Healthy Lifestyle

Best Anti-Aging Tip At Home

The best anti-aging treatment is one you do at home.

As my past and current patients and clients can tell you, I will keep explaining what sunscreen is for and why sunscreen is so important until you understand or pretend to so I stop talking.

My focus changed from working as an acne specialist at a top-rated dermatologist for over 15 years to include the ever-growing field of anti-aging treatments just 7 years ago in two San Diego offices. Switching from the damage of scarring caused sunburns to acne to having firsthand proof of what photo aging looks and feels like from my personal experience of growing up tan and working for major a suntan company was natural.

Today we understand sunscreens are a vital tool in the fight against skin cancer, and are highly effective in preventing skin aging caused by the sun, wrinkles, pigmentation irregula­rities, dehydrated and sagging skin

Intentional vs. Incidental Exposure

If I had a nickel every time one of my patients said “I didn't wear sunscreen today, I didn’t go in the sun today” I would be working at my future five-star resort for Alzheimer’s cure with acres of room for an animal shelter, funding research for the cure for mental illness! Meanwhile, I did not collect those nickels so back at the office I try to make everyone understand incidental sun adds up. Driving, walking to the car, going to lunch, picking up kids, etc.

Everyone should wear sunscreen every day.

Farah Ahmed and Curtis Cole, Ph.D. breaks it down for us.

Products that contain sun screening ultraviolet (UV) filters intended to provide sunburn protection can be divided into two basic categories. The first is when there is “intentional” exposure to sunlight for extended periods of time. This is typically associated with recreational activities such as swimming, hiking, sports activities, etc., with exposure to sunlight during the period of highest sunburn potential—10 am to 4 pm. These activities often induce sweating and may also include exposure to water for a significant amount of time. Sunscreen products for these activities are designed to resist removal by sweat or water by incorporating polymer substances and emulsifiers that lock the sunscreen filters onto the surface of the skin.

The second category of sunscreens typically performs a primary function other than sun protection, and is therefore intended for “incidental” sun exposure. The primary functions may be for moisturi­zation; to cosmetically improve the skin’s appearance and even out skin tone, such as tinted foundations; or to correct blotchy or uneven skin tone. Typically these products are for the face or “spot” use, such as on the hands, arms or décolleté, which are exposed and the most visible during the day.

These “cosmetic” products containing UV filters and providing a measurable sun protection factor (SPF) are also categorized by the FDA as drug products, and require the same exact labeling instructions and description as the “intentional” or “recreat­ional” sunscreen products. “Incidental” sun exposure products typically have a lower SPF as they are intended to be used only for short periods of sun exposure. Yet, they fulfill a critical role in providing the constant protection that is vital to maintaining healthy skin against cancer, wrinkles and age spots.1

Fundamen­tally, the two types of products are formulated with the same basic categories of ingredients, with the exception of film-forming polymers in the first category to provide protection against sweating and water resistance. Let’s look at the “skeleton” of these products to see how they are constructed, how they are similar, and how they differ.

The primary categories of ingredients are: spreading vehicles, emulsifiers, film-forming agents, additional benefit agents, colorants, fragrances and preserva­tives. In the Categories of Sunscreen Ingredients sidebar, examples of ingredients are provided for both the intentional, recreational sunscreens and the incidental, daily use sunscreens.

Sunscreen Active Delivery Systems

Products containing sunscreen filter actives are available in a wide variety of delivery systems designed to fit specific use conditions and consumer preferences. Compliant sunscreen protection requires convenience and product elegance to ensure the products are used regularly and in sufficient quantity. The effectiveness of a sunscreen-containing product is critically dependent on the amount used and the way the user applies it to their skin. Several studies2, 3 have shown a direct linear relationship between the amount of sunscreen applied to skin, and the resulting SPF. In short, if a user applies only half of the recommended amount that was used during clinical SPF testing of the sunscreen (2 mg/cm2), then the resulting SPF the user actually gets will be half of the amount stated on the product label.

Convenient packaging can support user compliance by making sunscreens readily available, such as a in stick applicator that can be carried in a purse or pocket, a spray product that is “easy” to apply to wiggling children, or a lotion bottle with a pump dispenser placed on a dressing table or makeup counter.

Small packages of lotion or powder products with sunscreen actives can also be carried in a purse for touch-up applications, or tucked away in the glove box of a car for access at a moment’s notice.

Each of these product forms has different vehicle constituents to fit the storage and use conditions, but all have the same intent—to deliver a thin film of sunscreen filter actives to the skin and provide an optical barrier to UV rays from the sun or other UV light sources, such as indoor fluorescent lighting.4 Let’s look at each vehicle type and examine the components.

Lotions and Creams. Lotions and creams comprised the majority of the sunscreen product category until the mid-2000s. Both of these forms are mixtures of water and oil, with the sunscreen filters dissolved into one or both of the two phases. Lotions and creams are typically oil-in-water (o/w) emulsions, which can be described as droplets of oil swimming in a sea of water, held in a stable matrix by ingredients called emulsifiers that physically and chemically maintain equilibrium between the oil droplets and the sea of water. Without the emulsifiers and physical energy used to form the emulsion, the two phases would separate into a layer of oil floating on a layer of water—like your oil and vinegar salad dressing before you shake it.

After the lotion or cream is spread onto the skin, the water evaporates and the emulsion “breaks,” leaving the layer of oil containing the sunscreen actives to spread and remain on the surface of the skin.

Cream products are simply “thicker” versions of lotions, where more viscous oils, waxes or thickeners are added to make the product more moisturizing. Water-in-oil (w/o) emulsions are also possible, wherein you can imagine water droplets floating in a sea of oil. These “reverse” emulsion products tend to be heavier to spread on the skin and slower to dry down, as they typically have a much higher proportion of oil to water, compared with the more common o/w products that are typically 60% or more water. W/O products can leave a thicker oil film on the skin surface and are naturally more water resistant. However, the trade-off is they can be considered more “greasy” to the touch.

There is no easy way to read a product label and determine if it is an o/w or w/o emulsion. A simple test is to put a drop of the emulsion product in a glass of water and see if it easily disperses with slight agitation, or forms tight balls. If it disperses, it is an o/w emulsion; if not, it is a w/o emulsion.

Both emulsion types are effective vehicles for delivering sun protection. It is simply a matter of consumer preference for the product type based on its esthetic properties, the level of moisturi­zation desired and the level of protection perceived.

Spray products. In the mid-2000s, spray sunscreens became a popular format and remain the highest selling category of the “recreat­ional” sun care market, with more than 50% of total sales. The vast majority of spray sunscreen products are solutions of alcohol containing UV filters, with some additional oils to form the film layer on the surface of skin. The alcohols provide a quickly evaporating vehicle, as well as a solvent that conveniently solubilizes and distributes the sunscreen actives in the container to evenly disperse them on skin. While concerns have been raised by the media and consumer advocates regarding the safety of inhaling of spray sunscreens, this risk is mitigated by the use of spray systems that provide droplet sizes in excess of 10 microns in diameter—a size shown to prevent deep inhalation into the lungs.

Stick products. Stick sunscreens are a convenient dosage form for spot applications such as the nose, ears and around the eyes. These consist of various moisturizers or emollients that can solubilize oil-soluble UV filters and provide a vehicle for any particulate sunscreens; i.e., those whose particles physically block, scatter and reflect UV, including titanium dioxide and zinc oxide. Also incorporated are waxes, thickening agents and polymers to help the product hold its shape at temperatures above around 120°F. When rubbed across skin, it leaves a continuous film of compounds containing the sunscreen filters that resists wash-off.

Powder products. Facial powder sunscreens consist primarily of titanium dioxide and zinc oxide powders that provide UV protection, together with emollient binders and mineral pigments that provide color and glow. These products help to even out and brighten skin tone while providing protection against damaging UV radiation.


1. TJ Phillips, J Bhawan, M Yaar, Y Bello, D Lopiccolo and JF Nash, Effect of daily versus intermittent sunscreen application on solar simulated UV radiation induces skin responses in humans, J Am Acad Dermatol 43(4) 610-618 (2000)

2. R Bimczok et al, Influence of applied quantity of sunscreen products on the sun protection factor–A multicenter study organized by the DGK Task Force Sun Protection, Skin Pharmacol Physiol 20 57–64 (2007)

3. H Ou-Yang, J Stanfield, C Cole, Y Appa and D Rigel, High SPF sunscreens (SPF>70) may provide ultraviolet protection above minimal recommended levels by adequately compensating for lower sunscreen used application amounts, J Amer Acad Dermatol 67 6 1220–1227 (2012)

CA Cole, PD Forbes, RE Davies and F Urbach, Effects of indoor lighting on normal skin. Annals NY Acad Sci 453 305316 (19

Sun and Fun...Be Aware Of Your Skin Changes

May is Melanoma Awareness Month

Good advice taken from Mankato Clinic, May 5, 2017

Mankato Clinic

The sun is shining and the weather is warmer, leaving many of us in southern Minnesota shedding some layers and baring our skin. But, when you do that, remember that May is Melanoma month and the perfect time for you to review proper skin-care etiquette for the summer ahead.

Melanoma is widely known as the most serious type of skin cancer and develops in your body’s cells that produce melanin, the pigment that gives your skin its color. Not just found in skin, melanoma can also form in your eyes and rarely in internal organs like the intestines.

It’s unclear what the exact cause of melanoma is but exposure to ultraviolet (UV) radiation from sunlight, tanning lamps and tanning beds largely increase your risk of developing skin cancer. To help reduce your risk of melanoma, limit your exposure to UV radiation as much as possible.

Often times, melanoma can be treated successfully if it is detected early, which is why it’s so important to understand the symptoms of the disease. Melanoma can develop anywhere on the body, but most often develop in areas that have more exposure to the sun like your back, arms, face and legs. They can also occur in areas that don’t receive much sun exposure like the soles of your feet, palms of your hands and fingernail beds. These harder to spot melanomas are more common in people with darker skin.

The first signs and symptoms of melanoma are a change in an existing mole or the development of a new pigmented or unusual-looking growth on your skin. It’s important to note that melanoma doesn’t always begin as a mole, but it can also occur on otherwise normal skin.

Checking for unusual moles that can indicate melanomas or other skin cancers is as easy as knowing your ABCs:

A – Asymmetrical shape. Look for moles with irregular shapes, like two different halves

B – Irregular border. Look for moles with notched, scalloped or irregular moles

C – Changes in color. Look for growths that have an uneven distribution of color

D – Diameter. Look for new growth in a mole larger than ¼ inch

E – Evolving. Look for changes over time, like a mole that changes in color or shape or grows in size. Moles can also change and develop new signs and symptoms and may bleed or itch.

An easy rule of thumb: look for the “ugly duckling” – a mole that doesn’t belong with the rest.

Unfortunately, everyone is at risk for melanoma, but factors that can increase your risk include: fair skin, a history of sunburn, excessive UV exposure, living closer to the equator or at a higher elevation, having many or unusual moles, a family history of melanoma or weakened immune system.

The best thing you can do for your skin is to give it the necessary protection it needs from the sun’s harmful UV rays. To help reduce your risk of melanoma and other types of skin cancer be sure to avoid the sun during the middle of the day, wear sunscreen year-round, wear UV protective clothing, avoid tanning lamps and beds and become familiar with your skin so that you notice changes. Seek your dermatology provider for routine skin exams to help better understand your skin and receive guidance of any questions or concerns you may have.

See a Doctor if you suspect any of these signs.

See a Doctor if you suspect any of these signs.

Optimizing Risk Factors of Aging, Make Easy Changes for 2019

A transformation starts with you.   Optimizing risk factors of aging and enjoying life along the way.

Where to start? Well, we always say at the beginning. This is usually the best place to start. In this case since the beginning for us is in the past, let’s start where we are, this is as good a place as any. While setting a goal to start a new goal can lead to procrastination, pick just a few things and start making changes now.  Right this minute.  You know yourself better than anyone, look at the list below. Set your intentions now.  This means really pick one or two things or maybe all things that you INTEND TO DO.  My advice is start small.  What is important is your mindset. You are the vision in your mind’s eye, you are already the person making positive changes.   When you look at the list, imagine yourself already doing it. Push the images out of your mind of past experiences. These memories especially the negative ones are no longer important. Example, your vision of drinking 100oz.of water and reaching your goal is what you see.  See yourself at the end of the day with a big smile on your face and sense of accomplishment with an empty glass.


1.     Exercising or moving (see below)

2.     Drinking more water ½ your weight in ounces

3.     Thinking positive thoughts

4.     Being kind to others, cultivate relationships

5.     Eating healthy foods, choose fresh without preventives if possible

6.     Look at food labels for hidden sugar

7.     Give up fast food.  Just say no.

8.     Sleep 7 hours min.

9.     Make a list of the things to do so it is easier to plan

10.   Reach outside your comfort zone and say hello to someone new

11.   Ask your partner or spouse how they are doing and listen until they are finished

12.   Smile, practice smiling does help J

13.   Relax your jaw and shoulders

14.   Remind yourself how lucky you are, don’t take things for granted

15.   Keep your word, if you say you will do it.

16.   Don’t be afraid to ask for help, others will help if they can.

17.   Meditate, focus your mind on a mantra.


Let’s start with exercise.  We have scientific evidence that exercising has a positive effect on the aging brain.  Exercise helps different areas of your body in different ways.  There are hormones released in your bones when you exercise, endorphins are directly related to that euphoric feeling during and after exercise. Science has proven your gut reacts to exercise in a positive way.  Even the amount of happiness you feel can be factored in to moving your body!  Some say for as little as 7 minutes.


Leaving the Hospital After A Fall or Injury

Often my blog ideas come straight from a new client who is frustrated and needs an advocate. Frustrated with the amount of information given to them. Often clients are needing information about leaving the hospital after an illness or injury.

Being your own advocate is difficult when you are the patient. Having a caring advocate is important. You may have a friend or loved one be the advocate.

Start as soon as possible researching the needs.

1. Is home alone an option? If not will someone be there to care for the patient? Are there monies to cover home care or insurance coverage for help at home?

2. Is a skilled nursing facility (SNF) needed? Start researching SNF’s to get answers to important questions. Based on insurance or cash pay call or Google local choices and see which options best fit your needs.


1. DISCHARGE TIMELINE: When is the patient expected to be transferred to the SNF? Ask about the possibility of nursing home care as soon as the patient is hospitalized to have time to research SNF’s and to prepare for this transition.

2. SNF CHOICES: Which facilities are available to the patient and do they have an open bed? Can the patient request a single room, and is there an extra fee?

3. TRANSPORTATION TO THE SNF: How will the patient be transferred to the SNF? If transportation by ambulance is needed, are the charges covered by insurance?

4. SNF REVIEWS: Consult Nursing Home Compare for SNF information. Google the name of the SNF and read any online reviews or comments. Contact your state Department Of Health and ask for the most recent inspection results.

5. SPECIAL NEEDS: Ask the hospital discharge planner or case manager if the patient has special needs that the SNF will need to provide, such as a special diet or onsite physical therapy (PT) or occupational therapy (OT) services.

6. VISITING THE SNF: The patient’s advocate should try to visit the SNF choices in person. Check the toilet and shower facilities, cleanliness, patient activities and food selections. What is the caregiver to patient ratio – especially during evenings and weekends?

7. PATIENT RISKS: Nursing home patients may be at an increased risk of infection, overuse of antibiotics leading to “superbug” infections that may not be curable, falls, malnutrition, dehydration, medication interactions and side-effects, pneumonia and depression. Report any unusual symptoms you may observe in your loved one.

8. COORDINATION OF CARE: Which staff member is responsible for coordinating the patient’s care? Who is the physician in charge and how can he/she be contacted if there is a concern? Will the patient’s regular doctor visit the SNF? How are emergencies handled?

9. VISITING POLICIES: Does the SNF have a written visiting policy? If so, ask for a copy. Can approved visitors stay all night? Is there a policy for bringing food or other comfort items from home?

10. INSURANCE COVERAGE FOR SNF’s: Are there any needed services that are not covered by insurance? Is there supplemental Medicare coverage that needs to be billed? What is the protocol if the patient meets or exceeds their insurance maximum?

©2015 The Empowered Patient Coalition. An Empowered Patient ® Publication in collaboration with Julia Hallisy, D.D.S. and patient advocates Judy Wehrer and Paula Jean.

The Subject You MUST Bring Up

This holiday season take the time to start this conversation.

Advance care planning is not just about old age. At any age, a medical crisis could leave you too ill to make your own healthcare decisions. Even if you are not sick now, planning for health care in the future is an important step toward making sure you get the medical care you would want, if you are unable to speak for yourself and doctors and family members are making the decisions for you.

Start by thinking about what kind of treatment you do or do not want in a medical emergency. It might help to talk with your doctor about how your current health conditions might influence your health in the future. 

If you don't have any medical issues now, your family medical history might be a clue to help you think about the future. 

In considering treatment decisions, your personal values are key. Is your main desire to have the most days of life? Or, would your focus be on quality of life, as you see it? What if an illness leaves you paralyzed or in a permanent coma and you need to be on a ventilator? Would you want that?

There are two main elements in an advance care directive:

 Living will. A living will is a written document that helps you tell doctors how you want to be treated if you are dying or permanently unconscious and cannot make your own decisions about emergency treatment. In a living will, you can say which of the procedures described in the Decisions That Could Come Up section you would want, which ones you wouldn't want, and under which conditions each of your choices applies.

Durable power of attorney for health care. A durable power of attorney for health care is a legal document naming a healthcare proxy, someone to make medical decisions for you at times when you are unable to do so. Your proxy, also known as a representative, surrogate, or agent, should be familiar with your values and wishes. This means that he or she will be able to decide as you would when treatment decisions need to be made. A proxy can be chosen in addition to or instead of a living will. Having a healthcare proxy helps you plan for situations that cannot be foreseen, like a serious auto accident.

Some people are reluctant to put specific health decisions in writing. For them, naming a healthcare agent might be a good approach, especially if there is someone they feel comfortable talking with about their values and preferences. A named proxy can evaluate each situation or treatment option independently.

Other advance care planning documents. You might also want to prepare documents to express your wishes about a single medical issue or something not already covered in your advance directive. A living will usually covers only the specific life-sustaining treatments discussed earlier. You might want to give your healthcare proxy specific instructions about other issues, such as blood transfusion or kidney dialysis. This is especially important if your doctor suggests that, given your health condition, such treatments might be needed in the future.

Medical issues that might arise at the end of life include:

  • DNR orders

  • Organ and tissue donation

  • POLST and MOLST forms

DNR (do not resuscitate) order tells medical staff in a hospital or nursing facility that you do not want them to try to return your heart to a normal rhythm if it stops or is beating unsustainably using CPR or other life-support measures. Sometimes this document is referred to as a DNAR (do not attempt resuscitation) or an AND (allow natural death) order. Even though a living will might say CPR is not wanted, it is helpful to have a DNR order as part of your medical file if you go to a hospital. Posting a DNR next to your bed might avoid confusion in an emergency situation. Without a DNR order, medical staff will make every effort to restore your breathing and the normal rhythm of your heart.

A similar document, called a DNI (do not intubate) order,tells medical staff in a hospital or nursing facility that you do not want to be put on a breathing machine.

non-hospital DNR order will alert emergency medical personnel to your wishes regarding measures to restore your heartbeat or breathing if you are not in the hospital.

Organ and tissue donation allows organs or body parts from a generally healthy person who has died to be transplanted into people who need them. Commonly, the heart, lungs, pancreas, kidneys, corneas, liver, and skin are donated. There is no age limit for organ and tissue donation. You can carry a donation card in your wallet. Some states allow you to add this decision to your driver's license. Some people also include organ donation in their advance care planning documents.

At the time of death, family members may be asked about organ donation. If those close to you, especially your proxy, know how you feel about organ donation, they will be ready to respond. There is no cost to the donor's family for this gift of life. If the person has requested a DNR order but wants to donate organs, he or she might have to indicate that the desire to donate supersedes the DNR. That is because it might be necessary to use machines to keep the heart beating until the medical staff is ready to remove the donated organs.

Learn more about organ and tissue donation.

POLST and MOLST forms provide guidance about your medical care preferences in the form of a doctor's orders. Typically you create a POLST (Physician Orders for Life-Sustaining Treatment) or MOLST (Medical Orders for Life-Sustaining Treatment) when you are near the end of life or critically ill and know the specific decisions that might need to be made on your behalf. These forms serve as a medical order in addition to your advance directive. They make it possible for you to provide guidance that healthcare professionals can act on immediately in an emergency.

A number of states use POLST and MOLST forms, which are filled out by your doctor or sometimes by a nurse practitioner or physician's assistant. The doctor fills out a POLST or MOLST after discussing your wishes with you and your family. Once signed by your doctor, this form has the same authority as any other medical order. Check with your state department of health to find out if these forms are available where you live.

What About Pacemakers and ICDs?

Some people have pacemakers to help their hearts beat regularly. If you have one and are near death, it may not necessarily keep you alive. But, you might have an ICD (implantable cardioverter-defibrillator) placed under your skin to shock your heart back into regular beatings if the rhythm becomes irregular. If you decline other life-sustaining measures, the ICD may be turned off. You need to state in your advance directive what you want done if the doctor suggests it is time to turn it off.

Selecting Your Healthcare Proxy

If you decide to choose a proxy, think about people you know who share your views and values about life and medical decisions. Your proxy might be a family member, a friend, your lawyer, or someone in your social or spiritual community. It's a good idea to also name an alternate proxy. It is especially important to have a detailed living will if you choose not to name a proxy.

You can decide how much authority your proxy has over your medical care—whether he or she is entitled to make a wide range of decisions or only a few specific ones. Try not to include guidelines that make it impossible for the proxy to fulfill his or her duties. For example, it's probably not unusual for someone to say in conversation, "I don't want to go to a nursing home," but think carefully about whether you want a restriction like that in your advance directive. Sometimes, for financial or medical reasons, that may be the best choice for you.

Of course, check with those you choose as your healthcare proxy and alternate before you name them officially. Make sure they are comfortable with this responsibility.

Making It Official

Once you have talked with your doctor and have an idea of the types of decisions that could come up in the future and whom you would like as a proxy, if you want one at all, the next step is to fill out the legal forms detailing your wishes. A lawyer can help but is not required. If you decide to use a lawyer, don't depend on him or her to help you understand different medical treatments. Start the planning process by talking with your doctor.

Many states have their own advance directive forms. Your local Area Agency on Aging can help you locate the right forms. You can find your area agency phone number by calling the Eldercare Locator toll-free at 1-800-677-1116 or by visiting

Some states require your advance directive to be witnessed; a few require your signature to be notarized. A notary is a person licensed by the state to witness signatures. You might find a notary at your bank, post office, or local library, or call your insurance agent. Some notaries charge a fee.

Some states have registries that can store your advance directive for quick access by healthcare providers, your proxy, and anyone else to whom you have given permission. Private firms also will store your advance directive. There may be a fee for storing your form in a registry. If you store your advance directive in a registry and later make changes, you must replace the original with the updated version in the registry.

Some people spend a lot of time in more than one state—for example, visiting children and grandchildren. If that's your situation, consider preparing an advance directive using forms for each state—and keep a copy in each place, too.

After You Set Up Your Advance Directive

Give copies of your advance directive to your healthcare proxy and alternate proxy. Give your doctor a copy for your medical records. Tell close family members and friends where you keep a copy. If you have to go to the hospital, give staff there a copy to include in your records. Because you might change your advance directive in the future, it's a good idea to keep track of who receives a copy.

Review your advance care planning decisions from time to time—for example, every 10 years, if not more often. You might want to revise your preferences for care if your situation or your health changes. Or, you might want to make adjustments if you receive a serious diagnosis; if you get married, separated, or divorced; if your spouse dies; or if something happens to your proxy or alternate. If your preferences change, you will want to make sure your doctor, proxy, and family know about them.

Talking About Your Wishes

It can be helpful to have conversations with the people close to you about how you want to be cared for in a medical emergency or at the end of life. These talks can help you think through the wishes you want to put in your advance directive.

It's especially helpful to talk about your thoughts, beliefs, and values with your healthcare proxy. This will help prepare him or her to make medical decisions that best reflect your values.

After you have completed your advance directive, talk about your decisions with your healthcare proxy, loved ones, and your doctor to explain what you have decided. This way, they are not surprised by your wishes if there is an emergency.

Another way to convey your wishes is to make a video of yourself talking about them. This lets you express your wishes in your own words. Videos do not replace an advance directive, but they can be helpful for your healthcare proxy and your loved ones.

Be Prepared

What happens if you have no advance directive or have made no plans and you become unable to speak for yourself? In such cases, the state where you live will assign someone to make medical decisions on your behalf. This will probably be your spouse, your parents if they are available, or your children if they are adults. If you have no family members, the state will choose someone to represent your best interests.

Always remember: an advance directive is only used if you are in danger of dying and need certain emergency or special measures to keep you alive, but you are not able to make those decisions on your own. An advance directive allows you to make your wishes about medical treatment known.

It is difficult to predict the future with certainty. You may never face a medical situation where you are unable to speak for yourself and make your wishes known. But having an advance directive may give you and those close to you some peace of mind.

Advance Directive Wallet Card

You might want to make a card to carry in your wallet indicating that you have an advance directive and where it is kept. Here is an example of the wallet card offered by the American Hospital Association. You might want to print this to fill out and carry with you. A PDF can be found online(PDF, 40 KB).

Read about this topic in Spanish. Lea sobre este tema en español.

For More Information About Healthcare Directives

National Hospice and Palliative Care Organization
1-800-658-8898 (toll-free)

Center for Practical Bioethics
1-800-344-3829 (toll-free)
Health Resources & Services Administration

National POLST Paradigm

Put It In Writing
American Hospital Association

Content reviewed: January 15, 2018 

Soft Drinks and Disease

Soft drinks are the beverage of choice for millions of Americans, but sugary drinks increase the risk of type 2 diabetes, heart disease, and other chronic conditions.

·       People who consume sugary drinks regularly—1 to 2 cans a day or more—have a 26% greater risk of developing type 2 diabetes than people who rarely have such drinks. (46)

·       A study that followed 40,000 men for two decades found that those who averaged one can of a sugary beverage per day had a 20% higher risk of having a heart attack or dying from a heart attack than men who rarely consumed sugary drinks. (47) A related study in women found a similar sugary beverage–heart disease link. (48)

·       A 22-year-long study of 80,000 women found that those who consumed a can a day of sugary drink had a 75% higher risk of gout than women who rarely had such drinks. (49) Researchers found a similarly-elevated risk in men. (50)

·       Dr. Frank Hu, Professor of Nutrition and Epidemiology at Harvard School of Public Health, recently made a strong case that there is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases. (51)

Soft drinks and diabetes

Strong evidence indicates that sugar-sweetened soft drinks contribute to the development of diabetes. The Nurses’ Health Study explored this connection by following the health of more than 90,000 women for eight years. The nurses who said they had one or more servings a day of a sugar-sweetened soft drink or fruit punch were twice as likely to have developed type 2 diabetes during the study than those who rarely had these beverages. (52) Learn more about diabetes.


A similar increase in risk of diabetes with increasing soft drink and fruit drink consumption was seen recently in the Black Women’s Health Study, an ongoing long-term study of nearly 60,000 African-American women from all parts of the United States. (53) Interestingly, the increased risk with soft drinks was tightly linked to increased weight.

In the Framingham Heart Study, men and women who had one or more soft drinks a day were 25 percent more likely to have developed trouble managing blood sugar and nearly 50 percent more likely to have developed metabolic syndrome.

Soft drinks and heart disease

The Nurses’ Health Study, which tracked the health of nearly 90,000 women over two decades, found that women who drank more than two servings of sugary beverage each day had a 40 percent higher risk of heart attacks or death from heart disease than women who rarely drank sugary beverages. (48)

People who drink a lot of sugary drinks often tend to weigh more—and eat less healthfully—than people who don’t drink sugary drinks, and the volunteers in the Nurses’ Health Study were no exception. But researchers accounted for differences in diet quality, energy intake, and weight among the study volunteers. They found that having an otherwise healthy diet, or being at a healthy weight, only slightly diminished the risk associated with drinking sugary beverages.

This suggests that weighing too much, or simply eating too many calories, may only partly explain the relationship between sugary drinks and heart disease. Some risk may also be attributed to the metabolic effects of fructose from the sugar or HFCS used to sweeten these beverages.

The adverse effects of the high glycemic load from these beverages on blood glucose, cholesterol fractions, and inflammatory factors probably also contribute to the higher risk of heart disease.  Read more about blood sugar and glycemic load.

Soft drinks and bones

·       Soda may pose a unique challenge to healthy bones.

·       Soda contains high levels of phosphate.

·       Consuming more phosphate than calcium can have a deleterious effect on bone health. (54)

·       Getting enough calcium is extremely important during childhood and adolescence, when bones are being built.

·       Soft drinks are generally devoid of calcium and other healthful nutrients, yet they are actively marketed to young age groups.

·       Milk is a good source of calcium and protein, and also provides vitamin D, vitamin B6, vitamin B12, and other micronutrients.

·       There is an inverse pattern between soft drink consumption and milk consumption – when one goes up, the other goes down. (41)

5 Quick tips: Building strong bones

1. Look beyond the dairy aisle.

You can get calcium from sources besides dairy foods. Calcium-rich non-dairy foods include leafy green vegetables and broccoli, both of which are also great sources of vitamin K, another key nutrient for bone health. Beans and tofu can also supply calcium.

2. Get your vitamin D.

Vitamin D plays a key role along with calcium in boosting bone health. Look for a multivitamin that supplies 1,000 IU of vitamin D per day. If your multi only has 400 IU of vitamin D, consider taking an extra supplement to get you up to 1,000 IU or 2,000 IU per day. Some people may need 3,000 or 4,000 IU per day for adequate blood levels, particularly if they have darker skin, spend winters in the northern U.S., or have little exposure to direct sunlight. If you fall into these groups, ask your physician to order a blood test for vitamin D.

3. Get active.

Regular exercise, especially weight-bearing exercise such as walking or jogging, is an essential part of building and maintaining strong bones.

4. Be careful about getting too much retinol (vitamin A).

Don’t go overboard on fortified milk, energy bars, and breakfast cereals, all of which can be high in bone-weakening vitamin A. Many multivitamin makers have removed much or all retinol and replaced it with beta-carotene, which does not harm bones.

5. Help your kids build strong bones.

Youth and young adulthood is the period when bones build up to their peak strength. Helping youth lead a bone-healthy lifestyle—with exercise, adequate calcium, and adequate vitamin D—can help them keep strong bones through all their adult years.


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47. de Koning L, Malik VS, Kellogg MD, Rimm EB, Willett WC, Hu FB. Sweetened beverage consumption, incident coronary heart disease, and biomarkers of risk in men. Circulation. 2012;125:1735-41, S1.
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49. Choi HK, Willett W, Curhan G. Fructose-rich beverages and risk of gout in women. JAMA. 2010;304:2270-8.
50. Choi HK, Curhan G. Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study. BMJ. 2008;336:309-12.
51. Hu FB. Resolved: there is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases. Obes Rev. 2013;14:606-19.
52. Schulze MB, Manson JE, Ludwig DS, et al. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. JAMA. 2004;292:927-34.
53. Palmer JR, Boggs DA, Krishnan S, Hu FB, Singer M, Rosenberg L. Sugar-sweetened beverages and incidence of type 2 diabetes mellitus in African American women. Arch Intern Med. 2008;168:1487-92.
54. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr. 2006;84:274-88.

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