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Keith W Roach, MD, New York, NY (2026)

04/01/2026

Not all guidelines can be trusted. Here are some evidence-based guidelines from the AHA that I agree with and recommend:

Statement Highlights: Sustaining lifelong healthy eating patterns may reduce the risk of cardiovascular disease and other chronic health issues, according to the latest updated dietary guidance offered in a new scientific statement from the American...

03/30/2026

DEAR DR. ROACH: I have a sister who is in her mid 60s and has a very low weight. She cooks a lot but doesn’t eat much. Is there something to suggest to make her gain some weight? She weighs 80 pounds and is 5 feet, 2 inches tall. By contrast, I’m 5 feet, 4 inches tall and weigh 150 pounds. I am worried that if she gets sick, she will not have anything to live off of. -- P.L.W.

ANSWER: With all the recent press about GLP-1 medicines helping people to lose weight, there has been much discussion about the health risks of being obese. However, there are health risks of being underweight as well. In fact, the health risk of being as underweight as your sister is (a BMI level of 14) is about the same as the overall health risk of a person with a BMI of 50. (For her, this would equate to about 300 pounds.)

I don’t know why she isn’t gaining weight, but there are many possibilities. Weight loss due to psychiatric diseases like major depression and anorexia nervosa is common and underdiagnosed. Some diseases keep people from absorbing nutrients, especially celiac or Crohn’s disease. People can lose calories through their urine (such as diabetics), while others use up their calories too fast (due to high thyroid levels, advanced cancer, etc.). There are many other less-common possibilities.

One critically important issue is to be sure of how much your sister is eating. It sounds like she isn’t eating much, which makes some issues more likely than others. While there are appetite stimulants, I don’t use these unless I feel like I understand what is causing the problem. A careful evaluation by a general physician is called for.

Weight loss due to psychiatric diseases like major depression and anorexia nervosa is common and under-diagnosed.

03/30/2026

DEAR DR. ROACH: Can you say more about potassium and chronic kidney disease (CKD)? I have stage 3 CKD with a glomerular filtration rate (GFR) in the mid-40s. I like to have a banana for breakfast; is it bad for me? -- S.B.

ANSWER: CKD is separated into different stages depending on the estimated GFR, which signifies the overall function of the kidney. A normal GFR is considered to be 90 or higher, and people with kidney disease and a normal GFR are considered to be in stage 1. Stage 2 CKD is having a GFR between 60-89; stage 3a is 45-59; stage 3b is 30-44; stage 4 is 15-29; and stage 5 is 15 or less.

Most people with stage 3a CKD don’t have trouble with the modest potassium load from a banana, but high levels of blood potassium become much more problematic when a person has a GFR that is below 45.

Your regular doctor or kidney specialist (you should have one if you don’t already) should be periodically testing your blood. If your potassium level is already high, you may be recommended to reduce your intake of high-potassium foods. However, a plant-based diet that is rich in these foods helps to protect you against the progression of kidney disease, so I wouldn’t limit these foods unless your specialist tells you that it’s time.

Even with early-stage CKD, I wouldn’t use a potassium-based salt substitute without talking to your doctor first, who will likely want to look at a recent blood test.

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03/27/2026

DEAR DR. ROACH: I saw on a TV show that most people with a “penicillin allergy” probably don’t have one. Is this true? -- R.C.

ANSWER: Yes, it is. I often ask my patients what they mean by a penicillin allergy. Many don’t remember, or they were just told by their parents that they had a reaction. Some recall reactions that are not allergic (such as vomiting or “feeling sick”). Quite a few developed a rash after being on amoxicillin during or after what sounds like a viral infection.

Many diseases, including roseola and infectious mononucleosis, will predispose people to a rash after amoxicillin. But this isn’t a true allergy, so a person can be labelled “allergic” when they are not, which may keep them from getting an effective medication. People who are at a low risk for a severe penicillin allergy may get penicillin under medical observation.

Of course, I’ve had people tell me that they had anaphylaxis, which requires epinephrine. They never receive penicillin again (except in very rare circumstances where penicillin is the only effective treatment).

Most people who say they are allergic don't remember why, or if they really do.

03/27/2026

DEAR DR. ROACH: My heart rate variability (HRV) on my heart rate tracker has ranged from 12-14 ms for years now. I read that this means something is going on inside me. Do you have any insight into HRV? I’m a 64-year-old male who is in decent health. My Lipoprotein(a) level is 224 mg/dL, but my other heart tests are OK.

I play pickleball often, walk a lot, and go to the gym once a week. My heart rate is in the 40s when I’m sleeping and in the 50s when I’m resting. I’m 5 feet, 11 inches tall and weigh 170 pounds. -- J.N.J.

ANSWER: HRV is a measurement of how steady the heart rate is. It might be surprising that more variability is better than less variability. The heart should respond to small changes in pressure due to breathing, so a person’s HRV provides an assessment of the autonomic nervous system (the vast part of the nervous system that is not under conscious control).

HRV does give information to help guide a person’s prognosis for some kinds of heart disease, especially after a heart attack. However, a person’s HRV needs to be carefully measured with a clinical instrument under controlled conditions. Home monitors like wearable devices are not as accurate, as they are subject to random error, changes in the nervous system due to caffeine or ni****ne, sleep quality, the time of day, emotional stress, and other factors.

The absolute value of HRV from a wearable device is not considered particularly meaningful by experts. However, a trend in HRV over time is potentially significant. I would be more reassured by the unchanging nature of your HRV than the relatively low number that your home device is giving you. (An HRV of 12 ms is low. The most common measurement of HRV is through the standard deviation of NN intervals. A SDNN of less than 50 has a worse prognosis than an SDNN greater than 100 in people who recently had a heart attack.)

Even though HRV does provide some useful information, it is generally not routinely measured. Since your number is on the lower side, however, a more careful look at your other heart-disease risk factors is called for.

It sounds like you are doing well with exercise. Your physician should take a careful look at your diet, as it is also important for heart health. A Lp(a) of 224 mg/dL should be considered a very significant risk factor for heart disease, especially given your family history. Most experts would recommend combined treatment, such as a high-dose statin and a PCSK-9 inhibitor, even if your “regular” cholesterol numbers are in the normal range.

I'm a 64-year-old male who is in decent health.

03/26/2026

DEAR DR. ROACH: I am a 90-year-old man who is in reasonably good health. I try to follow best practices in terms of my diet, exercise and lifestyle. I take seven medications daily that control my blood pressure and cholesterol very well. My medications include 5 mg of warfarin daily due to a stroke from 20 years ago.

My dilemma is that many vegetables and fruits I would like to eat as part of a healthy diet (such as broccoli, spinach and asparagus) are high in vitamin K and are restricted for me. My PT/INR is closely monitored and varies somewhat within the desired range of 2.5-3.5 seconds (and sometimes outside this range). How can I best maintain a healthy diet under these circumstances? -- D.C.

ANSWER: Warfarin (Coumadin) was the only oral anticoagulant for many years, and it remains the only effective medication for several indications. Warfarin works by blocking vitamin K, which leads to a reduced level of clotting factors.

However, most people who are put on anticoagulants now use newer agents like apixaban (Eliquis) or rivaroxaban (Xarelto). These have major advantages such as steadier levels of anticoagulation without having to measure levels and without needing to watch your diet from the standpoint of vitamin K.

I suggest that you ask your doctor if you could switch to one of the newer agents. Well-done studies have now proven conclusively that the newer drugs are at least as effective as warfarin for most indications, but whether you can go on it remains a question for your neurologist.

If you need to stay on warfarin, then you should know that high-vitamin-K foods, many of which are very healthy for your body, are not “restricted.” What is critical is that you consume roughly the same amount of these foods every day. The dose of warfarin needs to be appropriate for the amount of vitamin K that you take in.

This means that if you start eating more vitamin K (leafy greens are the leading source), then you will need more warfarin. During this period of time, you would need to be monitored carefully, and the dose would likely be adjusted upward.

There are new alternatives available.

03/26/2026

DEAR DR. ROACH: I was diagnosed with a large fatty tumor on my left thigh. It’s very ugly. What can I do to get rid of it? -- V.O.P.

ANSWER: Lipomas are common fatty tumors that may occur on the trunk or the limbs. The vast majority are benign, but very large tumors can possibly be liposarcomas. So, an ultrasound or MRI prior to treatment should be considered.

Surgery is the standard treatment. I’ve had patients in whom surgery was done very easily and took very little time, while others have had much more extensive surgeries when the tumor is deep and not well-encapsulated.

The cosmetic results from surgery are variable, and I have had more than a few patients who were so unhappy with their appearance afterward that they wished they hadn’t gotten it done. So, if you are considering treatment just because of its appearance, I would think twice before committing to surgery. Liposuction is another option for lipomas, but this is often not attempted for very large tumors (greater than 11 centimeters).

What are my options?

03/25/2026

DEAR DR. ROACH: I have multiple bleeding moles. I know that they shouldn’t bleed, and I am waiting to see a dermatologist. What could be causing this? -- A.T.T.

ANSWER: A spontaneously bleeding skin lesion needs careful evaluation as there are both benign and malignant causes. The most common cause is a benign melanocytic nevus (a simple “mole”) that gets irritated, perhaps by rubbing, scratching or shaving.

There are other benign skin lesions that bleed easily, like a pyogenic granuloma, which can be mistaken for a simple mole. Seborrheic keratoses, which are bumpy skin lesions that look stuck-on, can also bleed easily if they’re irritated. There are also less-common lesions like a Spitz nevus, which easily bleeds.

However, all major skin cancers (basal cell, squamous cell and melanoma) can cause bleeding easily. If your dermatologist cannot tell for certain by looking at the moles or through a dermoscope, it’s likely that they will do a biopsy to be sure. (A dermoscopy uses a dermatoscope, a magnifier with special lighting, and either a liquid interface or polarization to see structures below the surface.)

What could be causing this?

03/25/2026

DEAR DR. ROACH: What are D-dimers? Are they something I should be concerned about? I am an 83-year-old male with the usual problems that men my age have, such as an enlarged prostate, high blood pressure, and high cholesterol. With medication and monitoring by my doctors, all of these conditions are under control. I also exercise and play golf every week.

This past August, I started to experience an extremely intense pain behind my left knee. It was in one small area and would come and go. After several hours, I went to our emergency room, where they did a sonogram that did not show any specific problem. Later that day, the pain eventually went away.

About a month later, during my yearly physical, I told my doctor what had happened. She scheduled me for another sonogram and a blood test. The sonogram, again, showed that nothing was wrong. However, the test did show that my blood had D-dimers. In my entire life, I have never heard of D-dimers. I like my doctor, but she never called to explain if D-dimers are something that I should be concerned about. An internet search just confused me.

I would appreciate your thoughts. Is this something I have had all my life? Will it go away? Should it be monitored with periodic blood tests? I should also say that the pain has not come back, although I feel a very slight pain in the area once in a while. -- G.G.K.

ANSWER: The D-dimer test looks for the breakdown of fibrin, which is a major protein that is involved in blood clotting. High levels of D-dimers are very nonspecific; they can be high after exercise, during pregnancy, or just with advancing age. (Sounds like you may have two out of these three.)

However, very high levels of D-dimers are almost always found in people with blood clots. Your doctor was worried that a blood clot was the cause of your leg pain, so when your D-dimer level was high, she appropriately ordered an ultrasound. If your D-dimer levels were negative, she wouldn’t have needed to order the ultrasound as it’s very unlikely to have a significant clot without high D-dimer levels.

Since you didn’t have a blood clot, and your leg pain is long gone (hopefully), you do not need to worry about the D-dimer blood test.

The pain in the back of his knee was the reason she ordered the test. But what does it measure?

03/24/2026

Dear Dr. Roach: Why didn't you recommend one of the at-home kits for the person with Lynch syndrome who had a bad reaction during her colonoscopy? I don't ever intend to have another colonoscopy. It is invasive, the prep is too much (yes, I understand why), and it takes up 24 hours of your time.

— A.T.

Dear A.T.: Lynch syndrome, also called hereditary nonpolyposis colorectal cancer syndrome, is a condition that is caused by a genetic mutation in a DNA mismatch repair gene. Without this mismatch repair system, some cancers are much more likely, especially colon cancer. People with Lynch syndrome are at a much higher risk for colon cancer.

Cologuard and other at-home tests are not intended for and have not been tested in people with Lynch syndrome. Furthermore, people with Lynch syndrome quickly progress from having normal tissue to having cancer and may bypass the DNA sequences that the stool-based tests are designed to detect. Lynch-syndrome cancers are also preferentially on the right side of the colon, which is harder for Cologuard to detect.

People with Lynch syndrome should get a full colonoscopy every one to two years, beginning several years before the youngest family member was diagnosed or between ages 20-25 — whichever is earliest.

Cologuard is a good test for people who will not or cannot do a colonoscopy. I continue to get a colonoscopy as it's a more sensitive test. Yes, the prep is unpleasant, but 24 hours of my time every 5-10 years is worth the improved detection from a colonoscopy to me. I take care of several gastroenterologists who also get colonoscopies for their own cancer screening.

I don't ever intend to have another colonoscopy.

03/24/2026

DEAR DR. ROACH: I take 1 capsule per day of over-the-counter Prevacid for acid reflux. If I do not take 1 capsule per day, I begin to experience reflux symptoms within a day or two. Prevacid provides me with better symptom control than other proton-pump inhibitors (PPIs) and much better control than H2 antagonist meds.

What are the risks of taking 1 PPI capsule daily versus tolerating acid reflux? Does Prevacid pose more or less of a risk than other over-the-counter PPIs on the market? -- G.K.

ANSWER: PPIs like omeprazole (Prilosec) and lansoprazole (Prevacid) prevent the stomach cells from making acid. They are very effective in people with severe reflux and can help with healing stomach ulcers. However, they do have some potential side effects.

People who regularly take them are at risk for infections, particularly the serious colon infection Clostridioides difficile. The risk is about 30% higher than for people who don’t take them and higher than it is for people who take H2 blockers like famotidine (Pepcid). However, for average-risk people, the risk is small -- roughly one person per thousand each year.

PPI users often cannot properly absorb calcium, magnesium and vitamin B12. In my patients who are on long-term PPI treatment, I periodically check their magnesium levels and recommend calcium citrate as well as B12 supplements.

The association of PPI use with pneumonia and dementia is controversial. I recommend that all adults over 50 get the pneumococcal vaccine, but it is particularly important in those who take PPIs. I have carefully read the studies on dementia, and at this point, I do not believe that there is a significant risk. However, I do warn patients that this is a possible side effect of long-term PPI use.

I see many patients who have taken PPIs for years; often they aren’t even sure why, so I do recommend stopping them. However, when a person needs them for symptom control, and a trial of H2 blockers isn’t effective, the benefits do outweigh the risks. I don’t know of any significant differences in risk among the available PPIs.

These medicines prevent the stomach cells from making acid. But there are side effects.

03/23/2026

DEAR DR. ROACH: I read your recent column about migraines and strokes. About 40 years ago, I began having occasional visual-interference episodes with zigzags, blurry central vision, and more that lasted for about 30 minutes. My doctor described them as ocular migraines.

When I read about migraines, the first possible cause that was listed were preservatives, so I started reading labels. My episodes occurred only after eating food with added nitrites and sulfates. It was very consistent, so I now read labels and avoid them. And thanks to the fact that more foods are now being made without them, at 85, I have not had an episode in many years. It has made me a more careful and healthy eater.

Would I still be more likely to have a stroke? Is this a common cause of these auras, or do causes vary in people? I would hope that others would find a sure cause and solution like I did. -- D.W.

ANSWER: Food additives, especially nitrites but also sulfites and sulfates, are known triggers of migraines in people who are susceptible. Finding and eliminating the triggers for migraines can be helpful, but not everyone is able to identify their triggers.

Red wine (which contains trace amounts of sulfites, even if more aren’t added) is one of the most common food triggers, but caffeine (and caffeine withdrawal) are another common cause. Poor sleep, excess stress, and hormonal changes (especially in menstruating women) are also commonly reported.

Some perceived triggers may actually be an early part of a headache. Chocolate cravings can be part of the prodrome of a headache, so people may think that chocolate caused the headache when, in fact, the headache was already on its way.

Headache with aura can be confused with a stroke. My column in January tried to point out that positive findings like zigzag lines make a migraine with aura very likely, while transient ischemic attacks and strokes are exceedingly unlikely.

However, there is an increased risk of stroke in people who have migraines with aura. This is particularly the case in younger women. I suspect but cannot prove that having fewer migraines after removing the triggers, as you have, probably does mitigate the small, increased stroke risk.

Still, it is important for all people with migraines to do what they can to reduce their stroke risk through a healthy lifestyle. Elevated blood pressure and cholesterol might be worth treating, even if they are fairly mild. Diabetes should be as well-controlled as possible. Finally, with strong evidence showing that the shingles vaccine reduces stroke risk, I’d recommend that you make sure you have had the two-dose shingles vaccine.

Finding and eliminating the triggers for migraines can be helpful, but not everyone is able to identify their triggers.

Keith W Roach, MD

04/01/2026

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