ARBITER 6-HALTS (Big win for Niaspan + Statin Combination)

The American Heart Association’s 2009 Scientific Sessions released the results of the Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol 6: HDL and LDL Treatment Strategies in Atherosclerosis (ARBITER 6-HALTs) trial earlier this week. And now medical office phones are ringing. Patients are asking, should I stay on my current cholesterol lowering medication or should I go on Niaspan?

This study consisted of 363 participants who were on statin (90% were on Lipitor (Atorvastatin) and Zocor (Simvastatin))medications for at least 3 months prior to enrollment into the study. The mean statin dosage was 42 mg. These participants were then divided in half. One group received Ezetimibe (Zetia) 10 mg daily while the other half received Niaspan 2000 mg daily (titrated up over 2 months ).

All participants had the following:

-LDL (bad) Cholesterol less than 100 mg/dL

-HDL (good) Cholesterol less than 50 mg/dL

-Known vascular or coronary disease risk equivalents

Baseline Statistics of both groups:

Mean LDL 84mg/dL and Mean HDL 43mg/dL (Ezetimibe group)

Mean LDL 81mg/dL and Mean HDL 42mg/dL (Niacin group)

After 14 months of treatment – the results:

Mean LDL decreased from 84 mg/dL to 66 mg/dL ; HDL decreased from 43 mg/dL to 40 mg/dL; Triglycerides decreased by 7% in Ezetimibe (Zetia) group.

Mean LDL decreased from 81 mg/dL to 71 mg/dL; HDL increased from 42 mg/dL to 50 mg/dL; Triglycerides decreased by 21%: in the Niacin arm.

Primary Endpoint:

Carotid Intima Media Thickness :

-Niaspan (Niacin) arm Statistically significant regression

-Ezetimibe (Zetia) arm Did not have significant regression but did stop progression

Secondary Endpoints Include:

Coronary Heart Disease (CHD) Death, MI(Heart Attack), Coronary Revascularization (heart stent or balloon to open artery or open heart surgery), Unstable Angina (unstable chest pain)

Ezetimibe (Zetia) group had 9 of the secondary endpoint events out of 165 participants. This is 5.5% in the 14 months of the trial.

Niacin group had 2 of the primary endpoint events out of 169 participants. This is 1.2% in the 14 months of the trial.

Dr. James O’Keefe, Cardiologist at the Mid-America Heart Institute in Kansas City, reports “This is a big win for the Niacin + Statin combination treatment. We have had other randomized studies such as HATS and FATS, both of which are smaller studies like ARBITER 6, which although not powered to show event reduction, did find significantly better cardiovascular outcomes with niacin”.

I was able to attend the meeting at the AHA Session earlier this week. The presenter and lead investigator, Dr. Allen Taylor, from Medstar Research Institute, Washington, DC, reported that in 2008 there were 9 million U.S. patients receiving treatment with Zetia and 2.5 million U.S. patients receiving treatment with Niacin. Although niacin isn’t an easy drug to use, due to its’ flushing side effect we should make strong efforts to help our patients tolerate this medication. Over time the flushing becomes less often, less intense and less in duration. In one Niaspan study, participants who took the medication for 6 months had approximately 2 flushes per month. Dr. James O’Keefe reports, “patients should avoid sustained release over the counter (OTC) niacin products, as they are more hepatotoxic (toxic to liver) than the immediate release (IR) OTC niacin or prescription, Niaspan. “

In summary, if you are taking cholesterol medications we recommend you do not stop your medications without speaking with your health care provider. If you are taking an over the counter niacin product make sure it is an immediate release niacin or we recommend taking prescription form Niaspan-which is often more tolerable. “In our experience, which is supported by this recent study, the combination of niacin with a statin such as Simvastatin (Zocor), Rosuvastatin (Crestor), Atorvastatin (Lipitor) is a great way to go both for buffing the cholesterol numbers and improving cardiovascular prognosis,” Dr. James O’Keefe.

Coronary Artery Calcium Scan

Coronary artery calcium scan is a simple 15 minute, non-invasive heart test that will assist in determining if one has coronary heart disease (plaque in coronary arteries). Coronary artery calcium (CAC) measures “hard” calcified plaque in heart arteries. This scan does not pick up soft plaque that may have formed in coronary arteries. As coronary plaque builds up, so does the threat of heart events. Arteries become more narrowed and blood has a hard time squeezing through; thus, increasing your risk for severe cardiac events (heart attack).

The Multi-Ethnic of Atherosclerosis (MESA) enrolled 6814 asymptomatic patients, of whom over half, 3563, had zero CAC score at baseline (no hard plaque found in coronary arteries). Study participants who went on to have heart catheterization (invasive procedure that visualizes inside heart arteries) due to symptoms, clinical indications, result of the coronary calcium score, abnormal stress test or preoperative risk stratification included 175 of them. In 96% of these cases, the documented baseline calcium score predicted the actual severity or extent of the obstructed coronary artery disease as found per heart catheterization. But, in the remaining 4% there was significant narrowing of heart arteries from soft plaques found via heart catheterization-despite a zero CAC score.

In symptomatic (chest pain or equivalent) or in suspected coronary artery disease (CAD) patients in the Emergency Room-a zero CAC score has a 96% negative predictive value, meaning that 4% of patients with a zero calcium score will have significant CAD, due to soft plaque. People who present with chest pain or equivalent or who are suspected of having CAD, generally need to have functional imaging (stress MPI, stress ECHO, etc.) rather than a screening calcium score.

In asymptomatic (having no symptoms) patients; but, at risk for heart disease, the CAC scan is an excellent choice. As, the main purpose for CAC scoring should be to detect early subclinical stages (before symptoms) of CAD for which specificity is virtually 100% (people w/o significant CAD will not have calcium in their vessels.)

Dr. Harvey Hecht from Lenox Hill Heart and Vascular Institute in New York, New York was quoted: “A strong argument can now be made for requiring coronary calcium screening before stress testing in asymptomatic patients. Also, less aggressive drug therapy is appropriate for zero-score patients, and at the other end of the spectrum, the presence of coronary calcium identifies the higher risk pool of patients in whom 95% to 96% of the events will emerge; it is this group that will benefit from highly targeted aggressive treatment.”

To wrap this up, if patients present to the emergency room with chest pain symptoms a functional imaging study should be recommended versus a coronary artery calcium scan. In asymptomatic patients screening for early signs of heart disease a coronary artery calcium scan would be an excellent choice. Remember, early detection is the key to preventing heart events.

Hospitalization for Heart Disease on the Decline!

The U.S. Agency for Health Care Research and Quality reported hospitalizations for coronary heart disease (blocked heart arteries) has decreased by 31% from 1997-2007. Additionally, hospitalizations for a heart attack decreased by 15%. No longer is hospital stay for coronary heart disease (blocked heart arteries) the No 1 disease treated in hospitals. It now trails behind pneumonia and heart failure (when your heart isn’t pumping efficiently).

The report included other noteworthy facts.

• Congestive heart failure rates were unchanged between 1997-2007.
• Admissions for irregular heartbeat were up 28% between 1997-2007.
• Heart catheterization (invasive procedure to assess heart arteries) is the second most common procedure among hospitalized men, and the fourth most common in women.
• Although hospital stays for blocked arteries have significantly decreased circulatory conditions (combining: congestive heart failure, heart attack, blocked arteries, and irregular heartbeat) were the most frequent major cause of hospital stays in 2007.
• High Blood Pressure was a co morbid condition (existing simultaneously with and usually independently of another medical condition) in 35% of all hospital stays in 2007.
• When pregnancy and child birth stays were excluded, women still accounted for more hospital stays (59%) than males (41%) in 2007.

We should applaud ourselves for taking better care of our hearts. However, we still have a lot of work to do. Heart disease is still the leading cause of death for both men and women in the United States. Stroke remains the third leading cause of death in the United States. If you haven’t had your heart risk assessment call your local Health Care Provider or visit your local Cardio Wellness Center to do so. Many with heart disease-their first symptom is their last. Don’t let this be you. Most of heart disease can be prevented.

One last note- heart failure hospital stays have not declined since 1997 and stroke remains our 3^rd leading cause death in the United States. High Blood Pressure is often present before heart failure and/or strokes occur. Know your blood pressure number and manage it. One in three of us have high blood pressure….do you know your pressure?

Levit, K., et al. HCUP Facts and Figures: Statistics on Hospital-based Care in the United States, 2007. Agency for Healthcare Research and quality 2009.

Feel Better Now

-Sometimes we all get stuck in a rut. With the changing of the seasons now is a good time to change ourselves for the better. Check out these four key topics to better yourself.

Nutrition

Have lean protein & two colors at each of your meals.

Lean protein – healthy nuts, fish, chicken, turkey, edamame, all natural peanut butter

Two colors- fruits and vegetables

Bread- if you must have it, look for fiber content of 5 grams per slice. Remember each slice is 80-100 calories, bread raises blood sugar and contributes to weight gain.

Artificial Sweeteners- Avoid. They make you crave carbs and sugars. Since they have been developed the world has not gotten smaller.

Omega 3 Fish Oils- Helps to promote healthy cells in your body.

Improve Work/Life Balance

Rest/Reflection- schedule in rest and thinking time for yourself. Write it on the calendar.

Keep Connected- initiate daily communication with a relative or friend. Keeps you interested and aware of others.

Compliment- Compliment others on their good deeds, accomplishments, and/or good qualities every day.

Listen To Your Heart- if you want something, pursue it.

Exercise

Get Moving- be active throughout your day. Park farther away, take the stairs, walk the long way around….just because you can.

Half-hour power- walk, cycle, swim, hike 30 minutes everyday

Weights- in addition to aerobic activities, weight train to maintain bone density and add muscle strength.

Sleep Better

Caffeine – avoid caffeine and sugary snacks 12 hours before going to bed. They can cause lots of dreams and restless sleep.

Relax- take a 10-15 minute stroll prior to hitting the sack or take a hot bath

Adequate amount- try to get 7-9 hours of sleep each night.

FDA Approves New Medication to Reduce the Risk of Heart Attack in Angioplasty Patients

The U.S. Food and Drug Administration approved Effient (Prasugrel) in July 2009. Effient is approved to reduce the risk of blood clots from forming in patients who undergo angioplasty. It is a blood thinning drug that prevents platelets from clumping or sticking together, which can result in clogged arteries and may lead to heart attack or stroke.

A study enrolling 13,608 patients which compared Effient to another blood thinning medication, Plavix (Clopidogrel) was completed. These patients presented with a heart attack or threatened heart attack and were about to undergo angioplasty, a procedure where a balloon is used to open the artery that has been narrowed.

Effient is more efficacious than Clopidogrel in preventing deaths from blood clots, non-fatal heart attacks and nonfatal strokes in patients receiving stents. However, those receiving Effient had a greater risk of bleeding than those taking Clopidogrel. Patients who have a history of stroke were more likely to have another stroke while taking Effient.

Effient appears to be an excellent alternative treatment for preventing dangerous blood clots from forming and causing a heart attack in those patients who present with a heart attack and are in need of stenting.

However, it is recommended to not use Effient in those patients who have active pathological bleeding, history of transient ischemic attacks (TIAs) or strokes. Effient should not be used in patients who are in urgent need for surgery-including open heart surgery. Due to the fact, that when possible, patients should discontinue Effient at least 7 days prior to any surgery (as directed by a physician). In general, patients who are 75 years of age or older it is not recommended to use Effient because of increased risk of fatal and intracranial bleeding and uncertain benefit.

As with any treatment, physicians and patients must carefully analyze the potential benefits and risks associated with the use of Effient – as each individualized case is unique.

How Simple Modifications Can Add Longevity to Your Life

This was done a couple of years ago. I’m not very good at the interview/video thing…but the story told here is wonderful. I do not believe I have seen higher Triglycerides than this.

UltraViolet Rays and Sunscreens

Did you know the sun produces 3 types of ultraviolet (UV) Rays? There are UVA, UVB, and UVC rays. The atmosphere completely absorbs the UVC rays. However, both the UVA and UVB rays reach our bodies…but they have a different effect on us.

UVA rays are known to cause wrinkles and at high doses may be the cause of skin cancer-melanoma. UVA radiation does not have the ability to enable us to produce vitamin D. UVB radiation, however, is responsible for sunburns and vitamin D production. Since, UVB radiation can cause sunburns if in the sun too long-UVB radiation may also be part of the cause of skin cancer-melanoma. This is due to the fact that when we develop a sunburn we cause mutation to the skin cells. These skin cells replicate in a mutated state until later they appear in the form of skin cancer. Thus, the key is not to burn.

Sunscreens were first used in the 1940s. What I have found most interesting is up until the late 1990s these sunscreens only blocked UVB radiation (the UV rays that cause sunburns). These sunscreens did not protect against UVA radiation; as they were not thought to be harmful rays, since they did not cause sunburns. Thus, allowing us to absorb mega doses of UVA radiation that we would not normally be able to stay out in the sun and absorb.

Perhaps, this gives us some insight as to why melanoma rates have been increasing by 2% every year over the past thirty years. We now know, UVA radiation at high doses is thought to be one of the causes of skin cancer- melanoma. Therefore, UVB protection only sunscreens have been phased out and broad spectrum sunscreens were developed. This occurred in the late 1990s. These broad-spectrum sunscreens protect us against both UVB and UVA radiation.

Dr. Holick, our nation’s leading expert on vitamin D, completed studies involving sunscreens. His data demonstrates: sunscreens with a SPF 8, reduces vitamin D production by 97.5% and SPF 15, reduces it by 99.9%. Therefore, sunscreens almost completely prevent the body from making any vitamin D from the sun. The point to remember is that it is okay to get “raw” exposure to the sun- 10-15 minutes 2-3 times per week. The key is not to burn. After about 10-15 minutes of “raw” exposure to the sun you should utilize a broad-spectrum sunscreen to protect against having a sunburn.

Lastly, I often get asked, “Can I get a sunburn or UVB radiation from sunshine that warms the skin through a window?” No. UVB radiation from sunlight does not penetrate through glass. Thus, you will not burn and your body will not make vitamin D from sunshine through a window.

So go out in the sun responsibly. Do not burn. Use broad-spectrum sunscreens if you plan to be out in the sun longer than 10-15 minutes to prevent sunburn. Use common sense. Sunshine is not to be feared. Sunlight is the fuel that enables us to manufacture vitamin D. The benefits of vitamin D on human health are many, varied and profound. Just as with oxygen, air, water, our bodies need sunshine. Use it responsibly.

FDA Approves Triple-Drug Polypill for the Treatment of Hypertension

Do you have high blood pressure? Tired of taking multiple pills to lower your blood pressure? This just might be your solution. The FDA has approved a triple-drug polypill for the treatment of hypertension (high blood pressure). The polypill, called Exforge HCT contains the calcium channel blocker amlodipine (Norvasc), the diuretic hydrocholorothiazide (HCTZ) and the angiotensin receptor blocker valsartan (Diovan). This is the only single tablet that combines three drugs for treatment of high blood pressure in the United States. This drug may be used as add-on/switch therapy for individuals not adequately controlled on any two components of the triple combination.

There have been several studies demonstrating, the less pills one takes the more compliant they are. Three drugs that treat hypertension being contained in one pill should assist us in becoming more compliant in taking our blood pressure lowering medications. The tablet comes in the following dosages:

Tablets: (amlodipine/valsartan/hydrochlorothiazide mg)

5/160/12.5

10/160/12.5

5/160/25

10/160/25

10/320/25

If you are taking these three pills separately; you should consult with your health care provider to see about the possibility of changing over to the polypill. You may find that you miss fewer dosages, becoming more compliant with taking your medications. By doing so will allow for better management of your blood pressure and your health.

High Blood Pressure: Do You Know Your Pressure?

Many patients who come to the office have high blood pressure. What is alarming is they find excuses for the cause of their high blood pressure. Examples include:

• I was running late
• I walked in from the parking garage
• I didn’t sit long before my blood pressure was taken
• I had a disturbing phone call
• I ate at a restaurant last evening
• I had a busy day at work
• I had a hectic schedule
• I am under more stress than usual today

Sound familiar?

So many people do not believe they have high blood pressure, even when they come to the office and see their blood pressure is elevated. The other side of the coin is when we treat patients with high blood pressure; patient’s often think it is a disease that can be cured and once their blood pressure is controlled they stop their medications or reduce their current dosage of the medication. Yes, if one is overweight and sedentary they can lower blood pressure by weight loss, decreasing sodium in their diet and exercise—but it is a condition to be managed. For the most part however, once one is on a blood pressure lowering medication you are most likely going to need to stay on the medication.

The facts regarding high blood pressure are: 1 in 3 adult Americans has high blood pressure. Data from the Framingham Heart Study suggest persons 55 y.o. and older have a 90% risk of developing high blood pressure during their lifetime. High blood pressure is associated with:

• 69% of first heart attacks
• 74% of heart failure cases
• 77% of first strokes

In order to prevent these events we must monitor our blood pressures at home and discuss options with our health care provider if our blood pressure is consistently greater than 130/80. As health care consumers, we must know our own blood pressure numbers and seek help if our blood pressure is elevated in order to optimize our health.

So…do you know your numbers?

Top 3 Questions providers ask me about Vitamin D

What lab test do you order to assess Vitamin D levels?

The best lab test to assess Vitamin D levels is the “25 OH Vitamin D Level” test.

What Vitamin D level is considered deficient?

Ideal blood level: 40-70 ng/mL

Sufficient blood level: 30 ng/mL

Insufficient blood level: 21-29 ng/mL

Deficient blood level: 10-20 ng/mL

Severly deficient blood level: 0-10 ng/mL

How do you treat patients with Vitamin D levels considered less than optimal?

21-29 ng/mL: Recommend 50,000 IU of Vitamin D2 (Once per week for four months)

Less than 20 ng/mL: Recomment 50,000 IU of Vitamin D2 (Twice per week for four months)

I would also advise patients to maintain a daily dosage (over the counter) of 2,000 IU to 5,000 IU of Vitmain D3. Three months after beginning treatment, I would check up on my patient’s 25 OH Vitamin D level.

Stent Patients Advisory: Switch Heartburn Drugs

WARNING

Anyone taking the clot-preventing drug Clopidogrel (Plavix) after receiving a stent in a coronary artery opening procedure should avoid a type of popular heartburn medications called proton pump inhibitors (PPIs).

PPIs include medications such as Nexium, Prevacid, Protonix, Aciphex and Prilosec.

The Clopidogrel (Plavix) Medco Outcomes Study was recently presented at the Society for Cardiovascular Angiography and Interventions (SCAI)’s annual scientific sessions.

The study reported patients taking both Plavix and PPIs experienced a 50% increase in the combined risk of hospitalization for heart attack, stroke, unstable angina (chest pain), or repeat revascularization. A more in depth review demonstrates patients who received a PPI had a 70% increase in the risk of heart attack or unstable angina; 48% increase risk of stroke or stroke-like symptoms’ and a 35% increase in the need for a repeat coronary procedure.

This study followed 16,690 patients taking Plavix for a full year following coronary stenting. The patients in the study were taking PPIs – Protonix, Nexium, Prilosec, and Prevacid for an average of nine months post stenting. This trial did not look at outcomes in patients on newer PPIs such as Aciphex or Kapidex. The experts report that PPIs decrease the efficacy of Plavix secondary to decreased absorption as compared to the population of patients who used Plavix alone.

Patients who receive a stent are prescribed Plavix to prevent clots from developing. Plavix does increase the risk of bleeding and GI upset; therefore, many providers have routinely given PPIs to patients taking Plavix to prevent gastrointestinal side effects.

The SCAI now suggest providers who are treating post stenting patients on Plavix therapy to consider prescribing histaminergic (H2) blockers such as Zantac or Tagament or antacids instead of a PPIs due to the high risk for adverse events with Plavix and PPI combination as demonstrated in this recent study.

If you are currently taking Plavix and a PPI, I would encourage you to discuss this combination with your health care provider. Perhaps a H2Blocker would be a better treatment for you.

From Sun Worshipers to Sun Phobes

What happened? One minute we are worshipping the sun, building solariums in our hospitals, gagging down cod liver oil, baking in the sun, and now in the 21st Century we have frightened ourselves out of the daylight. Why is that?

Well, unfortunately, over the past 20 years the relationship between sunlight and skin cancer has been blown out of proportion. AND as per our typical American tradition, we go to extremes when it comes to our health. So from Sun Worshipers to Sun Phobes we went. Wearing long sleeves, long pants, floppy hats, and slathering every inch of our bodies with sunscreen every time we go out in the sun. The cosmetic arena of the pharmaceutical industry helped us in our beliefs, too, as the once anti-sunburn cream turned into the new cancer prevention cream.
So let’s discuss sunburns. A sunburn is much different than a tan. The redness of a sunburn is caused from increased blood flow to the skin so that it can attend to cells that have been damaged by the sun. When damaged enough squamous and basal cells in the skin cannot repair themselves so they die off so they won’t replicate in a mutated state and cause cancers. Severely damaged melanocytes stay alive however. These cells replicate in a mutated way and present themselves later in life as cancer-melanoma. So the key here is not to not go into the sun; but, to go into the sun…just don’t burn.

Let’s look at the Skin Cancer facts (The UV Advantage 2003- Authors Holick and Jenkins)

Non-melanoma- caused by long term sun exposure

• Fewer than ½ of 1% die
• Claims 1200 lives annually

Melanoma-seen more often in people who do NOT receive regular sun exposure

• Comprises 10% of all skin cancers
• 85% of skin cancer deaths
• Kills 7,000 annually

With those facts we need to be cautious about going into the sun and not burn. But, let’s compare the sun risk with diseases that can be prevented by regular sun exposure:

• Colon, Breast Cancers 20-65% mortality rate
• Kills 138,000 annually.
• Osteoporosis affects 25 million Americans.

And every year 1.5 million people with osteoporosis suffer broken bones which can be fatal when the person is elderly.

(Yes, sun exposure reduces the risk of these cancers and osteoporosis)
The risk of sun exposure pales in comparison to the sun’s benefits. Sun exposure can not only result in fewer cases of internal cancers (breast, ovaries, colon, prostate, stomach to name a few) but can reduce fractures from osteoporosis, reduce rates of depression associated with seasonal affective disorder as well.

Look at the maps (above this post). Look where most of the Colon and Breast Cancers are located (red states)…in states with less sun exposure…states away from the equator.

With all the advances we have made in medicine over the past 20 years it is disturbing to know that Vitamin D deficiency and its’ disease states are once again on the rise in the United States. Yes, rickets (weakening of bone in children) and osteomalacia (vague aches, pains and weakening of bones in adults) are back on the rise.

What about fibromyalgia? Let’s shed some light on Fibromyalgia. Is it Fibromyalgia or is it really Osteomalacia? Fibromyalgia was basically unknown until about 15-20 years ago. Fibromyalgia symptoms are muscle pain and weakness. The condition is usually diagnosed when providers can’t find anything else to explain the vague muscle and bone aches. There is no specific test to confirm a fibromyalgia diagnosis. Guess what folks? Check your Vitamin D levels. Dr. Holick reported that between 40-60% of people who came to his clinic with fibromyalgia actually had Osteomalacia due to Vitamin D deficiency. There’s a lot to be learned from this. We all should get about 10-15 minutes of raw exposure to the sun two to three times per week. The key is not to burn. In cities north of Atlanta from November to February the sun’s rays are not strong enough to give us Vitamin D. Therefore, it is important for us to get adequate supplements during these months. I recommend the CardioDaily multivitamin as it is the only multivitamin I know that has 2000 IU of Vitamin D in it.

Most people ask what foods can we get Vitamin D from. An 8 ounce glass of Vitamin D fortified milk is suppose to contain 100 iu of Vitamin D. However, in studies most so-called Vitamin D fortified milks contained less than 20% the amount listed on the label. Although, milk, eggs, and salmon contain Vitamin D, they are in amounts too small to maintain adequate levels for our bodies. So in the winter months here in Kansas City (or any city north of Atlanta for that matter), make sure you take your CardioDaily. If you haven’t had your Vitamin D level checked you might want to have this done…you just might be surprised.

Questions you might have:
Do I advocate Tanning? Not true. I would advocate common sense when it comes to being in the sun.
Do I lie out in the sun for hours w/o protection? Not True.
Do I go out in strong sunshine w/o sunscreen on and does my skin get tanned? Yes. Why? I recognize my body needs a certain amount of sun exposure to be healthy.
Do I put sunscreen on after a certain amount of time? Yes. Why? I understand there are risks as well as benefits with being in the sun

Becky K. Captain, RN, MSN, CLS, BC, FNP-C
Nurse Practitioner

Exercise for Life

Exercise is your insurance policy. It doesn’t have to cost you any money AND it will give you more time on the clock of life. As an added bonus, exercise will add quality to your life. Close your eyes and picture yourself 10 years from now with your overweight, tired, low self -esteem body lying on a hospital bed with a heart monitor and a nurse constantly checking your blood pressure, blood sugar and heart rate. Your worried family is by your bedside. Open your eyes. Scary, huh? Now close your eyes and picture yourself and family on a sandy beach or out in nature with all the energy you never imagined possible due to the reconditioned body you have carved. Feels good. Doesn’t it? All of us have the ability to change our mindset and choose a different future, or a different past. Becoming fit doesn’t take years—you’ll see the benefit of exercise within a few weeks.

Does the following sound familiar? You know you’ve got to start exercising and you vow to park the car in the furthest parking space, hit the gym after work, sign up for an exercise class, and take the stairs.

But a week passes and before you know it, parking spots are opening up right in front of the stores and buildings, the elevator is already in the lobby and you’ve had an intense week of juggling work, kids and deadlines. How could you have ever thought you could fit in exercise when you have 100 things to do (including your bone density test)? Really, what were you thinking? You still have to organize the sock drawer and Tupperware cabinets. How can you exercise with those items in such chaos?

Been there? Many of us have.

So why does exercise seem so wonderful until we actually have to do it? Lack of motivation? OR is it a misunderstanding that leads us to believe motivation is something that will come to us if we wait long enough…that someday we’ll wake up and finally want to exercise. We must stop living in that fantasy. The reality of motivation—it is something we create—not something we wait for. So, stop waiting for the motivation to come to you—just do it! Make it happen today!

Here are six ways to create your motivation.

1. Don’t Count the Calories Burned
One of the ways to keep exercising is not counting the calories burned or weight lost. There are more important things transforming in your workout, such as new-found self-esteem, stress reduction, increased endorphin levels (happy hormone), improving memory and cognition and adding longevity to your life, to name a few.

2. Be Accountable
Hold yourself accountable. Mark an “X” on your calendar every time you exercise. Seeing your motivation (or lack thereof) in black and white helps to keep you focused on your goal.

3. Join Up!
Join a club, exercise class, or exercise with a buddy or a dog. Statistics tell us that we are more consistent with exercise when we do it with a companion. Just knowing someone is waiting for you to exercise helps you to show up and get it done.

4. Challenge Yourself
Sign up for a local 5K walk/run or bike trip. It will help you stay focused on your exercise goal while accomplishing a new activity. Not only will you benefit from the exercise; but, from your community involvement too.

5. Reward Yourself
Put a dollar or two in the jar every time you complete a workout. When you have enough money, treat yourself to a massage, new CD, workout outfit, session with a personal trainer, or new piece of sport/exercise equipment.

6. Motivate Your Mood
Often people will say it’s my mood that either motivates me to exercise or not. Regardless of your mood prior to exercise—exercise has been known to improve your mood. Work out your aggressions in the gym instead of at home or work. The only obligation in any lifetime is to be true to yourself. So, ask yourself what the secret to YOUR success is. Listen to your answer. Then practice it. See you at the gym or out on the sidewalks and trails!