Keith W Roach, MD

02/18/2026

Dear Dr. Roach: I recall reading articles about prisoners who suffered horribly for minutes prior to dying, while undergoing a death sentence that was imposed on them for committing particularly serious crimes. Is there a medical reason as to why such prisoners can't be put under a deep sleep before undergoing the death sentence procedure?

— A.D.D.

Dear A.D.D.: Although I have also read and been horrified by the reports of suffering among death-row inmates, it is unethical for physicians to take any part in state-sanctioned killing. A physician's role is to heal.

While I understand your humane desire to relieve people's suffering, physicians should not place any intravenous lines, prescribe or administer lethal drugs, or provide advice on how to kill a prisoner, even if the goal is to reduce suffering. This is the position of the American Medical Association, the American Psychiatric Association, and the American College of Physicians. I am in complete agreement with this ethical guideline.

https://www.detroitnews.com/story/life/advice/2026/02/18/dr-roach-physicians-arent-allowed-to-take-part-in-state-sanctioned-killing/88606128007/ #

A physician's role is to heal.

02/18/2026

DEAR DR. ROACH: I wear a smart watch, and a few times now, it has alerted me that my heart rate is below 45 bpm. This has only occurred when I’m in my recliner, relaxing and starting to nod off.

I am a 61-year-old male who jogs 3 miles approximately three days a week. I also do “chair exercises” at the local senior citizen center twice a week. When I am out for a jog, my heart rate averages in the 140s-150s, so I don’t feel like I am pushing myself too hard.

Should I be concerned if/when my resting heart rate falls below 45 bpm? Other times when I’m in the recliner watching TV or just reading, it has hovered in the low 50s. When is a low heart rate too low? I should probably mention that I’m 6 feet, 3 inches tall and weigh 190 pounds. -- T.M.

ANSWER: In general, a low heart rate is too low when it is causing symptoms such as fatigue, lightheadedness or fainting. Heart rates in the 40s are not unusual for trained athletes, especially when they’re asleep, so I would not be concerned at all in your case.

I have had patients with the same story, except that the heart rate gets into the 30s and, on one occasion, the 20s. Even though these patients did not identify any symptoms, my cardiology colleagues still advised a pacemaker for this extremely slow heart rate.

After the pacemaker was placed, the patients did note that they felt a lot better. It turned out that they thought they were just getting old when, in fact, it was the slow heart rate that was keeping them from doing the things they wanted to do. It just happened so slowly that it was hard to notice.

It is true that as we get older, many different parts of the body don’t work the same way they did when we were younger. But a physician should think twice -- or even three times -- before blaming a patient’s symptoms just on their age.

Finally, even though your weight is appropriate for your height, a slow heart rate during sleep should make a physician think about obstructive sleep apnea. People of any age and size can get sleep apnea. The STOP-Bang (Snoring, Tiredness, Observed stop of breathing during sleep, high blood Pressure, BMI over 35, Age greater than 50, Neck size greater than 40 centimeters, and the male Gender) score can help identify your risk for sleep apnea. If you meet three or more (especially over five) of these criteria, a sleep study should be considered.

Low heart rate can cause dizziness, even fainting.

02/16/2026

Dear Dr. Roach: I have a diabetic nonhealing ulcer on my right heel. I was told that the blood circulation in my foot is not very good, which is why the ulcer is not healing.

Five years ago, I had a nonhealing ulcer in my left heel. It got infected, and the infection went into my heel bone. After several months, I agreed to an amputation. But this time, I was prescribed antibiotics with bandage changes that happen every two or three days. The ulcer has not healed now for over a month. Is it still possible that healing could take place?

— L.H.

Dear L.H.: I hope so. Most diabetic ulcers can be healed if they are treated the right way early enough. We really want to avoid amputations as they are bad for your function and cause worse outcomes later on.

One major issue is the poor blood flow to the area. People with diabetes may develop poor blood flow due to large arteries being blocked or when the small vessels are not working well. If there are blockages in large vessels, such as the femoral artery or one of its branches, then a vascular surgeon may be able to bypass the blockage. Newer techniques of angioplasty and stents may also be used and are less invasive and risky. But an angiogram is usually necessary to determine whether this approach would be useful.

If the poor blood flow is due to the small vessels, then surgical approaches are not as important as medication treatment and proper wound care. Diabetes needs to be meticulously managed, with blood sugar levels kept in the normal range as much as possible; a continuous glucose monitor can help determine if your regimen is adequate.

I cannot recommend highly enough an experienced wound care nurse, who is the expert in managing nonsurgical wounds (and postsurgical wounds, too). The pressure must come off the heel.

Nonhealing diabetic foot ulcers are one of the clearest indications for hyperbaric oxygen therapy. Not everyone has this therapy available, but it can be very useful in addition to standard therapy. Finally, antibiotics are guided by the results of wound cultures. These cultures need to be done by an expert to get the correct results.

I have a diabetic nonhealing ulcer on my right heel.

02/16/2026

DEAR DR. ROACH: I’m a 78-year-old white male who is a nonsmoker; I am 5 feet, 6 inches tall, weigh 135 pounds, and consider myself to be in excellent health.

A diagnosis from a recent bone density scan showed that my FRAX 10-year probability of a major osteoporotic fracture was 11.6%, and my probability of a hip fracture was 7.3%.

I exercise seven days a week and believe that my diet is excellent. My standard blood panel results are always normal in all categories. Would it be advisable for me to take Fosamax at a 70-mg dosage? -- C.Y.

ANSWER: The FRAX score is the easiest way of understanding the results of a bone density scan. Even though the odds are that in 10 years, you will not have had a fracture, your risk of a hip fracture is high enough that most experts would recommend treatment to lower your risk.

Generally speaking, treatment is recommended with a FRAX score above 20% for any major osteoporotic fracture or a score that is more than 3% for a hip fracture. Your risk for a hip fracture is significantly above the recommended threshold, even though your overall risk is not, which leads me to suspect that your hips are preferentially affected by osteoporosis.

If medication is recommended, a bisphosphonate such as alendronate (Fosamax) would normally be the first-line treatment for men, and 70 mg weekly is a common dosage.

The 78-year-old is very active and in excellent health, but his FRAX scores were high.

12/19/2025

Influenza is skyrocketing in my state, as in many others. Please, please, please get your flu shot if you haven’t, and wear a mask in crowded spaces, especially if you are at high risk. 

12/16/2025

DEAR DR. ROACH: I am a 68-year-old female who was first diagnosed with osteopenia and now osteoporosis. My physician has highly recommended medication or a monthly injection. I have completed hours of research and am very unhappy with the many personal stories of side effects. Evenity, the one drug that actually claims to rebuild bone, is not covered under Medicare, and the price is $2,086 per shot/per month for one year. (So sad!)

I read with great interest an article on the Osteoboost belt, which is the first medical device approved by the Food and Drug Administration. The clinical trial showed an average of 85% reduction in bone loss, and it was also used by astronauts to avoid bone loss while in space. Can this be true?

I asked my doctor about Osteoboost, and she stated that she doesn’t know anything about it. This was discouraging for me. I am hoping you have some insight or research you can share. I stay active with exercise and moderate weights, but Osteoboost has my interest. I hope some of the claims hold true. The price is over $900, so I’m hoping to hear some real and trusted information. -- K.S.R.

ANSWER: Osteoporosis is a big issue for many women and a few men, so new therapies are always of interest.

First, though, romosozumab (Evenity) is not the only medicine to rebuild bone. Older drugs like alendronate (Fosamax) slow the breakdown of bone, allowing the body’s natural rebuilding of bone to catch up. Anabolic agents like parathyroid hormone analogs (teriparatide) also directly increase bone growth.

Evenity is unique because it both slows down bone breakdown and stimulates new bone growth. It is usually covered 80% by Medicare in the United States when given in a doctor’s office, with most supplemental plans paying the rest. You should check with your insurance provider to see how much you would pay. There is a concern about Evenity increasing the risk of heart disease, so I have so far avoided recommending it to people who are at a higher risk for heart disease.

I have written before about the use of vibration machines like Osteoboost. Recent trials have shown an increase in bone density with the device but have not shown a reduction in fracture rates, as those trials need to be larger and of a longer duration than the trials that have been published so far.

Alendronate, teriparatide and romosozumab all have clinical trial data showing reductions in fracture rates. The vibration devices may reduce fall rates, which may help with fracture reduction.

Astronauts in space typically used resistive exercises to combat bone loss in low-gravity situations, although vibration studies performed on Earth were promising, and I saw a proposal for a trial on the International Space Station. Note that the device is not FDA-approved, but it is FDA-cleared, which requires less stringent scrutiny.

Drug-free regimens would be a large addition to the available therapies for osteoporosis, but I still await more studies before recommending vibration devices.

In addition to exercise, a diet high in natural calcium (such as dairy and fish with tiny bones, like anchovies and sardines) as well as vitamin D supplements can help prevent the progression of osteopenia and the worsening of osteoporosis. Five or six prunes a day also help to strengthen bones.

Recent trials have shown an increase in bone density with the device but have not shown a reduction in fracture rates.

12/15/2025

DEAR DR. ROACH: Everyone in my family except for me has converted to using almond milk instead of cow’s milk. I just saw something on the internet that says almond milk is possibly the worst plant-based milk substitute. I trust your opinion and research. Can you please educate me on what is best? Are plant-based milks really better than cow’s milk, and which plant-based milk is best? -- D.G.

ANSWER: When trying to compare plant-based milk substitutes with each other and with animal milks in their health impact, it’s important to look at what each of them have in terms of macronutrients and micronutrients.

Cow’s milk, like other animal milks, contains macronutrients like protein, sugars and fats as well as micronutrients like calcium. (Most cow’s milk is fortified with vitamin D.) While most North Americans consume adequate protein, many people try to increase their protein intake through cow’s milk.

Similarly, although the data are mixed, most experts agree that saturated fat, which is found in cow’s milk, increases heart disease risk. (Cow’s milk can be whole, low-fat, reduced fat or skim, varying in their percentages of overall fat.) However, cow’s milk contains beneficial fats like conjugated linoleic acid and methyl-branched-chain fatty acids. Most North Americans consume much more simple sugar than what is optimal with cow’s milk.

Almond milk has much less protein than cow’s milk (1 gram versus 8 grams), and the quality of the protein based on the amount of essential amino acids is less. Soy milk is much higher in protein than almond milk -- almost as much as cow’s milk, about 7 grams. Coconut milk has almost none.

However, almond and soy milk have no saturated fat (or almost none) and more monounsaturated fats. Coconut milk has about the same amount of saturated fat as cow’s milk. Almond, soy and coconut milks are typically fortified with calcium to match what is found in cow’s milk, but the calcium in plant milks is not absorbed as well.

Almond milk can be bought unsweetened or sweetened with typically 7-8 grams of sugar per cup, compared to 12 grams per cup in cow’s milk. Cow’s milk has multiple other micronutrients naturally, while plant-based milk is fortified with vitamin A and D.

So, is your family right that almond milk is the worst? No, I don’t think so. In my opinion, the nonexistent protein and high saturated fat content of coconut milk makes it the least acceptable from a health perspective. Soy and almond milk seem like the better alternatives, but neither of them is really comparable to cow’s milk in terms of other micronutrients.

The choice of almond versus soy milk is not clear from a health perspective, so your taste preference should be your guide. In all cases of plant-based milks, I recommend unsweetened and unflavored products.

Almond milk has much less protein than cow’s milk (1 gram versus 8 grams).

12/15/2025

DEAR DR. ROACH: I get regular pedicures. I never go for gel, but I often use a bright color. When the polish comes off, almost every single one of my nails is quite mottled with brown and white spots. Of course, I thought about not wearing polish and allowing the new nails to slowly grow out, but I can’t stand the look of my toes.

I know this is just a cosmetic problem. My pedicurist seems to know nothing about it. The real question is, what causes such gross discoloration in some people but not in other others? -- N.W.

ANSWER: I’ll bet you have keratin granules, which represent damage to the nail. They are often described to be chalky white and happen in many people if nail polish is left on too long (more than 7-10 days). Experts recommend an acetone-free remover when it’s time to remove them. You can also use a base coat to protect the nail. Let the nails go without polish periodically.

Fortunately, keratin granules are not dangerous and will grow out. They can be mistaken for toenail fungus, so your regular doctor or a dermatologist can help if these tips don’t stop them from developing.

12/12/2025

In my home state of New York, there is a lot of flu! Not a lot of Covid or RSV, but definitely get your flu shot as soon as possible if you haven’t already.

12/12/2025

I hope this will be interesting to my readers, but I am posting it mostly because it’s really excellent science writing.

A new study implicates a pair of substances secreted by immune cells in inducing myocarditis among mRNA-based COVID-19 vaccine recipients — and proposes a strategy to mitigate this effect.

12/12/2025

Dear Dr. Roach: You recently posted a couple of articles about the respiratory syncytial virus (RSV) vaccine and the benefits versus the risks. I know the risks are based on data. But I wonder how many people have severe reactions to the vaccine, and it doesn't get reported because they don't end up going to the hospital or the doctor.

I recently received the latest COVID and RSV vaccines, and four days later, I started experiencing extreme nausea and vomiting for two days, along with muscle aches, tingling, and hot and cold flashes. I was miserable and couldn't sleep. This happened over the weekend. If it had lasted until Monday, I would have gone to urgent care. But by Monday morning, I was feeling better, so it was never reported.I'm a 67-year-old female in relatively good health. But I feel like someone older experiencing what I experienced over the weekend could be very dangerous. I tried to drink as much water as I could, but it made me nauseous, as did any food. So, I ended up being pretty dehydrated. My point is that my fairly severe reaction was not reported, and I wonder how underreported these data really are.

— T.B.

Dear T.B.: I am sure you are right that many adverse vaccine events are not reported. Most patients don't report expected side effects from vaccines, and even when they do, a minority of providers will make a report to VAERS, the Vaccine Adverse Event Reporting System at the Centers for Disease Control.

However, providers are mandated by law to report certain serious adverse events from vaccines (those that are listed in the table of reportable events, which is vaccine-specific) or any adverse event that is listed by the manufacturer, which would prevent the person from getting any more doses of this vaccine.

I report unexpected side effects to VAERS, although most of my colleagues do not always do so. Many people do not know that they can also self-report to the VAERS system by going to VAERS.HHS.gov/reportevent.html.

The data on adverse events that I generally use for my column do not come from self-reports or physician reports; they come from the original studies on the vaccines, where all adverse events are carefully reported.

For RSV in particular, this means a study published in 2022 from Belgium, which showed that 72% of vaccine recipients (and 28% of the recipients who received a placebo, plain salt water) had at least one adverse reaction. The most common symptom was pain at the injection site (61%), but headache, fatigue and muscle aches were also fairly common.

Nausea and vomiting were not reported as side effects in the paper for RSV. However, nausea and vomiting were reported in 9% of Moderna COVID-19 vaccine recipients, compared to 8% in the placebo group. Taking the two vaccines at the same time makes side effects more likely and also makes it impossible to tell for certain which vaccine caused the side effect.

You are correct that there is underreporting of adverse effects from vaccines; however, in the vast majority of cases, the side effects from the vaccine are relatively mild and much less dangerous than getting the actual disease.

The Vaccine Adverse Event Reporting System (VAERS) is a national early warning system to detect possible safety problems in vaccines used in the United States. VAERS accepts and analyzes reports of adverse events (AEs) after a person has received a vaccination. Anyone can report an adverse event to....

12/11/2025

Dear Dr. Roach: I have benign prostatic hyperplasia (BPH), and I am taking tamsulosin daily. It works and helps with my daily urination. How long should I continue to take it? Are there any related side effects? Or should I consider an eventual prostatectomy? Thank you.

— A.

Dear A.: Tamsulosin is an effective treatment for most men with symptoms of an enlarged prostate. (BPH signifies noncancerous growth of the prostate gland.) It works by relaxing special muscle fibers in the prostate ("smooth muscle"), which allows the urethra — the tube that carries urine from the bladder outside of the body, going straight through the prostate — to drain the bladder faster and with less pressure.

The most common side effect of tamsulosin and similar medicines (called "alpha blockers") is lightheadedness, especially upon standing. Newer medicines like tamsulosin and alfuzosin are less likely to have this side effects compared to older medicines like doxazosin, but it can be a problem, especially when first using it.I tell my patients to first sit up on the bed, make sure that you are OK, stand up, make sure that you're OK again, then walk to the bathroom. Headaches, runny or stuffy nose, and ej*******on problems are other possible side effects. If you haven't developed these within a few weeks, you aren't likely to.

Before having cataract surgery, any person who has ever taken an alpha blocker should tell their eye surgeon. Tamsulosin is particularly likely to cause a problem called "intraoperative floppy iris syndrome," so the surgeon needs to be prepared just in case.

For my patients who are getting a good result with this class of medicine, I don't recommend changing it unless it stops working or they develop side effects. Before considering prostate surgery or another prostate procedure, such as laser, steam, freezing or embolization, I often recommend a second class of medicines, the 5-alpha reductase inhibitors finasteride or dutasteride. These take longer to work but have a benefit of reducing prostate cancer risk by about 60%.

Most men have a good outcome with traditional prostate surgery or one of the newer, less-invasive techniques. However, I have had a few of my own patients and many readers tell me that their symptoms worsened after this treatment. This is why I don't recommend surgery unless the medicines aren't working and the symptoms are bothersome enough to consider a procedure.

It works and helps with my daily urination.