's fair enough. All right. Have we covered everything? I'm trying to think as a person with allergies if I feel that we have.

Dr. Miller: I do want to mention one thing. So some people use decongestants that they buy over-the-counter. Medications that actually dry out the mucosa. They're different than the nasal sprays that I'm talking about. They're steroid-based. So, when you go to the drugstore and buy what's called a decongestant, especially a decongestant nasal spray, we find that if those are used more than three, four days in a row, you can develop a rebound phenomenon that basically addicts you to that medication. So we would advise people not to use decongestant for treating allergy.

Interviewer: Okay.

Dr. Miller: So to stick with the steroid nasal sprays and the first-line antihistamines, if you can tolerate them or perhaps more commonly the non-sedating antihistamines.

Interviewer: Actually, you know what, you triggered another question as an allergy sufferer. Can I go and just get some over-the-counter stuff? I know the Flonase equivalent now is available over-the-counter.

Dr. Miller: Yeah. All the things that I'm talking about are over-the-counter.

Interviewer: So you don't even really need a visit to your physician for those things?

Dr. Miller: No. You can try those. And especially with the internet now you can look online and provided you have a reasonable source to read about what you can treat your allergies with, you can use a combination of a nasal steroid or you could use an antihistamine or you could use both to treat. Again, I think the simple stuff is if you can avoid the triggers, that's the very best thing. But again, many people can't, you have to be outside.

Interviewer: All right. So, if somebody tries over-the-counter stuff and they get relief, great. If not, what's the next step at that point? When do you want to go see a doctor?

Dr. Miller: So, one, if you're having symptoms on a pretty much daily basis and these symptoms are causing fatigue or if you're missing work and also if your sleep is impaired due to these allergies, you're up at night sneezing and you're back and forth to the Kleenex box, it's probably time to go to the physician. And the first thing that they would do is see if you're taking a maximal, not a maximal, but an appropriate number of over-the-counter medications that we talked about earlier, whether you're using them appropriately.

And if that's not working, then the next step would be to use prescription medications, which are a little more potent and could suppress the allergic reaction. Again, you may end up having testing because testing can help you identify the actual allergen triggers that you might want to avoid. Once you know that, it might be a little bit easier to figure out when you're exposed to an allergen and what to do after you're exposed or to prevent exposure.

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Interviewer: Does gargling salt water when you get sick actually do anything? We'll find out next on The Scope.

Announcer: Health information from experts supported by research. From University of Utah Health, this is thescoperadio.com.

Interviewer: Dr. Tom Miller, so there's kind of this rumor thing out there. My mom tells me, my wife tells me, when I start, like, talking about how I'm getting a tickling in my throat, I feel like I'm getting sick, they say, "Oh, you got to gargle salt water. You got to gargle salt water." And I'm like, "I don't want to gargle salt water," but I do because, you know . . .

Dr. Miller: Because you don't want to get in trouble.

Interviewer: I'm an obedient son/husband. But does it actually really do anything? Does it shorten the duration? Does it actually prevent something from coming on? Give me the . . .

Dr. Miller: Well, it depends. Let's talk about does it actually do something. I think, you know, gargling salt water, for some, might soothe that tickle in the throat or that little bit of pain in the back of the throat due to a virus. But in terms of will it shorten the length or duration of that illness, no it won't do that. But it's perfectly fine to gargle with it. I wouldn't swallow the salt water. That has its own implications. But if you find that it soothes the back of your throat, you could go ahead and gargle. And the same is true with mouthwashes like Listerine or Scope if that tends to make you feel better for a little while. That's fine, but it's not going to shorten things, or it's not going to make that virus go away.

Interviewer: So that salt's not getting back there and causing a toxic environment? Are there other things that people do that really they think is going to shorten the duration, but it really doesn't? Just it kind of soothes things . . .

Dr. Miller: Throat lozenges, you know, and things for cough that come along with that tickle in the back of the throat. They soothe the back of the throat. they make you feel better, but it's not going to change the duration of the illness or the intensity.

Interviewer: Yeah.

Dr. Miller: You know, throughout the day.

Interviewer: And zinc tablets, what about those? That's another one I hear.

Dr. Miller: It hasn't been proven to really reduce the length of the cold, but it's not going to hurt people.

Interviewer: So if you want to do it, then go ahead. It's not . . .

Dr. Miller: Yeah, it's fine. I don't say to people that it's going to make a difference, but I tell them if they think it's going to make a difference or if they've tried it and they feel like it's made a difference, I'll tell them scientifically there's not a lot of evidence for that, but it's available over-the-counter. If they want to use it, they can.

Interviewer: All right, sounds good. So if you want to use those things, you can if it brings you some sort of relief or comfort. Don't expect it to really shorten the duration. And maybe you do it just to keep your mom/wife happy.

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Announcer: Need reliable health and wellness information? Don't listen to the guy in the cube next to you. Get it from a trusted source, straight from the doctor's mouth. Here's this week's listener question, on The Scope.

Interviewer: Today's patient question is about sleep. This particular individual's having a hard time falling asleep at night. So they'll go to bed, they lay down, but you know, they can't get to sleep. Dr. Tom Miller, what do you recommend to your patients in that situation?

Dr. Miller: Well, first thing I ask is, what's changed? Is there more stress in their life? Is there something going on at work? Is there a family problem? Is it related to depression, perhaps? I'll look at those issues.

The next thing is, are they following a sleep schedule? Are they getting to bed at the right time, same time? And are they getting up at the same time each day? Because of our busy lifestyle we're sometimes all over the place. Monday through Friday, we may have some variable times in which we go to bed because of when we're going to work and we have morning meetings. And then on the weekends maybe we stay up late and go out and then get up late.

These kinds of disruptions in sleep patterns make it difficult, even more difficult to get a normal night sleep. The first thing I'd say is let's try to get you back into a regimented sleep pattern, so that you go to bed at the same time each night. After that try to mitigate the stress. You know, what are you doing at work or what can you do with work or family that would help you. Sometimes this may result in counseling or maybe even in the most extreme case, a change in job, you know, so that they . . . if it's bad enough, that they can get sleep.

And then ultimately if folks are still having trouble falling asleep, a short course of medication designed to help people fall asleep can be helpful. But I don't like the idea of using those long term because they have some problems associated with them. So there are number of medications on the market as prescription medications that do help people fall asleep, and they're pretty effective in small doses, for, say, up to two weeks. The other thing that I will talk to folks about is alcohol. If they're using alcohol to get to sleep, that's not a good idea.

Interviewer: All right, so you're not a big fan of the medications generally because they can actually cause more problems down the road when you stop taking them. Is that correct?

Dr. Miller: I think the problem with meditation is we jump to that as a solution before we look at sort of lifestyle issues. Whether you're, you know, increasingly stressed at work, whether you have frustrations, whether there might be depression, those are the issues that I like to tackle first before moving on to medications. You can do them simultaneously, but not assessing the lifestyle aspect of insomnia would not be the right way to approach this problem.

Interviewer: So take a look at the lifestyle, try to get that consistent sleep pattern. If you go to your physician at that point, if those other things aren't working, they might put you on a short course of some sleeping medication. If you come off . . .

Dr. Miller: As you're working on your lifestyle changes.

Interviewer: Yeah, yeah.

Dr. Miller: Getting to bed at the same time, tackling those frustrations at work, trying to regiment your lifestyle in a way that allows you to reduce the amount of stress and frustration that you might have in your life.

Interviewer: Yeah, those are underlying causes.

Dr. Miller: Underlying causes.

Interviewer: And if they get to the point where they've tried those things and they feel that they've put in a good effort towards those things, still not working, where do you go from there?

Dr. Miller: We start looking at sleep patterns and thinking about things like obstructive sleep apnea. We think about depression. Has the physician done the right evaluation to sort out whether the person has anxiety state or is depressed? There are different treatments for those problems. So, as we go down, you say an algorithm for insomnia, we will get to those sorts of things where we are digging in a little deeper to try to find a solution and treatments.

Interviewer: So it sounds like the first step for a lot of people is something they can do on their own. It's just take a look at their life and see are there causes of stress and what can I do to perhaps reduce that, maybe finding professional help.

Dr. Miller: Yeah, the majority of folks with insomnia usually have this for a short period of time. It doesn't go on for a long periods of time. So, for instance, in grief response if someone in the family has died and you're not sleeping, you know, treating that short term likely will result in a return to normal sleep patterns, as would be the case with stress at work. These things usually disappear as soon as the stress is resolved.

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Interviewer: You may have heard there's a new shingles vaccination, and your doctor might have recommended that you get it. Should you? Well, we'll talk about that next on The Scope.

Announcer: Access to our experts with in-depth information about the biggest health issues facing us today. The Specialists, with Dr. Tom Miller is on The Scope.

Interviewer: Let's talk about shingles. First of all, let's just set the stage. What is shingles?

Dr. Miller: Let's talk about that. So shingles is what we call recurrent chicken pox. Now, before the chickenpox vaccine was given routinely to children, most of us, probably greater than 95% of us, have had chicken pox and may not even remember it as kids. Now, once you've had it, it never goes away. The virus goes into your nerves in your spine and hides, and for reasons that are not entirely clear, probably because our immune system sort of forgets that the virus is hidden over time, chicken pox comes out again as shingles or herpes zoster. So it doesn't present as a fulminant, itchy rash like we get when we're kids, but it comes out in specific areas where the nerves innervate parts of the skin.

Interviewer: Meaning it's painful.

Dr. Miller: Well, it's painful, and what's even more concerning and more damaging, probably 10% to 20% developed what we call postherpetic neuralgia, which is a pain that continues after 90 days. And it's very severe and very hard to treat. Some people when they have postherpetic neuralgia can't even wear a shirt because it's painful.

Interviewer: Sounds miserable.

Dr. Miller: Treatments are not very good either. So the best you can do is prevent shingles.

Interviewer: And there is a shingles vaccine. And a lot of people have already gotten it, and now I'm hearing about a new shingles vaccine. So help me kind of reconcile if I should get it or not.

Dr. Miller: Well, that's right. So we say there's about a 30% lifetime chance that you'll develop shingles, and shingles rises in incidence after the age of 50, and by the time you're 80 years old, probably about 20% of people who develop shingles will have postherpetic neuralgia, which is this chronic pain that goes on and on and on.

If you vaccinate, it's basically waking up your immune system to watch out for that virus sneaking out of its hidden cave and coming back and bothering you. So the first vaccine was a live vaccine that was developed in the middle of the last decade. And it was pretty darn effective. But there's a new vaccine that is recommended even if you've had the older vaccine, that is not a live vaccine. And the advantage to that is we can now give this newer vaccine to patients who are immunocompromised. That is to say that their immune system is not quite up to par. It would have been dangerous to give them even a weakened live vaccine because they could develop full chicken pox. So we didn't we didn't give that older vaccine to folks who are immunocompromised.

Interviewer: So if you've been told you couldn't get the shingles vaccine before, now you can?

Dr. Miller: Now you can.

Interviewer: Okay.

Dr. Miller: If you have a history of being immunocompromised.

Interviewer: So that person for sure should get it. Who else should think about getting it?

Dr. Miller: Well, anyone who's over the age of 50 and certainly over the age of 60, the advantage to the newer vaccine is it is a more potent and efficacious vaccine. It works better than the older vaccine. So, in time it will become probably the sole vaccine available.

The issue with the newer vaccine is, one, it has more side effects. And two, it's costly and the older vaccine was costly, but this is a little more costly. So side effects, and what I mean by that is about 10% of the time people after getting the vaccine will develop a flu-like illness that's bad enough that they may not want to go to work.

Interviewer: So symptoms like chills, body aches . . .

Dr. Miller: Chills, aches, malaise, you just don't feel quite right. It lasts for 24 hours to 48 hours and then it's gone. This is not a reason to not get the vaccine. It's self-limited. It doesn't mean that it's going to go on. It was also a sign that this is a very immune genetic vaccine, that it is revving up the immune system and making the immune system remember that it has to go after the zoster or go after the shingles virus if it comes out of the nerves in the spine. And we know that this new vaccine is more effective in the sense that it lasts longer.

Interviewer: So if I got a shingles shot a couple years ago, and I'm 65, if I'm over 50, should I really consider turning around and getting this one?

Dr. Miller: The recommendation is to receive the new vaccination, even if you had Zostavax, the first vaccination, the live vaccination that was out.

Interviewer: At any point?

Dr. Miller: At any point.

Interviewer: Okay.

Dr. Miller: Well, I probably say, if you've had Zostavax, you would wait a year, maybe two or three years before getting the new one.

Interviewer: You can talk to your physician about that if that's the case, yeah.

Dr. Miller: You can talk to your physician. And then I think the second thing is some people assume that this particular vaccine is covered under Medicare. Certain vaccines are covered under visits during for people who have Medicare insurance, such as the flu shot and a couple of other vaccines, pneumococcal vaccine for instance. This one is not. It's covered under Part D. So you really need to find out from your insurance what the cost of this vaccine will be. The other slight disadvantage with the newer vaccine is it's a two-shot vaccine. You take the first shot and then come back in three months for the second shot.

The total course of therapy on average or treatment on average is about $340 if you were just to pay out of pocket, and for many people who don't have insurance, that's a big inhibitor. But since most of us over 65 will have Medicare and some coverage, it'll be cheaper. But again, check with your private insurance or check with Medicare to know what it's going to cost you so you don't get hit with sticker shock.

Interviewer: Yeah, and then take a look at I mean, it sounds like if it develops into the long-term chronic pain, not being able to put on a shirt, I mean, that sounds like it might be worth figuring out how you could come up with a little extra money if you're not able to.

Dr. Miller: Well, that's true. I think one of the problems that we see folks experience, they come in and they hear about it, and then they get the vaccine, but they experience the sticker shock. And either they decide not to get the vaccine or they wait.

And just as long as you know what the cost is, you can make an informed decision. And I certainly recommend it in all of my patients over the age of 50 and certainly over the age of 60.

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Interviewer: It's a very common medical complaint that doctors get, dizziness. What does it mean and what can you do about it? We'll talk about that next on The Scope.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists" with Dr. Tom Miller is on The Scope.

Interviewer: We're with Dr. Tom Miller, and we're going to talk about when a patient comes to him with a complaint of dizziness. What does that mean, and what can you do about it? So I come to you, I'm saying, you know, I've been feeling dizzy lately. What do you do at that point?

Dr. Miller: That's a really good question. And dizziness is one of the most common complaints that we get in primary care clinics. And basically, you have to break it down, because dizziness is just a non-specific term that means anything from fuzziness in the head to spinning to lightheadedness when you stand up.

Interviewer: All right. I'm assuming since you have to break it down, there'd be different ways that you'd handle the specific symptoms.

Dr. Miller: Right. So as soon as the patient says, "I feel dizzy," then you start to ask questions that are modifiers to how you're going to approach this problem. So, basically, one of the questions I ask, I ask them to describe dizziness. And so they'll say, "I feel lightheaded when I stand up, or I feel lightheaded when I'm getting up out of bed. I get a fuzzy feeling. I start to lose vision, or I feel like I might pass out." That's one type. The other type is, "Do you have the sensation of spinning?" which is vertigo. And that's a very specific type of dizziness, spinning. The room is spinning. You're spinning. You're moving in space. That's very different than a lightheaded feeling or sensation.

Interviewer: So if it's a lightheaded feeling and sensation, what does that mean for the patient?

Dr. Miller: Well, sometimes, it just . . . You know, this can happen in well-trained athletes. So imagine that you go out on a hot day and you run about four miles. You come back, and you're a little bit dehydrated. Your blood vessels are dilated. You sit down on the couch, you begin to watch your favorite sports show on TV, the phone rings and you jump up to get the phone, and whoa, you get wobbly. You start to lose vision. Basically, what happens there is your blood pressure dips, and you're not getting enough blood to the brain, and you start to pass out. That's a type of dizziness that causes lightheadedness.

Interviewer: Okay, that's sounds scary.

Dr. Miller: Basically, that's due to low blood pressure. It's not really scary. I mean, basically, with a couple of . . . First of all, you need to hydrate when you get home, right? Now, sometimes, it can be in people who do have problems like heart disease, or they're on antihypertensives or blood pressure medication that lower their blood pressures to a point that when they stand up and move around, they become they too light. They become to the point where they don't think they're going to stay awake. They're going to fall down. They start to lose vision. Their vision dims. Maybe they're hearing starts to disappear. And it's just this sense that they're going to go down. And so, basically, in that situation, you want to crouch down, and it pushes all that blood back up into your head. So you get down, you crouch down, and then the blood returns, and you're going to be okay.

Interviewer: Like put your head between your legs, crouch down sort of a posture?

Dr. Miller: Yeah, exactly.

Interviewer: What does that look like exactly?

Dr. Miller: Well, actually, probably the best way, if you can handle it, is to squat down. Squatting pushes blood back up into your cardiovascular system and drives blood into your brain, so that . . .

Interviewer: Staying in an upright position when you squat down? Okay.

Dr. Miller: You just squat down. Or if you really feel like you're going to pass out, you lie down.

Interviewer: Okay.

Dr. Miller: All right. And then some people get into a hot tub. They might have a half a glass of wine. They get out of the hot tub, they're relaxed. Boom, they have that sensation. That's pretty common. Basically, as soon as you sense that, and some people for reasons we don't quite understand, are just sensitive to those types of environments where, you know, they're . . . after exercise, or they're coming out of a hot tub, they might get very lightheaded when they stand up. So squatting down immediately is a way to remedy that or lying down will get the blood back to the head and resolve that problem.

Now, in the future, you have to prevent it. And to prevent it, you have to stay well hydrated. You have to be aware of the situations that create this sort of lightheadedness. So that is, again, you know, if you're exercising on a hot day and you relax, you have to realize that you need to hydrate. Also for people who are taking blood pressure medications, they need to be very aware of the situations in which they can become lightheaded, because you don't want to get to the point where you actually pass out or hurt yourself and that happens. That does happen.

Interviewer: Yeah, sure. Because that . . . It's not actually the lightheadedness that's causing the problems, it's what happens after you pass out. Right. Yeah.

Dr. Miller: Yeah, you hit your head and you really have a problem. So, you know, also think about people who are getting up in the middle of the night to go to the bathroom and they get lightheaded. It's dark. They trip, fall, and hurt themselves.

Interviewer: But otherwise, it sounds like the lightheaded type of dizziness is not, in of itself, something scary. You just need to be aware of what's causing it, try to do things to prevent it. If you feel that way, crouch down, try to get that blood back to the brain, and you're good.

Dr. Miller: In a majority of situations. Now, if you're on blood pressure medications, you may be on too high of a dose. You may need to go back to your physician and have your doses adjusted or your reason for taking those medications re-evaluated. Certainly, if you have heart failure, that is a whole 'nother issue. That's sort of beyond the scope of this discussion.

Interviewer: Gotcha. But as a general rule, that lightheaded type of dizziness, in of itself . . .

Dr. Miller: If you're aware of it and you know what you need to do immediately is get down to ground. Squat down or lie down and get your feet up.

Interviewer: Gotcha. What about the spinning kind now?

Dr. Miller: That's vertigo. Vertigo is a sensation of spinning or turning in space. It's that sensation we get when we spin around on a chair, or we turn around and around and around as little kids, you know.

Interviewer: It's been a long time since I've done that because I don't like that feeling.

Dr. Miller: Well, you could be on a fun ride at an arcade somewhere and you have that same sensation. So, basically, that is a sensation that occurs because of changes in the inner ear. So the semicircular canals, which direct sensation and position in space, have this abnormal input. And when that happens, you get the sensation of spinning. You might actually be spinning. And when you stop, you still have the sensation that you're spinning, or it may occur for other reasons.

Now, the most common reason or one of the most common reasons that people get vertigo without actually spinning around in a circle is something called benign paroxysmal positional vertigo. And this occurs as . . . in many people as, not many, in some people as we get older, where you have these little tiny particles break loose and rattle around in the semicircular canals. And what those little particles do is they bang on the hair cells that sense your position in space, and they send this very aberrant signal. And all of a sudden, you have this very strong sensation that you're spinning and turning when you're actually standing still.

Usually, this common cause of vertigo, benign positional vertigo, occurs when you roll over in bed, or you bend over to pick up a shoe, or you look up at a cabinet and try to take a cup out of the cabinet, and all of a sudden, you'll just have this incredible intense spinning sensation that lasts maybe 10 to 15 seconds. And it's reproducible usually by doing that same maneuver. Now, people when they come in and complain of this, they think they're dying, or they're having a stroke. And so it's our job to sort out whether it is temporary as it is in this benign positional vertigo. And if it is, it's likely due to this little particle that's banging around in the inner ear. And there's treatment for that. It's actually physical therapy.

Interviewer: Okay.

Dr. Miller: You could do a maneuver, and usually the maneuver will help put those little particles back where they belong . . .

Interviewer: Really?

Dr. Miller: . . . and then, you're okay. You're on your way. In some cases, if it's worse, we send them to an ear, nose, and throat specialist, and they do their special work, and that takes care of it.

Interviewer: Just want to make sure that I understand. So the lightheaded type of dizziness, unless you're on some sort of medications, sounds like it's not necessarily something you need to mention to your doctor?

Dr. Miller: You can if it's recurrent. I mean, obviously, if you're having situations where it's occurring more frequently and it didn't occur before, that's something you probably should see the physician about.

Interviewer: And the spinning type?

Dr. Miller: The spinning type is something that most people will seek attention for because it's so intense. And you know, if it's bad enough, it'll cause you to throw up. And it's so abnormal and unusual that people seek care for that.

Interviewer: Gotcha.

Dr. Miller: And there is treatment. There's treatment. There are less common causes of vertigo, viral causes where you just all of a sudden have intense spinning sensation and you're sick for three or four days and you're bedridden and sometimes hospitalized because you can't keep any food or fluids down. And that eventually resolves.

Interviewer: Gotcha. So in both of these . . .

Dr. Miller: Sometimes, even more rarely, it would be a stroke.

Interviewer: In both of these instances, perhaps talk to your primary care physician if it's becoming something that happens a lot?

Dr. Miller: Right.

Interviewer: And you know, not only for your quality of life but your peace of mind. But as a general rule, neither one of these two things sounds too threatening?

Dr. Miller: Not too threatening, but can be pretty scary if you haven't had them occur before. And I would think that most people from time to time have experienced the lightheaded kind of dizziness, and they usually will figure out what causes that. It's usually getting up too quickly.

Announcer: Have a question about a medical procedure. Want to learn more about a health condition. With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today, "The Specialists" with Dr. Tom Miller is on The Scope.

Interviewer: Fatty liver disease affects more than 80 million Americans, and many of them don't even know they have it. Dr. Tom Miller, why does fatty liver disease concern you as a doctor?

Dr. Miller: Well, fatty liver disease is becoming the most common chronic liver disease in the industrialized Western world, and especially in the United States. And it used to be, we had viral hepatitis as a cause of liver disease and a major cause of transplantation, which it still is, but very shortly the major reason for liver transplantation due to liver failure is going to be fatty liver.

Interviewer: And not necessarily caused by alcohol. I always thought it was, you know, people that drank a lot tend to get fatty liver disease.

Dr. Miller: Well, they get liver disease. It's not necessarily fatty liver disease as you would think about it, and it was and still continues to be a cause of liver disease, but because of our lifestyle and the fact that 30% of the people living in the United States have obesity, fatty liver disease is now the most common cause of chronic liver disease.

Interviewer: Yeah, 80 million Americans, that's quite a . . . that's almost an epidemic, isn't it? Like, if 80 million Americans had any other sort of disease, we would be freaking out.

Dr. Miller: Right. I think the term might be just a little bit . . . The categorization of it is a little bit misleading because not everyone with fatty liver disease goes on to develop liver failure. In fact, a small percentage of those people end up with liver failure, but given the large number of people with fatty liver disease, a significant number of Americans will end up with end-stage liver disease.

Interviewer: And what exactly is going on? So I think the name implies that there's some fat, maybe excess fat deposits in the liver, but why is that bad?

Dr. Miller: Fat is a cause, a driver of inflammation, and we don't exactly know why, but when people gain weight, some of that weight is stored centrally and also stored between the cells in the liver. So if you look at a person's tissue from the liver, you will see if they have fatty liver, which is called non-alcoholic fatty liver. You'll see fat stores or globules in between the cells. For whatever reason, this causes inflammation, and inflammation predisposes to damage, fibrosis, and destruction of the active cells in the liver which help us cleanse our body of toxins.

Interviewer: And you're talking about scarring.

Dr. Miller: I'm talking about scarring.

Interviewer: That's why I used those words, yeah.

Dr. Miller: Fibrosis leads to scarring.

Interviewer: Yeah.

Dr. Miller: Now, again, most people with fatty liver don't end up with inflammation, and we don't exactly understand why some people have problems with inflammation related to their fatty liver versus those who don't. And not everyone who has inflammation in the liver goes on to develop cirrhosis.

Interviewer: But it's certainly a path you don't want to go down and find those things out.

Dr. Miller: No, definitely not, and it can be treated.

Interviewer: All right. So, when a patient comes into your office, can you look at them and tell if they have the bad kind of fatty liver disease that could lead to transplant or death?

Dr. Miller: I think the way that we think about it now, I believe the way we think about it now is if you're obese, that is you have a body mass index greater than 30, your chances are pretty high of having non-alcoholic fatty liver disease. So, basically, the same thing that we've talked about on these shows in the past, right diet, right weight, right exercise is your best treatment to prevent it. This is a problem with industrialized countries having too much food and the wrong kinds of food available.

Interviewer: Yeah. And once that scarring happens, there's no cure for it. It eventually will lead to liver failure.

Dr. Miller: Once you start down a path of scarring, your chances of ending up with end-stage liver disease and needing a transplant are pretty high. Not only that, you are predisposed, with that scarring, to liver cancer.

Interviewer: And if you start to lose some weight, I understand it doesn't take, necessarily, a lot of weight reduction to reduce the number of fat cells in the liver and kind of start backing that thing up if scarring hasn't occurred.

Dr. Miller: Right. I think one, again, wants to head for a normal BMI, which is between 18.5 and 25.

Interviewer: Okay.

Dr. Miller: And that's not easy. I mean, I tell you that that's the treatment, but attaining that treatment for everybody is difficult because we don't have a medication for weight loss that works, and basically it's a lifestyle adjustment, which is hard for people given the abundance of food.

Interviewer: And there are tests that you can do to determine, for sure, if there are.

Dr. Miller: There are. So we basically start looking at the issue of inflammation in people who we think might have fatty liver disease by looking at the enzymes that the liver produces on a blood test. If these are elevated, there are a number of causes, but eventually, if you can rule out sort of the medical, the drug-associated causes and other causes, that is if they're not drinking, you can think that this is probably related to a non-alcoholic fatty liver disease. And if you really want to know damage to the liver, you're going to have to do a liver biopsy. There's another test now that's non-invasive, but liver biopsy is still the gold standard.

Interviewer: And we haven't really hit on this, but it often doesn't have symptoms.

Dr. Miller: The vast majority of people with non-alcoholic fatty liver disease are not symptomatic.

Interviewer: Yeah.

Dr. Miller: And, in fact, you're only symptomatic towards the end . . .

Interviewer: When it's kind of too late.

Dr. Miller: . . . with this disease when you have fibrosis and scarring or liver cancer. So, again, we want to look at obesity and lifestyle as a response to prevent this.

Interviewer: So get that body mass index back into a reasonable area?

Dr. Miller: Well, it's the same thing we talk about for all of the things that we now kind of associate with the Western world diet, which is high blood pressure, heart disease, metabolic syndrome, type 2 diabetes. They're all in a basket, including this non-alcoholic fatty liver disease. And, again, the treatment is at our hand, but it's not easy to achieve.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Interviewer: Rosacea is a chronic and potentially disruptive disorder that causes itching, redness, and unsightly bumps on the face. It can continue to get worse without treatment, so early detection is important. Dr. Miller, what patients are at risk, and what should they be looking for?

Dr. Miller: Most cases appear between the ages of 30 and 50 years old and may afflict people with fair skin, basically those of northern European ancestry. Women are more likely than men to develop it, and there is usually a family history. So, if a patient is at risk for rosacea, the key is to seek treatment early.

Interviewer: And what are the signs to look out for?

Dr. Miller: Flushing and redness on the cheeks and nose that last unusually long, and one can also have tiny visible blood vessels on the face, and these signs are commonly accompanied by stinging, burning, and itching. If you see any of these signs, you should see your doctor or dermatologist for diagnosis as there is excellent treatment.

updated: September 27, 2021
originally published: February 22, 2018

Announcer: The Health Minute, produced by University of Utah Health.

Interviewer: All right, here's the scenario. My wife is blaming me for giving her a cold that I had, but her symptoms are completely different. So, Dr. Tom Miller, is it possible for different people to come down with different symptoms from the same bug? Am I really responsible here?

Dr. Miller: People can come up with variations on the theme but caused by the same virus or same bug. Could she have gotten it from you? I would say that if you actually picked it up two weeks ago and you were better in about four or five days, or starting to get better, that she would pick it up a week later, it's possible but probably less likely. And I think the bigger thing is that these viruses tend to circulate in the community. So you could pick it up from somebody at work, you could pick it up in the grocery store. And so what's your best defense? Wash your hands. Wash your hands during the cold and flu season, especially if you're around someone who has a cold. Just make sure you wash your hands frequently.

Announcer: To find out more about this and other health and wellness topics, visit thescoperadio.com.

Interviewer: You have a pretty bad sore throat. Dr. Tom Miller, is that worth a trip to the doctor?

Dr. Miller: It might be. Most sore throats are caused by viruses. But if you have tender, swollen lymph nodes in your neck, if you have a fever of greater than 100 or 100.5, and if you look in the back of your throat with a penlight and you see sort of plaques on your tonsils, there's a good chance that you have strep throat, especially if you live with young kids who also get strep throat more commonly than adults. It might be worth a trip to the doctor.

He'll evaluate those same things. If you have all three of them, he's likely to give you an antibiotic. If you have one or two of them, he'll do what's called a rapid strep test. That will tell him if you have strep throat, and if you do, you'll have an antibiotic. That will reduce the symptom duration by one or two days and you'll feel better and get back to work.

Interviewer: So strep throat pretty much the only sore throat that you're going to get an antibiotic for.

Dr. Miller: There are others but more rarely.

updated: November 11, 2021
originally published: July 13, 2017

Interviewer: You go to your doctor, they say your cholesterol is too high. Why should you care and what does that mean for your health? And what can you do about it? That's next on The Scope.

Interviewer: All right, Dr. Tom Miller, you know every year you go get you physical. One of the numbers you're going to get back is your cholesterol numbers. There are two or three of those numbers, and my doctor my tells me, "Oh, your cholesterol doesn't look good." What's going on?

Dr. Miller: Well, we've known for many years that high cholesterol can generally imply poor outcomes in the long term. It's related to vascular disease over many, many years, and it's associated with other risk factors for vascular disease, such as high blood pressure.

Interviewer: And which all can lead to heart attack or stroke?

Dr. Miller: Exactly.

Interviewer: Yes. So that's why if you see those high numbers they're predictor score, that this person is more likely to have those outcomes.

Dr. Miller: That's exactly right. So there's several things when people talk about cholesterol. Let me break those down real quick for you. First, is total cholesterol. And generally, if your cholesterol is over 200, that's too high, but you can break it down further from there. You break it down into triglycerides, you break it down into HDL, that's the good cholesterol, and then you break it down into LDL, the bad cholesterol. The way I kind of think about, Scott, is when you have a high HDL, that's the good stuff, it reminds me of a taxi that's ferrying sort of cholesterol and bad stuff away from the arteries and takes that back to the liver where it's chewed up and metabolized, and you don't have to worry about it anymore.

Interviewer: So you want lots of that HDL to help your body dispose off that stuff.

Dr. Miller: Yes, high HDL is better. High HDL is better.

Interviewer: Okay.

Dr. Miller: And you know how you get high HDL? Exercise.

Interviewer: Oatmeal. No, exercise.

Dr. Miller: Well, not so much oatmeal but exercise and weight loss and stopping smoking actually raises HDL as well. So really, what you do when you do those three things is you increase the number of taxis that are delivering bad cholesterol away from the arteries into the liver where it's chewed up. LDL, you think about that as a taxi taking cholesterol down to the arteries and depositing it into the sides of the arteries into the lumen or the walls of the arteries. And so that's where it sits, and over long periods of time, you get these plaque build-ups, and if those plaques rupture, then you can have bad things like a heart attack or a stroke.

Interviewer: So is the total cholesterol a sum of your HDL/LDL in the triglycerides? Is that where that number comes from?

Dr. Miller: Yes, basically, there's a little equation of that, but not to trouble ourselves too much about it. But the higher the HDL, the higher the total cholesterol. The higher LDL, the higher the total cholesterol. So if you actually have a nice high HDL and a low LDL, that's okay if your total cholesterol is just a little elevated.

Interviewer: Okay.

Dr. Miller: So total tells you kind of, is a sign post about you need to look at this more closely.

Interviewer: Okay. So you get that big number. Well, if the number is not big then you're probably fine. But if it's a big number then you need to look at how does that break down; the good versus the bad. If you got more good, fine.

Dr. Miller: Well, sometimes you can look at that ratio too. So you can look at that ratio total cholesterol and HDL. And there are calculators now that are put out by the American Heart Association in conjunction with the American College Cardiology that look at not only the total cholesterol and HDL, but they mix in your blood pressure and your other risk factors, whether you smoke, whether you have diabetes, and if you're on blood pressure medication. And it gives you score, and that score kind of tells you what your 10-year risk is.

Now, no calculator is perfect, Scott, but it's a pretty good indication of, "Wow, I'm doing really well. I'm eating right. I have low blood pressure and I don't have other risk factors," or, "Warning, I've got to do some other things to improve my health." Now, one of these things might be that you need to take a medication to lower your cholesterol while you're waiting for the lifestyle things to catch up.

Interviewer: Let's go back to the original question. Your doctor is concerned about your cholesterol numbers, so odds are at the point what he's going to say is you have high LDL, which is bad.

Dr. Miller: That could be one thing he says . . .

Interviewer: Exercise. I need you to exercise more. I need you to quit smoking.

Dr. Miller: Right, and you would say those things anyway, right?

Interviewer: Okay.

Dr. Miller: I mean, generally, those are great ideas, but we stress them more if your cholesterol and blood pressure are elevated.

Interviewer: What else would you doctor tell you to do to try to get that under control then?

Dr. Miller: So you want to follow a low cholesterol based diet, and there are ways to do that. You can Google a step one cholesterol diet and it will tell you. And basically, it's common sense. Don't eat a lot of animal products because animal foods have cholesterol, plants don't, they don't have cholesterol. So you're not going to get cholesterol from plants, so the more vegetarian based your diet is, the more leafy green vegetables you eat, the chances are you will help lower your LDL cholesterol.

And so you want to stay away from high cholesterol meats, fatty meats. You want to trim fat off of any kind of meat that you are eating chicken or steak, and some common sense things. And most of us have heard these over and over on the news and on the media but we have to pay attention to it on the cholesterol side. But at some point it might be high enough, you actually need to be treated for it.

Interviewer: You could do all the right things and still . . .

Dr. Miller: Yes, there are some folks that have a genetic predisposition to have high LDL cholesterol and they are predisposed to really heart disease. And so we do get after them with drugs and we have good drugs now to treat high cholesterol.

Interviewer: And nothing you can do if you're genetically disposition, if you do all the other stuff right.

Dr. Miller: Yes. First step in this treatment basically, and this is true for high blood pressure as well, is to get after your lifestyle improvements. So getting your body mass index down between 18.5 and 25 and exercising on a daily basis. And I'm not talking about on Schwarzenegger type weight room stuff, I'm just talking about going out and getting to walk for 30 to 60 minutes a day.

Interviewer: Elevating that heart rate.

Dr. Miller: Yes, getting your heart rate up to a moderately elevated level. We're not talking about Olympian athlete type redlining heart rates, we're just talking about getting out and doing a brisk walk or a swim or cycling.

Interviewer: Do you find that patients when you give them this information that they tend to think, "Well, really how much is that going to make a difference?" Are they skeptical?

Dr. Miller: I don't think patients are skeptical. I think we all want to do the right thing. And I think the vast majority of us believe that exercise is healthy. It makes us feel better and losing weight makes us feel better. There's a body image piece there. It's just hard to do. We don't have a pill to help you lose weight effectively.

Interviewer: And for cholesterol. . .

Dr. Miller: And we don't have a pill to make you exercise. So it's a lot of coaching. It's like you can do this, go out and do it. So you build your patient's will power up by suggestion.

Interviewer: And doing that will noticeably decrease cholesterol numbers?

Dr. Miller: Yes, it will definitely help reduce cholesterol in the vast majority of people, but not always to a level that would be necessary.

Interviewer: Got you. But it does make a difference?

Dr. Miller: It does make a difference, and it a makes difference for reasons other than just lowering cholesterol and lowering blood pressure. So there's many different reasons to stay healthy with lifestyle interventions.

updated: March 10, 2023
originally published: May 27, 2017