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Health care reform’s impact on Medicare




Break the habit What works (and what doesn’t) when it comes to quitting smoking By Will Dendis


he American cigarette smoker in 2010 lives in a hostile world. Every year, a new study links smoking to another disease or cancer. Evidence of the ill health effects of personal tobacco use and secondhand smoke have been accumulating for a few decades now, and it’s safe to say at this point no smoker is ignorant of them. It seems every time the state needs to close a budget gap, legislators increase taxes on cigarettes. New York State collects $4.35 on every pack (20 cigarettes), with average price of a pack now $9.20. What was once a highly social habit has been increasingly squeezed out of the public sphere by smoking bans.Today, smokers may smoke in a personal vehicle (though it will diminish its resale value significantly), in the open air (but not in a park or within 50 feet of a public building) and in their home (good luck finding a smoker-friendly landlord). In 1998 the satirical newspaper The Onion made light of smoking bans with an article headlined, “Smoking Now Permitted Only In Special Room In Iowa.” Twelve years later it doesn’t seem as far-fetched. And in what has been perhaps the greatest blow to their once glamorous image, cigarettes, once the great unisex accessory, the oral

fixation that didn’t make you fat, instrumental in countless couplings through the small gift of a light or spare cig in exchange for a few minutes of conversation, has been linked to impotence! The American cigarette smoker in 2010 wants to quit, and has probably tried before, maybe even succeeded for a few months (or years) before relapsing. But those failed attempts, combined with constant reminders of health risks and increasing outsider status, tend to create a feeling of inferiority and powerlessness. Helping people quit smoking is no longer just about raising awareness of physical damage. Successful smoking cessation methods address both the physiological portion of quitting smoking (experienced in withdrawal) and behavioral triggers — the hundreds of little ways a smoker has integrated the cigarette into daily rituals.

Triggers: identify and replace A common mistake, believes James Kreitner, a physician’s assistant at Kingston Hospital, is to expect nicotine replacement products to take away [Continued on page 2]

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Break the habit [Continued from page one]

the cravings. The patch and the gum do have a role to play, but it’s entirely chemical. The symptoms of tobacco withdrawal, which include irritability, trouble sleeping, head and stomach ache, are, Kreitner said, “really the result of brain chemistry changing. [Nicotine] maintains higher levels of certain neurotransmitters that stimulate the pleasure centers of the brain. So when one abruptly quits smoking and there’s nothing to support those elevated levels, specifically of dopamine, the dopamine levels start coming back down to normal. The brain resetting its chemistry back down to normal means you get withdrawal symptoms.” Nicotine replacement does a good job of mitigating withdrawal symptoms, and the products are easy to use. Harder to grapple with are the triggers. Many smokers share the same ones. “The first one of the day, after a meal, with a cup of coffee, after sex, on the phone, behind the wheel, with friends that smoke, with alcohol,” said Kreitner. “Several of those triggers are like double-edged swords – a cigarette goes really good with a cup of coffee and it turns out that caffeine is a stimulant and it clears the nicotine out of the body more quickly. So not only do you have nicotine withdrawal enhanced by the stimulant in caffeine, but you have the fact that a cup of coffee and a cigarette go well together.” Alcohol is even worse for a smoker making a go at quitting, said Kreitner, because not only do smoking and drinking go well together, its tendency to reduce inhibitions can cause the would-be ex-

smoker to fall off the wagon. Famous last words: “Can I bum a cig?” Once the triggers are identified, they have to be replaced with rituals not associated with smoking. This is a chance to reverse any feelings of fatalism and resignation to poor health that come from a smoking habit. Replace the cigarette with something healthy. Always have a cigarette after a meal? Go for a ten-minute walk, suggests Theresa Miller, director of the Tri-County Cessation Center. Ritualize consumption of fresh fruit and water, always taking time out from whatever’s going on to do so — a huge part of tobacco’s stress-relieving properties comes

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from the “break” not the “smoke.” Always have one with the morning coffee? Have a coffee at work, indoors, where you can’t smoke. Pay for gas at the pump to avoid being confronted with a wall of cigarettes like that in the convenience store. “Consistent with this developing of a new healthy lifestyle, get out there and do healthy things,” said Kreitner. “Get out and take a walk, have healthy snacks, drink lots of water. Start incorporating this whole new healthy lifestyle into your way of being.”

Never too late to stop Some long-term smokers might think it’s too late to quit. While it’s true that the cancers associated with smoking, like all cancers, are caused by cumulative exposure over many years which cannot be undone, smoking is also the number one cause of stroke, heart and vascular disease, and for these conditions, quitting allows the body to begin the process of turning back the clock. Studies have shown that 15 years after quitting, an ex-smoker’s risk of heart disease is similar to a non-smoker. So even someone well into middle age can quit and bring the risk down significantly before the age when these diseases often begin to manifest. The qualifier “often” is important there because of the attitude of many smokers, particularly young ones, which goes something like this: “Smoking is bad, sure, but it won’t catch up with me until I’m in my sixties or seventies, and that’s about the time most people die of something anyway. Might as well be smoking.” “That’s part of the denial that goes on,” said Kreitner. In fact, to a varying degree depending on genetics, smoking impacts one’s health well before that time. In addition to diminished lung capacity, inflamed gums, discolored teeth, and prematurely aged skin, life-long smokers are pretty much guaranteed to develop chronic bronchitis, which means spending a good portion of the golden years hacking up a lung well before the grim reaper arrives. High blood pressure and heart disease often set in decades earlier, and these conditions require constant medication and limit quality of life in very real ways. “Everybody who knows the 70- or 80-year-old who’s still smoking and getting along okay,” said Kreitner. “And that helps promote that whole false thought process.” Like most ailments, the diseases caused by smoking are part environment, part genetic. We can influence the first, we can’t influence the second. And you can’t bet on good genetics just because your grandma was smoking two packs a day at 90.

Professional help There are many smoking cessation classes that provide support and guidance for smokers attempting to quit. Chapters of Nicotine Anonymous, modeled on the successful drug and alcohol programs, can be found throughout the Hudson Valley, as can professional counselors for those who desire a one-on-one approach. Two alternative therapies that have proven successful are hypnotherapy and acupuncture. Frayda Kafka, a Kingston-area hypnotist, has been helping smokers quit for 30 years. To sum up her thinking and method: smoking is an unconscious habit, and hypnotism accesses the unconscious mind and speaks to it in a language it understands; cravings are stimulated by stress (in the broadest sense of the word, all rituals and routines are a

response to stress), and the work of the hypnotist is to replace the desire for a cigarette with a positive thought. Kafka teaches her patients to invoke this themselves with ten-second “self-hypnosis” when a craving manifests, thereby, “reframing” the habit. That’s a word that’s used by hypnotists. Making the unconscious habit conscious and switching that response to something else. “The bottom line is people are smoking for immediate gratification,” said Kafka. “If I can help the individual find something that gives them pleasure just by the very thought of it — something simple like beach, ocean, the name of a grandchild, going fishing — and teach them to repeat that phrase to themselves…” Dr. Peter Lichtenstein, a New Paltz acupuncturist and chiropractor, has developed a five-session, weeklong program designed specifically for smoking cessation. The treatment focuses on the ear. “Auricular acupuncture specifically helps all kinds of anxiety and withdrawal symptoms,” said Lichtenstein. “You’re much calmer, able to deal with the withdrawal. Able to sleep better.” He also uses points in the wrist and leg, and other areas depending on the patient. For instance, if coughing is a problem, the lungs; if indigestion, the stomach. Between sessions, patients are fitted with seeds and/or BBs, held onto the main points with flesh-colored adhesive tape.When a craving strikes, the patient can apply pressure and restimulate the points from the session. Lichtenstein said the treatment alleviates the symptoms of withdrawal by an average of 60 or 70 percent, sometimes more. But it rarely takes away all cravings. That’s why it’s vital the patient has to really want to quit. That’s a common theme with all the people we talked to for this story: the patient has to really want it.Treatments can help smooth out the rough edges, but there is no panacea.

November, 2010 • Page 3

Making it happen Confrontation isn’t recommended for those who would like their friend or loved one to quit. Better to show support if the smoker brings up the idea of quitting — many smokers are forever moving the goal post for their quit date — or sharing information about what methods work. As mentioned above, many smokers become discouraged after numerous attempts to quit, perhaps feeling like the habit was too strong for them when nicotine replacement products failed to kill the cravings. Let them know there’s more to it, and they’re not too weak to succeed. Kreitner, the PA, always brings up the question with patients, and he thinks all health care professionals should. If it’s known a patient smokes and the physician, PA or nurse doesn’t broach the subject, they lend tacit approval to the habit. If Kreitner knows a patient smokes, he might let the individual wait a little longer. His patients can’t help but notice the poster spelling out the 4,000 chemicals and 50 carcinogens in cigarette smoke, and that tends to provoke a conversation. It only takes a minute or two to run through the risks and the basics of smoking cessation, and to refer the patient to the New York State Smokers’ Quitline (1-866-NY-QUITS), which provides a plethora of information on smoking dangers and cessation, counseling for those who need

it, and most importantly, free nicotine replacement products to those who call. Also suggested: pick a date, preferably not before a big stressful event. Let friends and family know, so they can expect some irritability. This also has the effect of locking you into the quit attempt, like the proverbial heroic boast. Don’t shy away from graphic images of lung disease, like the ones used by some foreign countries in antismoking advertisements. The preserved lung of a smoker in the traveling “Body Worlds” exhibit was famous for shocking dozens of smokers into leaving their packs on the plastic display case. Tally the price of smoking and use the money for something good. It costs $3,358 a year to sustain a pack-a-day habit. Finally, brace yourself for battle. “It begins with wanting to make the change, and being willing to pay the price,” said Kreitner. “You may be uncomfortable for a few weeks. You may put on some weight, you may develop a cough, may have headache and agitation and not feel good about your life for a few weeks...[You’ve got] to be willing to do whatever it takes over the next several weeks as you transition into this new healthier lifestyle.And recognizing your triggers and establishing some coping mechanisms are part of a long-term success so that you don’t go back to smoking again.”


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Where the toes meet the turf Stepping correctly is the key to a happy, pain-free life By Dan Barton


onsider the foot. Most of us don’t, really, at least not when we’re young. We expect them to transport us wherever we need to go, and don’t think twice about wearing cheapo flip-flops for months on end or shoes we like the looks of, but offer little in the way of aid and comfort. It’s a very short-sighted way to treat one of the body’s most complex mechanisms. Each foot contains 26 bones, 33 joints, 107 ligaments and 19 muscles. Then, we get a little older or take a bad step, and the importance of taking care of our feet hits us like that all-squashing cartoon foot in Monty Python’s Flying Circus. Like an unexpected kick in the rear or having one’s tires slashed, foot pain is an immediate hobbler, a total jock-blocker to mobility, exercise and good health. According to podiatrist Dr. Doug Tumen of Hudson Valley Foot Associates, having poor foot health can open the door to all kinds of bad things happening. “In our practice … at least 25 percent of our patients are seniors, who say to us, ‘I wish I took better care of my feet when I was younger,’” said Tumen. “One of the things that I always hear from seniors is that ‘I can’t be as active as I used to be because my feet hurt,’” said Tumen. “They slow down, and the old rule is a body in motion tends to stay in motion and a body at rest tends to stay at rest. That applies to your body too, and if your feet don’t have that ability to move, then the rest of your body doesn’t follow.” An interesting statistic, Tumen noted, is that we take about 8,000 to 10,000 steps a day, and those steps, “believe it or not,” cover several miles a day even if one is not “exercise walking,” he said. According to the podiatrist, over the course of an average lifetime, a person will walk about 115,000 miles, which is about four times around the world, or about half the distance from the earth to the moon. “So when you think of it that way, if you’re going to go on a hike around the world, you’d want to have good feet.” Having foot problems can lead to dysfunction in

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Rob Sobel of Sobel Orthotics and Shoes of New Paltz, a board-certified pedorthist who makes custom shoe inserts, called orthotics. “If someone has an amputation [as a result of] their diabetes, their life expectancy is five years,” said Sobel. “The reason is usually ... they’re not going to take care of themselves [if they haven’t before].” An important part of diabetic foot care are diabetic shoes, said Sobel. “Diabetic shoes are a big deal because they’re lined with a material that doesn’t foster bacteria or fungus, and are either seamless or the seams have to be hidden in a way where it doesn’t cause any kind of irritation,” he said. “It’s important for them to get properly fitted for those shoes, not just buy something off the rack. And the nice thing is that they aren’t hideously ugly anymore.” “A large percentage of amputations are on diabetic feet, and I think the statistic is that about 80 percent of them can be avoided with proper education,” said Tumen.

Gotta be the shoes Tumen puts it simply. To have good feet, you have to have great shoes. “We see a lot of people as patients after the summer because they’re wearing flip-flops,” Tumen said. “We live in a concrete world; long-term use of poor shoes absolutely causes breakdown of the arches and wearing away the tread of the feet, not just We take abourt 8,000 to 10,000 steps covering several the shoes.” miles every day. And that doesn’t include exercise. Tumen is not a fan of the new trend of people running barefoot, pointing other parts of the body, Tumen said, noting that out that the surfaces people generally encounter leg pain and back pain often have their roots in the in the developed world — concrete — are far less feet. “It’s unfortunate, but people’s lives really are absorbing of shock than the African veldt our dischallenged when they get foot pain,” said Tumen. tant ancestors used to run around on looking for “A lot of our patients come in because they can’t their next meal. “Concrete makes a big difference exercise anymore because their feet hurt.” — running barefoot outside around Kingston or For diabetics, good feet are not just highly desirWoodstock, you’ll end up in our office with things able — they’re literally lifesavers. One of diabetes’ embedded in your foot … There’s certainly some many troublesome impacts is to degrade circulation benefits to running barefoot, but in general, it doesn’t (excess sugar crystallizes and slashes up very fine work in our world.” blood vessels and capillaries), which can lead to Tumen makes some interesting suggestions gangrene in the extremities and amputation. The about the shoe-buying process. “It’s better to shop loss of a foot starts a very grim clock ticking, said for shoes, especially when you’re an adult, later

in the day, when your feet are a little more swollen and you’ll have a better idea of proper fit,” he said. “[Also], one foot is bigger or smaller than the other — you want to pick the bigger foot. Your foot size actually often changes through life, so if you’re one size, don’t expect always to be that size. When you go to the store, always try on half a size bigger to see if that’s the proper fit for you. We actually measure people in our office to help them get the proper size, because with ligaments and gravity, your ligaments stretch out and your feet stretch out over time.” Sobel concurred about the sizing suggestion, noting that pride can get in the way of a proper fit. “Women have a tendency to get hooked on a number — ‘I’ve always been a size 7; I couldn’t possibly be an 8 1/2’ — but what they don’t realize is that the shoe manufacturers don’t have a consistent standard,” said Sobel. “For me to walk in and buy a pair of pants — I can buy a size 32 pair of pants and it’s going to fit me at the waist at 32, because it’s an actual measurement. Foot sizing is not like that.” Tumen offered advice on how to evaluate a shoe’s foot-worthiness.“In general, you want to have a shoe that has a nice thick sole, for shock absorption,” he said. “I always recommend running sneakers as a good everyday shoe. Running sneakers are built for the impact of runners, so for people who want a shock-absorbing shoe, those are probably the best. You want to have a shoe that has a good heel counter, which means the back of the shoe is firm, so when you squeeze it together, your fingers don’t touch. And a shoe that doesn’t fold in your hand like an accordion. That’s a shoe that doesn’t

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have a lot of support.” Even better, said Tumen, are custom-fit orthotics, shoe inserts especially made for an individual’s foot after measurement and analysis, kind of like how lenses for glasses are ground to a specific prescription. “For a lot of people, if they get custom supports, called orthotics, that goes a long way toward keeping their feet healthy,” Tumen said. And that’s where Sobel comes in.A board-certified pedorthist and biomechanics specialist in footwear and foot orthotics, Sobel went to Temple University’s School of Podiatric Medicine in Philadelphia, has worked in the industry for about five years and has had his New Paltz practice for two.All of his orthotics are made in-house and many of his customers are athletes, runners and triathletes who can’t afford to have their feet be killing them. “The initial office visit usually takes 40 to 45 minutes,” said Sobel. “I do a full biomechanical exam and a gait analysis because my belief is that if you can watch their feet in motion and make the cast and make the orthotic, that whole continuity there is huge as far as making for the best outcome.” A mold is made and a pediagraph, which measures where and how much pressure is being put on the foot. Then, Sobel said, it’s back to the lab where he said he starts “heating things up and grinding and making things happen.” While orthotics literally have the power to change people’s lives — Sobel speaks with great enthusiasm about people he has treated making huge turnarounds in their conditions once they got their feet feeling better — they aren’t cheap, acknowledged the pedorthist. They generally cost about $365-$400 for a pair, which typically lasts for three

November, 2010 • Page 5

years, and insurance doesn’t usually cover them. (The situation is different for diabetics on Medicare, who are entitled to a pair of special diabetic shoes and inserts a year.) Said Sobel, “You’re basically looking at a dollar a day for your foot comfort and health — if you look at it that way, it’s not so bad.”

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Page 6 • November, 2010

Medicare Parts A,B, D

Health care reform and Medicare The new legislation leaves traditional benefits intact and will result in many welcome changes By Andrea Barrist Stern


s of August 2010, 32,326 seniors were eligible for Medicare in Ulster County, according to the Ulster County Office for the Aging, and it would not be surprising if most of them are confused about the effect the health care reform bill will have on them. At over 2,000 pages, the Affordable Care Act, passed by Congress and signed into law by the President in March 2010, is nearly twice the size of Tolstoy’s War and Peace. It is also filled with language like “... (C) in clause (i) (as so designated by sub12 paragraph (B)), by redesignating clauses (i) 13 and (ii) as subclauses (I) and (II), respectively ...” Kari Hastings, coordinator of the Health Insurance Information Counseling and Assistance Program at the county’s Office for the Aging, has spent much of her time in recent months traveling throughout the area speaking to senior groups to address concerns. After all, seniors generally use the health care system more than young people do and those living on fixed incomes would be especially hard-pressed if their health care costs were to rise.

Kari Hastings, coordinator of the Health Insurance Information Counseling and Assistance program at the county’s Office for the Aging, is spending a considerable amount of her time these days couseling seniors about health care reform.

then gradually reduced to give the various participating companies time to adjust. In most parts of the country this reduction will be phased in over three years. The bill would bolster the existing Medicare prescription drug benefit by addressing the socalled “doughnut hole” problem. Currently, there is no coverage after a senior has spent $2,700 on drugs in a year and until the same senior has spent $6,154 on drugs, when coverage begins again.The new health care reform bill will gradually reduce the prescription drug costs to seniors in this gap. In 2011, seniors will get a 50 percent discount on brand-name drugs purchased during this gap. By 2020, the federal government will pay 75 percent of a senior’s drug costs between $2,700 and $6,154.

Cuts and enhancements While the sweeping health care overhaul includes about $455 billion in spending cuts for Medicare and other federal health programs over the next 10 years, there are no cuts to the traditional Medicare benefit. The lion’s share of the spending cuts will affect Medicare Advantage, a program that utilizes private insurance companies like Humana and UnitedHealth Group to deliver Medicare benefits and offers extra benefits that seniors in traditional Medicare don’t get. Much of this extra coverage could be dropped as the government subsidies to Advantage programs are brought in line with the costs of traditional Medicare benefits. Medicare Advantage subsidies will be frozen in 2011 and

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Medicare will also begin to pick up the tab for annual wellness visits and increase reimbursements for primary care physicians, said Hastings. Currently, Medicare only pays for a general check-up when someone first enters the program. Many analysts believe regular check-ups would help improve the overall health of seniors and allow for better coordination of care among physicians. One way the health care reform legislation will expand health care coverage is by requiring that most U.S. citizens and legal residents purchase “minimal essential coverage” for themselves and their dependents. Many insurance companies require Medicare-eligible seniors to avail themselves of the federal program’s benefit, penalizing individuals who do not, according to Hastings.

Medicare has several parts. Medicare Part A (hospital insurance) helps pay for inpatient care in a hospital, a skilled nursing facility or hospice and for home health care under certain conditions. Most people don’t have to pay a monthly premium for Medicare Part A because they or a spouse paid Medicare taxes while working. Medicare Part B (medical insurance) helps pay for medically necessary doctors’ services and other outpatient care. It will also now pay for wellness services. Most people pay a monthly cost of $110.50 that will remain at the same level in 2011, according to Hastings. The cost is deducted from the individual’s monthly Social Security payment but may be waived based on an individual’s reported income. New York does not consider assets when deciding waivers, Hastings noted. Medigap insurance to supplement the cost of services not covered by Medicare is now available through nearly a dozen approved companies. The rates charged by UnitedHealth Care alone for coverage endorsed by the American Association of Retired People (AARP) range from $86.25 to $193 per month. The Medicare Advantage plans are considered Medicare Part C. Part D is prescription drug coverage: a mix of the public and private sectors, with the federal government determining the benefits


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in either basic or enhanced Part D plans that are also sold by private insurance companies. UnitedHealth Care’s basic Part D supplemental plan costs $38.60 per month; the enhanced coverage is $92.70. (These are the AARP-endorsed plans.) The health care reform bill aims to balance some of the Medicare cuts through savings in terms of productivity with the establishment of a “PatientCentered Outcomes Research Institute. Studies have shown huge variations in costs in different part of the country with little or no differences in outcomes. The new health care reform legislation allows Medicare to test payment systems that are thought to be more efficient, both in terms of coordination and care. It is believed this will prevent duplication of services, provide improved care for individuals with chronic conditions and reward quality of care rather than quantity of services. An Independent Payment Advisory Board will be established under the new legislation to recommend continued Medicare savings and ways to extend the program’s future solvency. Some critics have charged that this board will be responsible for most Medicare reductions but wording in the legislation prohibits the board from submitting any idea that would ration care, raise taxes beyond what the legislation allows, or

November, 2010 • Page 7

change benefits. In other words, findings from the new institute cannot be used as an excuse to deny coverage of particular treatments. Most taxpayers will not pay the new bill’s higher Medicare payroll tax that is being used to help fund the changes. The bill will raise the tax to 2.35 percent from the current 1.45 percent for individuals earning $200,000 or more and for couples earning $250,000 or more. The legislation would also create an entirely new tax of 3.8 percent on unearned income (dividends, interest, etc.) for individuals in these same higher income groups. The new taxes would not take effect until January 1, 2013.The Joint Committee on Taxation estimates they would bring in $210 billion between 2013 and 2019.

Other general changes Health care reform would mandate that most U.S. citizens and legal residents purchase “minimal essential coverage” for themselves and their dependents either through their employers or through new “exchanges” that will sell policies to individuals. The states will set up the exchanges that are to be administered by either a government agency or nonprofit organization. The federal government will provide the states with funding for the start-up of these exchanges that are supposed to be open for business by 2014. The exchanges are intended to serve as cooperatives, allowing individuals to band together for insurance purposes, and would have oversight to ensure they meet government standards and offer plans in the best interests of health care consumers. They are prohibited from setting premiums but can ask insurers to justify rate hikes and can even require insurers to drop a plan from their product inventory if they are not satisfied with the insurer’s rate increase rationale. When up and running, the exchanges are supposed to offer four levels of plans. Insurers would be required to charge the same rates outside the

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Page 8 • November, 2010

exchange as inside for comparable plans. Individuals who ignore the mandate and do not purchase health insurance will have to pay a penalty tax to the federal government beginning in 2014. The tax starts small but will be substantial by 2016. A person without insurance would have to pay whichever is greater: $695 for each uninsured family member, up to a maximum of $2,085 or 2.5 percent of household income. Certain individuals with religious objections would be exempted as would Native Americans, illegal immigrants and prisoners. In addition to expanding coverage, it is believed the flood of healthy young insurance customers into the market will help the insurance companies balance out the losses they would incur by no longer being able to deny coverage to individuals with preexisting conditions, a key aspect of the new health care reform.

Financial aid Congressional budget experts have estimated that some 25 million people will shop for coverage in these exchanges and of these, about 19 million are likely to be eligible for financial aid. The cutoff level would be an income of four times the poverty level. That’s about $44,000 a year for one person and $88,000 for a family of four. Subsidies would be figured on a sliding scale based on a complicated formula. Essentially, individuals who make three or four times the poverty level would get enough money so that they would not have to pay more than about ten percent of their income for a decent health insurance package. People who make less would pay less. Individuals who make about $14,000 and four-person families with incomes of about $29,000 would not have to pay more than three or

Additional help N

ew York State’s EPIC (Elderly Pharmaceutical Insurance Coverage) program provides additional prescription drug assistance for seniors. Residents 65 or older with annual incomes under $35,000 (single) or $50,000 (married) are eligible, according to Kari Hastings of the Ulster County Office for the Aging. EPIC covers almost all brand name and generic medicines as well as insulin and insulin syringes. If you are single with an annual income no higher than $20,000 or married with a joint income no higher than $26,000, you would pay an annual fee as well as a co-payment for each prescription. EPIC will also pay your monthly Medicare Part D premium up to the average cost for basic coverage. If you are single with annual income from $20,001 to $35,000 or you are married with joint income from $26,001 to $50,000, there is no annual fee. Instead, you pay the full price (or co-payment if you have other prescription coverage) for your prescriptions until you meet your annual EPIC deductible. EPIC keeps track of what you have spent and notifies you when you have met your deductible. After that, you pay only the EPIC co-payment. If you have Medicare Part D coverage, your EPIC deductible will be lowered by the average annual cost of the basic Part D plan. The lower deductible is intended to provide additional savings to help individuals pay for their Medicare Part D premiums. For information, contact the Ulster County Office for the Aging (845) 340-3456 or the toll-free EPIC helpline: 1-800-322-3742. Applications can be downloaded at health_care/epic. The federal government also offers a program called Extra Help to help seniors with limited incomes with the costs of Medicare prescription drug coverage. Many seniors qualify but don’t know it, according to Hastings. Social Security will require information on your income and the value of your savings, investments, and real estate (other than your home). Married individuals will have to supply information for both parties. Basically, annual income must be limited to $16,245 for an individual or $21,855 for a married couple living together. But even if your annual income is higher, some help may still be available. Apply for Extra Help online at; call Social Security at 1-800-7721213 to apply over the phone or request an application; or apply in person at the local Social Security Office, 309 Grant Avenue, Kingston, near Tech City.


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four percent of their incomes for insurance. Those who make even less — under 133 percent of the federal poverty level — would be able to enroll in a newly expanded Medicaid program. Most of the changes will take place in 2014. Many individuals who have been unable to afford health insurance because of the cost are expected to be able to do as a result of the reform. While adults with preexisting conditions cannot be denied coverage beginning in 2014, insurers are no longer allowed to deny such coverage to children. Dependent children will be able to remain on their parents’ policies until the age of 26. Also children’s eligibility for the popular Children’s Health Insurance Program, which assists low-income families, must be maintained. States will not be able to cut children from the program until 2019. Under the legislation, “qualified health plans” now have to provide immunizations and other preventive health care services for infants, children and adolescents. For further information, contact the Ulster County Office for the Aging, 1003 Development Court in Kingston at (845) 340-3456. The Medicare Rights -best foot.0809 Center can be staff contacted at 888-795-4627 or WT.3.00x4.UC.crtr - Page 1 - Composite 1-800-MEDICARE (800-633-4227).

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New routines at the gym Trainers keep people focused but classes offer new options By Kim Davis


he cold weather is a signal for many to renew their subscriptions at the gym, and the options have never been more varied. MAC Fitness, which has two locations, on 9W and at Kingston Plaza; the YMCA of Ulster County and Kingston, located at 507 Broadway in Kingston; and IXL Health & Fitness Center, located on 9W in Saugerties, all offer a range of classes and personal trainers, along with fully equipped exercise facilities and cycling rooms. How do you decide which course of exercise is right for you? According to Lyle Schuler, owner of MAC Fitness, classes are the most popular option for most people: they’re fun, social, and you get tons of moral support from the other participants. He also notes, however, that at his facility, 20 percent more people are choosing to work with a personal trainer than a couple of years ago, a trend he attributes to the costs and uncertainties associated with health care insurance. “People are realizing they can take better care of their health by getting involved in preventative measures,” Schuler said. “They’d rather pay a little more now than risk their health later.” More stress in people’s lives lately is another factor accounting for the increase, he believes. Working with a trainer “helps people be more consistent,” Schuler noted. The trainers at his gym vary the routine, which not only engages people more but also is designed to adjust to changes in the body that occur through regular exercise. “When the average person exercises, their body plateaus,” said Schuler. “The programs need to be re-evaluated, because otherwise the body won’t respond as well. Trainers earn their value because they adjust the programs for clients so that the goals are continually targeted.” Often, a client will work with a trainer for three to six months to establish a program, then continue on their own, he said. Sarah Campbell, club manager at IXL Health & Fitness Center, said the individualized attention is obviously part of the advantage of working with a trainer. “It’s nice to work with a trainer because it’s one on one,” she said. “They’re by your side and can give you tips on your form and different exercises you can do to help that.” She noted that a first year’s membership at her facility includes two

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barbell strength training program — and water fitness classes. (The latter is particularly helpful for people recovering from an injury). All classes, except swimming lessons and the personal trainer, are included in the monthly membership fee. The Y facilities include a wellness center, weight room, racquetball and hand-ball courts, indoor track, and pool. For more information, go to

While working with a trainer has its definite advantages, classes and group activities are really exploding in popularity, according to the gym spokespersons. “Over time, a treadmill gets boring,” said Schuler. “No matter how many bells and whistles are on an elliptical machine or stair climb, in the end most people shift toward the group exercise experience.” Here’s a look at some of the most popular classes and latest trends:

Zumba to Cardio at IXL The most popular class at IXL is Zumba, which club manager Sarah Campbell said is “more like a party.” Noted Campbell, “You’re having fun while you’re working out.” Indoor cycling is also very popular, a high-energy class which accommodates different levels. IXL offers 25 classes a week, including strength training, cardio, a body sculpting class, and a Silver Sneakers class for seniors, which focuses on flexibility and balance, with a lot of stretching. The most popular membership option is the monthly fee. For more information, go to

LesMills program MAC Fitness is the area’s sole provider of a licensed exercise program called LesMills, according to Schuler. Leslie “Les” Roy Mills is a retired New Zealand athlete who represented his country at the Olympics over two decades. He gave his name to a company founded by his son who developed a series of group fitness-to-music classes that are available internationally: BodyStep, BodyCombat, BodyPump, BodyAttack, BodyBalance, BodyJam, BodyVive and RPM. Schuler attributed the popularity of the program to “the great music and routines.” The music is an upbeat mix of the best pop songs, both current and from the past, and both the soundtrack and routines are varied every 90 days. In “body pump,” participants work with a barbell to tone and condition every muscle in a 40 to 50 minute workout. “Body combat” is based on the martial arts, with lots of kick boxing and regular striking moves. “There’s no real physical combat, but you get some stress reduction,” said Shuler. Yet another LesMills class is “body step,” with new moves designed around one- and two-step risers. “When you step out onto a platform six to ten inches off the floor, you get a lot of contracting and lengthening in the gluts and calves,” Shuler said. The “body flow” class incorporates yoga, pilates and tai chi, resulting in a “mind body workout” rather than adrenaline pumping. The movements work on your core muscle groups — the sternum, rib cage, navel, and pelvis — strengthening and lengthening muscles and improving posture. The class A LesMills “Body Combat” class at MAC Fitness. is particularly good for people over age 40, who need to improve their flexibility, Shuler free personal training sessions, so members can said, noting that much of the aging process is due try it out. IXL also offers a group fitness class that to stiffening and muscle shortening. “Exercise is a combines the attention of a personal trainer with great equalizer” in terms of keeping muscle supple the support of the group. Limited to six people, the and flexible, he noted, adding, “From a physical class provides the advantages of a group as well standpoint, a lot of the aging process happens as the one-on-one intensity of a trainer. because we stop moving.” Joan Keating, membership director at the YMCA, Schuler said Zumba — a Latin-based dance — is said that the Y primarily encourages classes, alalso a hit with members. A year ago, one Zumba though personal trainers are available. Y members class was offered; now there are eight a week. Inwho use a trainer generally do so because they door cycling is popular as well. The lights are kept “are focused on an intensive goal, such as a big dim so that participants — who each choose their weight loss or an upcoming marathon.” The role of own speeds and tension — can better experience the trainer is to “stay on top of them to do it.” their imaginary bike ride. Prompted by the instruc-

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“Body Pump” is another of the LesMills class options.

tor’s narration, the routine might include climbing the hills around Minnewaska. It’s a great workout, with the emphasis on the large muscle groups, said Schuler. Kettle bells are a relatively new workout involving arm swings and suspension training. The idea is that people are using their body weight against the straps. TRX suspension training is a twist, in which members flip truck tires and push weights onto a track. The training “gives you the ability to lift a suitcase out of the trunk of your car,” said Schuler. “You’re moving back and forth and up and down at the same time,” as opposed to the single plane of movement on an exercise machine, he pointed out. For more information, go to

Inside and out at the YMCA “The hottest class right now is Zumba,” said YMCA membership director Joan Keating. “The latest thing we’ve added is water Zumba. You have to slow the movements down to do them in the water.” She attributes the popularity of Zumba to the upbeat Latin music and energetic dance steps. Indoor cycling

classes are also very popular. Keating noted that the Y promotes group fitness classes because they fit in with the organization’s emphasis on community and building relationships. “People encourage each other to work out and encourage each other outside as well,” she said, noting that the Y also sponsors running, bike and hiking clubs. In addition, there are yoga, pilates, “boot camp” — a

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national parks. As time went by, however, Annette began to develop mental problems, which eventually grew into full-blown schizophrenia, spending time in and out of institutions. Sadly, three years ago, she committed suicide, leaving her husband with many painful questions — and their two adolescent boys to raise alone. One son has since begun showing signs of possible schizophrenia as well, and requires large amounts of his father’s time and attention. Morrison, now 51, is dealing with an enormous amount of stress. He was having trouble sleeping and having digestion problems, bordering on ulcers. To relieve some of his anxiety and depression, his doctor first prescribed an anti-depressant, but he experienced problems from the side effects. “I was falling asleep at my desk and missing meetings,” Morrison explained during a recent conversation, “and while my employer was understanding, it was really affecting my work. I had to stop the pills.” When it became legal in Colorado, his doctor prescribed marijuana, which Medical marijuana comes in many different varieties. he acquires legally from his local dispensary both in Weed, pot, dope, Mary Jane, cannabis, ganja, smokable form as well as in foods like cookies and herb, marijuana — it goes by many names. But soda. He no longer had problems at work. whatever you want to call it, it is a substance that “Both ways of taking marijuana help a lot, but I has been legalized for medicinal purposes in many worry about what the smoke could do to my lungs,” areas. In the U.S., medical marijuana legalization he said recently. “I play it safe and alternate the pipe has been passed state-by-state; to date, 14 states with eating it. Now, I feel better than I have in years.” have legalized the use of cannabis for medical Medical marijuana is apparently being used with purposes. New York is not among them. success by elderly patients as well. Evelyn Talbot The 14 states that have granted access to medical (also not her real name) is an octogenarian living in marijuana so far are Alaska, California, Colorado, Rhode Island. She has endured chronic back pain Hawaii, Maine, Michigan, Montana, Nevada, New since a car accident fractured her skull and spine Jersey, New Mexico, Oregon, Rhode Island, Verat age 35. Operations haven’t helped, and other mont, and Washington. And Washington, D.C., the medicines don’t touch the pain that can keep her nation’s capital, also passed it earlier this year. up through the night. Now, however, every night In Colorado, marijuana has been available for before bed, she opens a small jar of cannabis oil medical use since 2009. Since then, more than and measures out a quarter-teaspoon to mix with 100,000 Colorado residents have become legal homemade applesauce. Soon after she eats it, she users for medical purposes. Here’s the story of drifts off to sleep. one of them. “It’s really been a lifesaver for me,” Talbot said by phone of her cannabis oil. “I used to walk into the A father’s tale walls sometimes. I was so tired because I didn’t David and Annette Morrison (not their real names) sleep.” Today, she’s not only healthy enough to rehad a happy life in Denver, Colorado when they main independent in her home, she also continues first married. Both enjoyed the great outdoors, hikto operate a clothing business she owns. ing and camping in many wilderness regions and

Waiting to inhale

Ulster Publishing’s high tech guru examines a different subject for a change By Bill Pfleging


long-time resident of Ulster County — let’s call him Liam — is now 55 years old. Almost 20 years ago he began to suffer severe arthritis, to the point of being occasionally bedridden. He lost his job as an aide for a local facility for the disabled and subsisted on disability payments. After only a few years, the prescription drugs he was taking for pain and to reduce the swelling in his joints started to have a deleterious effect on his system, and he was told that he would be on dialysis within a few years due to the damage the drugs were causing in his kidneys. While researching other possible methods of treatment, Liam learned that one of the beneficial effects of marijuana was as an anti-inflammatory as well as a painkiller. He decided to step outside the law and try it. “I was headed for kidney failure,” said Liam, “and doctors couldn’t offer me any better alternative. I really didn’t have a choice.” He acquired some marijuana and found that it worked as well or even better than the pharmaceuticals, without any of the destructive side effects the prescriptions caused. Using it only in the evening at bedtime, sometimes smoking and sometimes cooking it into food, Liam found it didn’t have any effect on his daytime performance. He’s been using marijuana as a medicine to control his arthritis successfully for over 15 years now. “Using marijuana made it possible for me to return to work and lead a basically normal life, instead of taking drugs that were eating out my insides,” he explained. “My big worry is that if I get caught, I won’t be able to get the medicine I need. Sounds crazy, doesn’t it?”

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multitude of medical problems. Some of the uses include chronic pain in AIDS patients and patients with spinal cord injuries, as well as muscle spasms in multiple sclerosis patients. It’s also used to treat arthritis, gastro-intestinal disorders, cancer, and many other ills. Cannabis was a part of the American pharmacopoeia until 1942, and is currently available in Canada, Austria, Germany, the Netherlands, Spain, Israel, Italy, Finland, and Portugal. In November of 2009, the American Medical Association (AMA) voted to reverse its long-held position that marijuana be retained as a Schedule I substance with no medical value. The AMA adopted a report drafted by its Council on Science and Public Health (CSAPH) entitled, “Use of Cannabis for Medicinal Purposes,” which affirmed the therapeutic benefits of marijuana and called for further research. The CSAPH report concluded that, “short-term controlled trials indicate that smoked cannabis reduces neuropathic pain, improves appetite and caloric intake especially in patients with reduced muscle mass, and may relieve spasticity and pain in patients with multiple sclerosis.” Cannabis is a genus of flowering plants than include three species: Cannabis sativa, Cannabis indica and Cannabis ruderalis; all are indigenous to Central and South Asia. Cannabis in the form of hemp has long be used for fiber in various parts of the world. Cannabis has also been used as a recreational drug in addition to its medical uses. To satisfy the U.N. Narcotics Convention, some hemp strains have been developed which contain minimal levels of THC (tetrahjydrocannabinol, the pshoactive molecule that produces the “high” associated with marijuana.) Extracts such as hashish and has oil are also produced from the plant. A February 2010 Quinnipiac Poll found that 71 percent of New Yorkers believe it’s a good idea to “allow adults to legally use marijuana for medical purposes if their doctor prescribes it.” Given the addictive properties of alcohol and tobacco and concerns about the use of both, why hasn’t New York joined with the other 14 states to legalize it?

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Currently in New York, there are twin bills, Assembly Bill 9016 and Senate Bill 4041-B that would legalize medical marijuana in New York State. The bills have passed through several committees with bipartisan support, and have made it farther than any past medical marijuana bills in the Senate but the legislation is now languishing in the budget committee. Both bills would allow state-qualified patients to possess up to 2.5 ounces of medical marijuana for therapeutic purposes. Unlike the medical

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cannabis laws that have been enacted in 13 of 14 states, however, New York’s proposals would not allow patients to legally cultivate their own medical marijuana. Instead, the bills seek to establish not-for-profit facilities to manufacture and distribute marijuana to qualified patients. As introduced, A. 9016 and S. 4041 define these patients as those diagnosed by their physician to be suffering “a severe debilitating or life-threatening condition, ... including but not limited to [an] inability to tolerate food, nausea, vomiting, dysphoria, or pain.” It appears doubtful, however, that medical marijuana will become legal anytime soon in New York given Governor-elect Andrew Cuomo’s opposition. “In my opinion, the dangers still outweigh the benefits,” Cuomo has said on the record. Among the most conservative New Yorkers, however, there is more support for protecting patients.When asked about medical marijuana recently, Cuomo’s Republican gubernatorial opponent Carl Paladino said, “Let the

people decide.” In California, where medical marijuana has been legal since 1996, the big debate during this recent election cycle was whether or not it is time to fully legalize marijuana for personal use other than just for medicinal purposes. Meanwhile, New Yorkers suffering from debilitating illnesses and pain that they believe could be helped with medical marijuana appear destined to have to wait, move to a more compassionate state, or procure their medicine the way it’s been done for almost 70 years — quietly.

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(and the coming of spring certainly wouldn’t be as powerful if there weren’t a winter).

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s the days grow shorter and the temperature drops, many people find their energy levels sagging. Having to spend more time inside as a way of avoiding the cold can lead to feelings of claustrophobia and lethargy. Some people become isolated. The onset of darkness in the late afternoon, combined with all these other factors, is enough to send a few people into a depression — an affliction identified as Seasonal Affective Disorder (SAD), whose symptoms may include oversleeping, lack of energy, difficulty concentrating, and social withdrawal. While less than ten percent of the population in the U.S. suffers from

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SAD — although another 14 percent are estimated to suffer from a milder form, called Subsyndromal Seasonal Affective Disorder — almost everyone is affected to some degree by the dreariness of the coming season. With effort, however, winter can be as enjoyable as summer — in its own special way. The long nights are an invitation to sleep more, and that’s not a bad thing, in itself. It’s a time of retrospection, of recharging one’s batteries, and the opportunity to read, make soup, watch movies, and otherwise engage in home-bound, more domestically-oriented activities can be enjoyable.Accepting and adjusting to the changing rhythm of the seasons can make the human experience richer, less monotonous

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While holing up for the next five months might appeal to some, it’s not ideal for many — nor even necessary. To really enjoy the season, it’s vital to stay active, get outdoors, and stay connected. Cindy Dern, who has been teaching movement at the Omega Institute and working as a dance therapist at Bendictine Hospital for many years, noted that everybody is slightly affected by the cold and diminishment of light. The key to avoiding the winter blues, she said, is to stay active. If the early darkness precludes one from taking that run around the neighborhood after work, then perhaps one should reschedule a run during lunchtime — or at least take a 15-minute jog before driving home for the day. And on weekends, when people are home, they should focus on getting out — taking walks, snowshoeing or cross-country skiing if there’s snow, even ice-skating. Her partner likes to skate on a pond off Wittenberg Road if it’s really cold. If one hasn’t been active, now is a great time to change one’s habits and incorporate more lifeenhancing movement into one’s life, said Dern. It can be as simple as taking the stairs rather than the elevator, parking farther away from the mall in the parking lot, pacing as one talks on the phone. If one is inclined not to go out, get a yoga CD or exercise tape, and schedule a regular work out at home. But Dern advised getting out doors. She starts her day with a 30-minute walk, which has become as much a part of her daily routine as brushing her teeth. On a snowy day, she enjoys the beauty and the solitude around Woodstock (where she lives); even when it’s cold, the exercise warms her up, so that by the time she gets home the house feels stuffy. When there’s snow, she snowshoes, a vigorous workout that costs nothing (once one has the shoes) and enables one to explore the woods without getting lost (since you can trace your tracks on the way back). Others might want to try cross-country or downhill skiing, sledding and tobaggonning (fun even if the kids are grown), and ice skating. (Fortunately for us here in the mid-Hudson Valley, these are all viable options, blessed as we are with abundant wildlife preserves, rivers, creeks, and ponds, and several ski resorts.) Even building a snowman is a great way to give one’s back, arms and legs a workout. Shoveling snow is also an excellent workout. Dressing appropriately for the cold is essential to enjoying the outdoors in winter. That means wearing a snug hat, good-quality insulated gloves, light-weight but well-insulated coat or jacket, woolen scarf, warm socks, and sturdy, insulated boots. (It may sound obvious, but if you’ve spent most of your life in the city, you might not be prepared. I remember what a difference it made when I finally bought a down coat, prompted by the necessity of walking the dog every morning; I could be out in the cold for hours, and not feel it! Now winter is not nearly the bugaboo it used to be.) In general, Dern said incorporating movement into one’s daily routine is the key to improved fitness. “Make a decision to be more active and stick to it,”

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she said. “People should make this commitment on a regular basis.” The commitment to, say, walk half an hour a day, should be made for at least a month, which is enough time to establish new habits. Do whatever is necessary to make that change: for example, if you need structure, join the gym, or take an exercise class. For some people, a group activity works best and might be more fun — like going contra dancing on a Saturday night, for example. Or join a group hike, which has the added benefit of affording you the peace and beauty of nature. The healthy effects of exercising more will snowball: “because you’re feeling good, you’ll make better choices about food,” Dern said. “You’ll be in a better mood, be thinking more clearly, sleep better, and if you should fall or otherwise hurt yourself, you’ll recover sooner, since exercise builds stronger bones.”

Seek out the light Maria LoCastro, clinical coordinator for the Partial Hospitalization Program at Benedictine Hospital, said she definitely sees more depressed people visiting the program in winter than at any other time of year. She said lack of light can be a real problem, since sunlight is a source of an essential vitamin. Vitamin D is synthesized in the skin when it is exposed to the sun’s ultraviolet rays, and the vitamin is believed to be essential in building strong bones, reducing hypertension, and protecting against cancer and a host of other auto-immune diseases.

November, 2010 • Page 15

LoCastro cited a recent study at the University of Manchester which found that Vitamin D boosts everything from mood to memory. The body’s requirements for the vitamin increase with age: participants in the study over age 60 who received lots of the vitamin showed marked improvement in their agility and emotional stability compared to their lower-level counterparts, LoCastro noted. Besides being a source of Vitamin D, light by its very nature is a mood lifter. The optimum exposure to sunlight is 45 minutes a day, LoCastro said. “If it’s a sunny day, be sure to get out.” It’s also good to get out on cloudy days, when some light is filtering through the clouds. When in your house or office, open the blinds, she suggested. Sit by a sunny window to absorb the healthful rays. Like Dern, LoCastro advised regular exercise, as well as avoiding or limiting use of alcohol (a depressant that can adversely affect sleep). Eating fish rich in Omega-3 fatty acids, such as salmon, herring and mackerel, is also a way of combating the winter blues, since the Omega-3 fatty acids are believed to help improve mood. (Interestingly, while researchers have discovered that SAD affects many Scandinavians, the exception was Icelanders, who are believed to be exempt from winter-related depression because of their high consumption of fish.)

“You can’t prevent entirely how the season affects you, but it helps to take steps to manage this early,” concluded LoCastro. “The earlier you address the problem and have an action plan, the better you’ll be able to intervene and not have it get to the point where you require hospitalization” — or, perhaps less dramatically but no less happily, curl up into a ball until spring.

Beth Donnelly DC


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Ulster Publishing's Healthy Image 2010  

The annual edition of our special health section

Ulster Publishing's Healthy Image 2010  

The annual edition of our special health section