My Health - Is adrenal fatigue “real”?

Low energy and tiredness are among the most common reasons patients seek help from a doctor. Despite being so common, it is often challenging to come up with a diagnosis, as many medical problems can cause fatigue. Doctors engage in detective work, obtaining a medical history, doing a physical exam, and doing blood tests. The results often yield no explanations. It can be frustrating for clinicians and patients when a clear-cut diagnosis remains elusive. An attractive theory, called adrenal fatigue, links stress exposure to adrenal exhaustion as a possible cause of this lack of energy.

But is adrenal fatigue a real disease?

The adrenals are two small glands that sit on top of the kidneys and produce several hormones, among them, cortisol. When under stress, we produce and release short bursts of cortisol into the bloodstream. The adrenal fatigue theory suggests that prolonged exposure to stress could drain the adrenals leading to a low cortisol state. The adrenal depletion would cause brain fog, low energy, depressive mood, salt and sweet cravings, lightheadedness, and other vague symptoms.

Numerous websites mention how to diagnose and treat adrenal fatigue. However, the Endocrinology Society and all the other medical specialties do not recognize this condition. The Endocrinologists are categorical: “no scientific proof exists to support adrenal fatigue as a true medical condition.” This disconnect between conventional and complementary medicine adds to the frustration.

A recent review of 58 studies concluded that there is no scientific basis to associate adrenal impairment as a cause of fatigue. The authors report the studies had some limitations. The research included used many different biological markers and questionnaires to detect adrenal fatigue. For example, salivary cortisol is one of the most common ordered tests used to make a diagnosis. The cortisol level, when checked four times in a 24-hour period, was no different between fatigued and healthy patients in 61.5% of the studies. The review raises questions around what should get tested (blood, urine, and/or saliva), the best time, how often, what ranges are considered normal, and how reliable the tests are, to name a few. In summary, there is no formal criteria to define and diagnose adrenal fatigue.

But what if I have symptoms of adrenal fatigue?

If you have tiredness, brain fog, lack of motivation, among other symptoms, you should first have a thorough evaluation with a medical doctor. Anemia, sleep apnea, autoimmune diseases, infections, other hormonal impairments, mental illnesses, heart and lung problems, and kidney and liver diseases are just some among many medical conditions that could cause similar symptoms. If the workup from your medical professional turns out normal and you believe you might have adrenal fatigue, I would recommend you consider a fundamental question: Why would your adrenals be drained? Take a better look at what types of stress might be affecting you. For many, the hectic pace of modern life is to blame.

The lack of a biological explanation can be disappointing. To make things worse, it’s not unusual for doctors to say “there is nothing wrong with you” or “this is all in your head.” The overwhelming amount of information on the Internet that recommends many types of treatment causes even more stress. Mental health conditions, such as depression or anxiety, may have symptoms similar to adrenal fatigue and may not respond well to antidepressants and counseling. And some patients do not believe that a mental health concern is the primary cause of their symptoms and many refuse medications due to concerns about their side effects.

So what’s a person to do?

Navigating this ocean of uncertainty is not an easy task. Symptoms associated with adrenal fatigue probably have multiple causes. Frequent follow-up visits and a strong patient-clinician partnership are critical elements for success. Alternative and complementary clinicians often have better results, because the appointments tend to last longer and they view patients through a more holistic lens. An important word of caution: some medical professionals prescribe cortisol analogs to treat adrenal fatigue. Cortisol replacement can be dangerous even in small doses. Unintended consequences can include osteoporosis, diabetes, weight gain, and heart disease.

Regardless of what we call it, there are millions of people suffering from similar symptoms, and a personalized plan that involves counseling, medications, supplements, lifestyle change, among others could work for many. Improvement following these programs is slow, and the evidence is weak, but I hope advances in big data, genomics and its the relationship with the environment and the microbiome, may shine a light on how to better help people who suffer from these ailments.

The adrenal fatigue theory may fit like a glove to explain your symptoms, which are very real. But before buying expensive protocols over the Internet to treat something we’re not even sure exists, take a deep dive and reexamine your lifestyle. The path to feeling better may be closer than you think.

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My Health - 4 tips for raising well-behaved children

Follow me on Twitter @drClaire

We all want our children to be well-behaved. We want our child to be the one who is kind, says “please” and “thank you,” does as he is told, and doesn’t get in trouble at school or bother kids at the playground. The problem, as any parent can attest, is that raising a well-behaved child is hard work.

Some of it is temperament — every child is different. Some children are rule-followers, and some of them, well, aren’t. But mostly it’s hard because it is an ongoing, exhausting process that requires that we always keep our eye on the ultimate goal (having a well-behaved child) rather than the short-term goal (such as having the screaming child in front of us stop screaming).

After more than 25 years of being both a pediatrician and a parent, here are four tips I think can make a big difference:

1.   Start early. It may be cute when your toddler hits somebody, and they are unlikely to do much harm, but if you wait until preschool or later to be clear that hitting isn’t okay, it’s going to be harder. Your child will be justified in her confusion: if something has been fine up until now, why isn’t it fine anymore? The earlier you teach your child that hitting or biting isn’t okay, and that “no” actually means “no,” the better.

There is a big caveat to this, though: it’s important to understand where your child is developmentally. A toddler doesn’t hit to be mean; she hits out of frustration and anger, or sadness. A 2-year-old doesn’t throw a tantrum to get back at you or ruin your day; he is doing it for the same reasons a toddler hits. So as you start early, the idea is to help your young child understand good and bad ways of expressing those emotions. It’s also important to understand what your child is capable of; there is only so much we can ask of any child at each stage of development. When you go for well-child appointments, talk with your doctor about realistic expectations for behavior at your child’s age.

2.   Be consistent. If jumping on the couch is fun, and sometimes Mommy and Daddy say no, but sometimes they let you, of course you are going to at least give it a try. But if you always say no, then your child learns the rules of the house and is less likely to jump on the couch. Once you’ve said no to something, it always needs to be no, which can be thoroughly exhausting — I understand that well. So pick your battles. Every family draws different lines in the sand. Any behavior that hurts someone (including hurting their feelings) or is dangerous should always be a no. And it’s good to teach children that certain settings (like religious services or public transportation, for example) require quieter, less active behavior — and to be respectful of others (being polite and sharing fall in there). But you can decide on the other rules. Maybe jumping on the couch is just fine in your house.

3.   Be loving. Catch them being good, too. Be very positive about good behaviors or when they pull it together and stop a bad behavior. When a child behaves well, we tend to take it for granted or are simply relieved, but a child deserves kudos for following the rules, not just punishments when they don’t. It also makes a difference to spend time with your children and show them that you are invested in them. It puts discipline in a context and makes it easier and more worthwhile for children to behave well for you.

4.   Set a good example. You can’t expect a child to say “please” and “thank you” if you don’t, or to treat others well if you don’t. Remember that children always pay way more attention to what we do than what we say. Just like Gandhi once said, “Be the change you want to see in the world.” Be the person you want your child to be.

If you are having a hard time, talk to your doctor. Some children have a tougher time than others, for all sorts of reasons; sometimes parents need help. Don’t be afraid to ask for help if you need it; it makes you a better parent when you do.

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My Health - Active mind/body, healthy mind/body

Spring is just around the corner and if you’re ready to reboot one of your New Year’s resolutions, here’s why exercise should be at the top of the list. Current medical research continues to robustly establish vigorous physical exercise as a major influence on overall health and well-being, in addition helping in the treatment of many diseases including depression, cardiovascular disease, diabetes, and arthritis. A recent study found that regular, intense exercise beneficially influenced the action of 400 genes — that’s right, 400 genes, a huge number — that produce proteins increasing the healthy functioning of mitochondria, the energy-producing machinery inside every cell. Exercise is synergistic with medicines and surgery. Developing, undertaking, and maintaining an exercise regimen is one of the best steps a person can take toward a self-actualized style of medical care.

An exercise “prescription”

We are a physician couple who have been physically active all our lives. We prescribe exercise regularly in our practices (one of us is a neurologist, the other a psychiatrist) and approach it in exactly the same way that we approach prescribing a medication, informing patients of dose and frequency benefits, possible side effects, and mechanisms of action. We describe a concrete regimen of exercise rather than simply saying, “exercise” and leaving it at that. Many patients don’t know how to get started, and specific details about using machines, weights, running, and other techniques prove valuable. Practical details are important, and we take time to answer any and all questions a patient might have. The physician-patient partnership around overall health goals is crucial. As partners, they can work together to include exercise as one tool among many to help achieve good health.

Follow-up is also key to encourage continued elaboration of goals, to educate about the interventions, and to support motivation. An exercise regimen is not static, and for best effect changes organically over time.

We have also found it is important to describe our own exercise experience, as a way of modeling what is possible.

Here’s how we make room for exercise

We have discovered many techniques that help us maintain our exercise routines in the face of the daily demands of busy lives. Here is a partial list.

• On Sunday night, when you think about your week, schedule your exercise just as you plan for work, errands, and other commitments. It’s easier to stick with it when you have concretely planned time.
• Mix it up. Plan different types of exercise to challenge different muscle groups, as research shows us this is the best way to stay in shape and develop endurance and muscle mass.
• Don’t get bogged down if you don’t have a lot of time. Research has demonstrated that intense, short bursts of exercise can be as effective as a longer workout, perhaps more so.
• Get your heart rate up, but watch it recover to baseline too. Wearing some type of heart rate monitor can be helpful.
• Try something new. Winter is a great time to try cross-country skiing. In the summer, why not go for a kayak paddle? Everything physical that you do counts as exercise.
• Find an exercise buddy. That way, if you want to beg off, your partner can motivate you, and vice versa. Our cardinal rule is: never miss your exercise session!
• Consider a consult with a personal trainer. You don’t need to commit to the time or expense of regular meetings, but a one-time consult can be informative and motivating.
• Keep an exercise journal, at least at the start. You will be surprised when you concretely see how much progress you are making (be sure to set goals).

Do remember to get an okay from your PCP before you start. And one last thing — it never fails to motivate us that exercise can decrease your risk of developing cognitive impairment. That thought has us lacing up our running shoes and heading out the door every time. Hope we see you out there.

Sources

Enhanced Protein Translation Underlies Improved Metabolic and Physical Adaptations to Different Exercise Training Modes in Young and Old Humans. Cell Metabolism, March 2017.

Three Minutes of All-Out Intermittent Exercise per Week Increases Skeletal Muscle Oxidative Capacity and Improves Cardiometabolic Health. PLOS One, November 2014.

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In a new online course from Harvard Health Publishing, Starting to Exercise, today’s leading fitness instructors show you workouts that work…the exercises that will help you enjoy a healthier, more vigorous, and longer life. You can access Starting To Exercise on your smart phone, tablet, or desktop computer. With easy log-in and simple-to-navigate screens, this online course is designed for adults of all ages.

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My Health - Spinning: Good for the heart and muscles, gentle on joints

As part of my 2018 fitness goals, I have resolved to spend two days a week in what I playfully call “the pain cave.”

No, it’s not a setting for Game of Thrones, but one of the most challenging (and rewarding) workouts I have ever tried: spinning, also known as indoor cycling.

Spinning classes are staples at most gyms, and there are even entire fitness centers devoted to nothing but spinning. A class typically lasts 45 minutes to an hour and is led by an instructor who guides everyone through a series of heart-pumping workouts. For instance, you might do speed work, where you pedal fast for brief periods followed by periods of rest and recovery. You also may do incline workouts, where you increase the resistance so it feels like you are cycling uphill.

If you haven’t tried spinning — or are looking for a way to liven up your exercise routine — you should give it a whirl, as it offers a wide range of benefits for people of all ages and fitness levels.

“Spinning is a great cardiovascular workout and can help build lower-body muscle strength,” says Greg Robidoux, a physical therapist with the Cycling Medicine Program at Harvard-affiliated Spaulding Rehabilitation Network.

It’s also perfect for people who don’t enjoy, or have difficulty doing, higher-impact cardio activities like running. Spinning is a low-impact exercise that places less stress on your joints, which makes it ideal for older adults with knee or hip issues or those recovering from orthopedic injuries.

Spinning classes are safe for most people, but get your doctor’s okay, especially if you have a heart problem or are recovering from an injury or surgery. “Once you are more comfortable on the bike, you easily can do your own workouts,” says Robidoux. “But you should experience several classes to get a feel for everything before going solo.”

Guidelines for a safe and effective workout

Look for proper credentials. Most spinning instructors are certified to teach spinning. Others may be only certified to teach aerobics, and while they may be experienced with spinning, they might be less knowledgeable about the equipment and how to move smoothly through different positions on the bike. Robidoux says to look for instructor certifications like Mad Dogg Spinning Instructor Certification, AFAA [Aerobics and Fitness Association of America], Indoor Cycling Certification, or Schwinn Indoor Cycling Certification.

Get fitted. Ask your instructor how to adjust the handlebar and seat height and position to ensure proper alignment, so you don’t put too much strain on your lower back and knees. Your legs should move in a circle with no jackhammer-like bouncing.

Take it easy at first. Only pedal at a pace that allows you to stay stable in the saddle, and never feel you have to do what everyone else is doing. “Go at a lower intensity if needed, stay in your comfort zone, and progress at your own pace,” says Robidoux. “It is perfectly fine to skip a workout, recover, and jump back in when you are ready, or do your own thing and just pedal.”

Keep it short. It’s okay to stay for only 20 or 30 minutes of a class at first, until you are more comfortable and your endurance increases.

Don’t forget a towel and water. You will sweat, so always have a towel handy to wipe your brow and a water bottle to stay hydrated.

Sit right. Also, invest in a pair of cycling shorts, which can make sitting on the saddle more comfortable.

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My Health - Transcranial magnetic stimulation (TMS): Hope for stubborn depression

Depression is the leading cause of disability in the United States among people ages 15 to 44. While there are many effective treatments for depression, first-line approaches such as antidepressants and psychotherapy do not work for everyone. In fact, approximately two-thirds of people with depression don’t get adequate relief from the first antidepressant they try. After 2 months of treatment, at least some symptoms will remain for these individuals, and each subsequent medication tried is actually less likely to help than the one prior.

What can people with depression do when they do not respond to first-line treatments? For several decades, electroconvulsive therapy (ECT or “shock therapy”) was the gold standard for treatment-resistant depression. In fact, ECT is still considered to be the most potent and effective treatment for this condition, and it continues to be used regularly across the country. For many people with depression, however, ECT can be too difficult to tolerate due to side effects on memory and cognition. For those individuals and the many others who have had an inadequate response to medications and therapy alone, there is a newer treatment option called transcranial magnetic stimulation (TMS).

What is transcranial magnetic stimulation?

Transcranial magnetic stimulation, or TMS, is a noninvasive form of brain stimulation. TMS devices operate completely outside of the body and affect central nervous system activity by applying powerful magnetic fields to specific areas of the brain that we know are involved in depression. TMS doesn’t require anesthesia and it is generally exceptionally well tolerated as compared to the side effects often seen with medications and ECT. The most common side effect is headache during or after treatment. A rare but serious side effect is seizures, and TMS may not be appropriate for people at high risk such as those with epilepsy, a history of head injury, or other serious neurologic issues.

Does TMS work?

Approximately 50% to 60% of people with depression who have tried and failed to receive benefit from medications experience a clinically meaningful response with TMS. About one-third of these individuals experience a full remission, meaning that their symptoms go away completely. It is important to acknowledge that these results, while encouraging, are not permanent. Like most other treatments for mood disorders, there is a high recurrence rate. However, most TMS patients feel better for many months after treatment stops, with the average length of response being a little more than a year. Some will opt to come back for subsequent rounds of treatment. For individuals who do not respond to TMS, ECT may still be effective and is often worth considering.

What is TMS therapy like?

TMS therapy is an intensive treatment option requiring sessions that occur 5 days a week for several weeks. Each session may last anywhere from 20 to 50 minutes, depending on the device and clinical protocol being used. When patients arrive, they may briefly check in with a technician or doctor and then begin the stimulation process. The technician will determine the ideal stimulation intensity and anatomical target by taking advantage of a “landmark” in the brain called the motor cortex. By first targeting this part of the brain, the team can determine where best to locate the stimulation coil as it relates to that individual’s brain and how intensely it must “fire” in order to achieve adequate stimulation. Calculations are then applied to translate this data toward finding the dorsolateral prefrontal cortex, the brain target with the greatest evidence of clinical effectiveness and an area known to be involved in depression. Though one session may be enough to change the brain’s level of excitability, relief isn’t usually noticeable until the third, fourth, fifth, or even sixth week of treatment.

Can TMS help with other conditions?

TMS is being studied extensively across disorders and even disciplines with the hope that it will evolve into new treatments for neurological disorders, pain management, and physical rehabilitation in addition to psychiatry. There are currently large clinical trials looking at the effectiveness of TMS in conditions such as pediatric depression, bipolar disorder, obsessive-compulsive disorder, smoking cessation, and post-traumatic stress disorder. While promising avenues for research, TMS for these conditions is not yet approved and would be considered “off-label.”

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My Health - Diet and depression

Just this week, I have seen three patients with depression requiring treatment. Treatment options include medications, therapy, and self-care. Self-care includes things like sleep, physical activity, and diet, and is just as important as meds and therapy — sometimes more…

In counseling my patients about self-care, I always feel like we don’t have enough time to get into diet. I am passionate about diet and lifestyle measures for good health, because there is overwhelming evidence supporting the benefits of a healthy diet and lifestyle for, oh, just about everything: preventing cardiovascular disease, cancer, dementia, and mental health disorders, including depression.

Diet and emotional well-being

Diet is such an important component of mental health that it has inspired an entire field of medicine called nutritional psychiatry. Mind-body medicine specialist Eva Selhub, MD has written a superb summary of what nutritional psychiatry is and what it means for you right here on this blog, and it’s worth reading.

What it boils down to is that what we eat matters for every aspect of our health, but especially our mental health. Several recent research analyses looking at multiple studies support that there is a link between what one eats and our risk of depression, specifically. One analysis concluded:

“A dietary pattern characterized by a high intake of fruit, vegetables, whole grain, fish, olive oil, low-fat dairy and antioxidants and low intakes of animal foods was apparently associated with a decreased risk of depression. A dietary pattern characterized by a high consumption of red and/or processed meat, refined grains, sweets, high-fat dairy products, butter, potatoes and high-fat gravy, and low intakes of fruits and vegetables is associated with an increased risk of depression.”

Which comes first? Poor diet or depression?

One could argue that, well, being depressed makes us more likely to eat unhealthy foods. This is true, so we should ask what came first, the diet or the depression? Researchers have addressed this question, thankfully. Another large analysis looked only at prospective studies, meaning, they looked at baseline diet and then calculated the risk of study volunteers going on to develop depression. Researchers found that a healthy diet (the Mediterranean diet as an example) was associated with a significantly lower risk of developing depressive symptoms.

So, how should I counsel my patients on diet? There are several healthy options that can be used as a guide. One that comes up again and again is the Mediterranean diet. Another wonderful resource for folks is the Harvard T. H. Chan School of Public Health website with an introductory guide to healthy diet.

The bottom line

The gist of it is, eat plants, and lots of them, including fruits and veggies, whole grains (in unprocessed form, ideally), seeds and nuts, with some lean proteins like fish and yogurt. Avoid things made with added sugars or flours (like breads, baked goods, cereals, and pastas), and minimize animal fats, processed meats (sorry, bacon), and butter. Occasional intake of these “bad” foods is probably fine; remember, everything in moderation. And, for those who are trying to lose weight, you can’t go wrong with colorful fruits and veggies. No one got fat eating berries or broccoli. Quality matters over quantity. And when it comes to what we eat, quality really, really matters.

Resources

Dietary patterns and depression risk: A meta-analysis. Psychiatry Research, July 2017.

Diet quality and depression risk: A systematic review and dose-response meta-analysis of prospective studies. Journal of Affective Disorders, January 15, 2018.

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My Health - 12 Home Remedies For Bronchitis Cough

12 Home Remedies For Bronchitis Cough

Health and Fitness Tips
Health is the level of functional and metabolic efficiency of a living organism. In humans it is the ability of individuals or communities to adapt and self-manage when facing physical, mental, psychological and social changes with environment.

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My Health - Dr. Google: The top 10 health searches in 2017

Follow me on Twitter @RobShmerling

Ever wonder what other people are wondering about? I know I do.

So, here are the top 10 health searches in Google for 2017. And just so you don’t have to look each one up, I’ve provided a brief answer. You’re welcome.

1.  What causes hiccups?

I was surprised this one made it to the top 10 list of health searches. Maybe this search is common because hiccups are as mysterious as they are universal. I’ve written about hiccups before, but let’s just say the cause in any individual person is rarely known or knowable. Then again, the reason hiccups stop is also unknown.

Some triggers include an overly full stomach, drinking too much alcohol, sudden changes in temperature, smoking cigarettes, excitement, stress, or other heightened emotions. More rarely, they are caused by a specific, identifiable disease, such as thyroid enlargement, a tumor in the neck, or kidney failure.

2.  What can I do to stop snoring?

It’s easy to see why this one might be high on the search list. And my guess is that the person googling this question is more often the bed partner, not the snorer. Common recommendations to reduce or eliminate storing include:

• Change body position (by elevating the head of the bed or sleeping on your side).
• Lose excess weight.
• Cut back on (or cut out) alcohol consumption.
• Reduce or avoid nasal congestion (by treating allergies, using a humidifier, anticongestion medications, or sinus rinses).
• Avoid medications (such as diazepam [Valium]) that relax muscles around the airway.
• Use an antisnoring device (whether over-the-counter solution or one recommended by your doctor or dentist).

3.  What causes kidney stones?

It has been said that kidney stones cause more pain than almost any other disease. So anyone suffering from kidney stones has a strong incentive to avoid the next one. The most common causes and risk factors include

• kidney disease that alters how the body processes calcium
• urinary tract infection with certain bacteria
• certain dietary habits, such as eating a lot of sodium and not drinking enough fluid
• genetic tendency (as kidney stones can run in families)
• digestive conditions that affect nutrient absorption (such as chronic diarrhea or previous gastric bypass surgery)
• certain medications (such as acyclovir and triamterene)
• certain diseases (such as obesity, gout, and high blood pressure).

4.  Why am I so tired?

This is a tough one because there are so many causes of tiredness and even the term “tired” can mean many different things including fatigue, lack of energy, sleepiness, weakness, and so on. Here are some of the most common causes of feeling tired

• an infection, such as the flu or pneumonia
• heart failure
• sleep apnea
• an underactive thyroid (hypothyroidism)
• liver disease (including hepatitis or cirrhosis)
• anemia
• a rheumatologic condition, such as rheumatoid arthritis
• depression or anxiety
• a side effect of a medication or drug
• chronic fatigue syndrome (in which the true cause is unknown)

Although there are many reasons for significant fatigue, the cause is frequently unknown (even after extensive evaluation).

5.  How long does the flu last?

The average, uncomplicated influenza infection lasts about 5 days. However, it’s not rare for symptoms to last a week or more.

6.  What is normal blood pressure?

Until recently, 120/80 or less was considered a normal blood pressure and 140/90 or higher was considered high blood pressure (hypertension). Intermediate readings were considered “elevated blood pressure” but not high blood pressure.

However, in November of 2017, the American Heart Association and the American College of Cardiology revised their guidelines to include 130/80 or higher as indicative of hypertension. As with all measures related to human bodily function, there is a range of normal. A blood pressure of 100/60 might be normal for a young, healthy adult but it might be too low for an elderly adult who is dizzy whenever he or she stands up.

7.  How to lower cholesterol?

Ways to lower cholesterol include:

• Change your diet by avoiding foods high in saturated fat such as red meat, cheese, and fried foods.
• Lose excess weight.
• Increase physical activity.
• Take prescribed medications.

8.  What causes high blood pressure?

In most cases, no specific cause can be found. However, risk factors and triggers include

• dietary factors (such as a high sodium diet or high alcohol consumption)
• advancing age
• excess weight
• genetic factors
• ethnicity (For example, hypertension tends to be more severe, start sooner, and occur more commonly among blacks.)
• kidney and vascular disease
• a sedentary lifestyle
• certain medications (such as anti-inflammatory and decongestant drugs, and illicit drugs such as cocaine)
• sleep apnea.

9.  What is ADHD?

“ADHD” stands for attention deficit hyperactivity disorder and refers to a condition in which a person finds it difficult to concentrate, focus, or sit still. This can lead to poor decision making, struggles in school or work, and difficulty maintaining relationships.

10.  What is lupus?

The term “lupus” includes a number of conditions, though it usually refers to “systemic lupus erythematosus,” a condition in which the immune system appears to react against tissues throughout the body. This may lead to inflammation in the skin, joints, heart and lungs, kidneys, brain, and other parts of the body. The cause is unknown and treatment usually involves suppressing the immune system.

Anything else?

If your question isn’t on this list, the Internet might have your answer. But, be aware that not all information on the web is reliable. I generally recommend websites affiliated with major medical centers or run by academic institutions (and be wary of those trying to promote a specific product or procedure). As always, if you have a specific question or concern about your health, it’s usually best to ask your doctor.

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My Health - Guns are killing our children. It’s time we did something

Follow me on Twitter @drClaire

We are all reeling from the news of the school shooting in Parkland, Florida that left 17 dead and 14 injured. A 19-year-old former student has confessed to the shooting. He used a semiautomatic weapon that he purchased legally a year ago.

Five years ago, when a gunman opened fire with a similar weapon at Sandy Hook elementary school in Newtown, Connecticut, killing first-graders and teachers, there was an uproar: we must stop this from happening, we said. We must do something.

But we didn’t.  And since the shooting at Sandy Hook, there have been at least 239 school shootings, with more than 400 people shot and 138 killed. And those are just school shootings; many more have been killed in other shootings, such as shooting in Las Vegas on October 1, 2017 that killed 58 people.

For many reasons, as a country we have struggled to take actions that limit access to guns. We take the Second Amendment very seriously: “A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.” The problem is, too many guns aren’t being used as part of a well-regulated militia — or for hunting or sport. They are being used by angry or mentally ill individuals to kill innocent people, including innocent children.

People kill, gun rights advocates say, not guns. And that is true. But without the guns, especially without guns like the one used in Parkland, they would be killing many fewer people, perhaps none at all. It isn’t just about the people and their mental health problems. It’s also about the guns.

Every year, 1,300 children under the age of 18 die from injuries due to firearms. If you expand the age to 21, that number is nearly tripled to 4,500 — and 20,000 are seen in emergency rooms for firearm-related injuries.

It’s time we faced facts and did something about the public health crisis of gun violence. The American Academy of Pediatrics has pointed out that there are some policy actions we could take that could make a tremendous difference:

• We should have a ban on assault weapons, and we should include in that ban guns like the ones used in Parkland, Newtown, and Las Vegas. As a nation, we need to have a very serious conversation about why anyone needs to own a gun that can shoot many bullets very quickly.
• We need stronger background checks, mandatory waiting periods and mental health restrictions for gun purchases. We need to close the gun show loophole, and do a better job of stopping gun trafficking.
• We need to make safe storage the law. We need trigger locks, lock boxes, gun safes and legislation to make sure they are used.
• We need mental health services to be widely and easily available, to help people before they think of using a gun on others or themselves.

Individual gun owners can help by making sure that their guns are safely locked and out of reach, with ammunition locked separately. A study published in 2017 found that 39% of parents wrongly thought their children didn’t know where their gun was stored.

We also need to do a better job of speaking up — and reaching out and taking action — when people talk about violence. The shooter in Parkland had been quite vocal on social media and with friends about his gun ownership and thoughts of hurting people. We can’t ignore or dismiss things like this. Just as important, we need to give law enforcement as well as friends and family members real tools to be able to intervene, get the person help and keep others safe.

We can’t wait any more. We can’t let any more children die. Our children need to be more important than our guns.

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My Health - Is red wine good actually for your heart?

Have you ever topped off your glass of cabernet or pinot noir while saying, “Hey, it’s good for my heart, right?” This widely held impression dates back to a catchphrase coined in the late 1980s: the French Paradox.

The French Paradox refers to the notion that drinking wine may explain the relatively low rates of heart disease among the French, despite their fondness for cheese and other rich, fatty foods. This theory helped spur the discovery of a host of beneficial plant compounds known as polyphenols. Found in red and purple grape skins (as well as many other fruits, vegetables, and nuts), polyphenols theoretically explain wine’s heart-protecting properties. Another argument stems from the fact that the Mediterranean diet, an eating pattern shown to ward off heart attacks and strokes, features red wine.

However, the evidence that drinking red wine in particular (or alcohol in general, for that matter) can help you avoid heart disease is pretty weak, says Dr. Kenneth Mukamal, an internist at Harvard-affiliated Beth Israel Deaconess Medical Center. All of the research showing that people who drink moderate amounts of alcohol have lower rates of heart disease is observational. Such studies can’t prove cause and effect, only associations.

Moderate drinking — defined as one drink per day for healthy women and two drinks per day for healthy men — is widely considered safe. But to date, the health effects of alcohol have never been tested in a long-term, randomized trial.

Grape expectations

Although some studies suggest wine is better for the heart than beer or hard liquor, others do not, according to a review article about wine and cardiovascular health in the Oct. 10, 2017, issue of Circulation. That’s not surprising, says Dr. Mukamal. “In many cases, it’s difficult to tease out the effect of drinking patterns from specific types of alcoholic beverages,” he explains. For example, people who drink wine are more likely do so as part of a healthy pattern, such as drinking a glass or two with a nice meal. Those habits — rather than their choice of alcohol —may explain their heart health.

Also, the French Paradox may not be so paradoxical after all. Many experts now believe that factors other than wine may account for the observation, such as lifestyle and dietary differences, as well as earlier underreporting of heart disease deaths by French doctors. What’s more, Dr. Mukamal notes, heart disease rates in Japan are lower than in France, yet the Japanese drink a lot of beer and clear spirits, but hardly any red wine.

Resveratrol reservations

What about the polyphenols in red wine, which include resveratrol, a compound that’s heavily advertised as a heart-protecting and anti-aging supplement? Research in mice is compelling, says Dr. Mukamal. But there’s zero evidence of any benefit for people who take resveratrol supplements. And you’d have to drink a hundred to a thousand glasses of red wine daily to get an amount equivalent to the doses that improved health in mice, he says. Also, a 2014 study of older adults living in the Chianti region of Italy, whose diets were naturally rich in resveratrol, found no link between resveratrol levels (measured by a breakdown product in urine samples) and rates of heart disease, cancer, or death. As for the Mediterranean diet, it’s impossible to know whether red wine is an important part of why that eating style helps reduce heart disease, says Dr. Mukamal.

If you enjoy red wine, be sure to limit yourself to moderate amounts. Measure out 5 ounces (which equals one serving) in the glass you typically use. Five ounces appears smaller in a large goblet than in a standard wine glass. Also, older men should be aware that both the National Institute of Alcohol Abuse and Alcoholism and the American Geriatric Society recommend that starting at age 65, men should limit their alcohol use to no more than a single drink per day. Age-related changes, including a diminished ability to metabolize alcohol, make higher amounts risky regardless of gender.

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My Health - Avoid These 9 Foods When You Have A Migraines

Avoid These 9 Foods When You Have A Migraines

Health and Fitness Tips
Health is the level of functional and metabolic efficiency of a living organism. In humans it is the ability of individuals or communities to adapt and self-manage when facing physical, mental, psychological and social changes with environment.

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My Health - Stem-cell transplant: A possible high-risk/high-reward treatment for scleroderma

Follow me on Twitter @RobShmerling

Some medical news stories don’t get the attention they deserve. Perhaps it’s because the disease is rare and not many people have ever heard of it.

I think this story about a new treatment for scleroderma is a good example.

What’s scleroderma?

The term “scleroderma” means “hard skin.” The name comes from the way it causes thickening and hardening of the skin. With “limited scleroderma,” the disease is mostly confined to the skin. With the “systemic” form of disease, other major organs, including the digestive tract, lungs, heart, and kidneys, may be affected as well. It is considered an “autoimmune disease”; there is evidence that the immune system of people with scleroderma is abnormal and appears to be attacking its host.

Better treatments are needed

Since the disease was first described by Hippocrates around 400 bc, reliably effective treatments have been unavailable. Existing treatments include moisturizers, medications to prevent heartburn and to improve circulation, and immune-suppressing medications. However, despite treatment, many people continue to suffer with bothersome symptoms and life-threatening complications such as severe scarring of the lungs or kidney failure.

A new study of stem-cell transplantation for scleroderma

Researchers publishing in a recent edition of the New England Journal of Medicine describe a new approach to treating severe scleroderma: stem-cell transplantation. With this treatment, stem cells (which can develop into many different types of cells) are removed and the body’s immune system is essentially wiped out with chemotherapy and radiation. The stem cells are then returned to the body where they rebuild the immune system — a sort of “rebooting” of the immune system.

It’s risky, especially soon after treatment begins, because there is a period of time in which the immune system doesn’t function well enough to protect the person from infections. In this study, 36 people with severe scleroderma received stem-cell transplantation and were compared with 39 otherwise similar people who received a year of standard immune-suppressing medication.

After 4.5 years, those assigned to receive stem-cell transplantation had

• improved overall survival compared with standard treatment (79% vs. 50%)
• less need for immune-suppressing medication (9% vs. 44%)
• fewer deaths related to worsening scleroderma (11% vs. 28%)
• more deaths related to treatment — (3% vs. 0%).

These findings suggest that stem-cell transplantation may be much better than standard treatment for people with severe scleroderma even though it is riskier in the short run.

What’s next?

Despite these encouraging results, other researchers need to reproduce these findings with larger and longer-term trials. And even if confirmed, there’s still plenty of room for improvement. Twenty-one percent of study subjects treated with stem-cell transplantation died within 5 years of treatment and treatment-related deaths were more common in this group. So, you can expect to hear about additional research that seeks to refine stem-cell transplantation and other treatment approaches for scleroderma.

Scleroderma remains a mysterious and sometimes deadly disease despite decades of research.  So, you can also expect researchers to report on new findings regarding how and why it develops in the first place. In addition, stem-cell transplantation would not be appropriate for less severe cases of scleroderma; we need better treatments for them as well.

News such as this represents progress for a condition that badly needs it. While you may not have heard much about this study in the news, it’s certainly one that will catch the attention of people with scleroderma, their loved ones, and their doctors.

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My Health - How to welcome back a colleague who is in recovery

It can be awkward or difficult to welcome back a colleague who has been absent for reasons related to mental health. These issues, historically, have been taboo, and are loaded with stigma. It is hard to know how to act toward a colleague who has returned from treatment for a mental health issue. Do I ask about it? Do I pretend that nothing happened? Do I say that I hope they are feeling better? Usually, none of these options feels right.

This difficulty is particularly true when colleagues return from being treated for problems with drugs or alcohol. The stigma in our society against people suffering from addiction is rampant and deadly. I have experienced such stigma myself and have written about it here. Many people view “addicts” as morally impaired and deserving of scorn and derision, and not worthy of compassion and care.

Fortunately, as our society comes to understand addiction as a brain disease, and as a medical problem much like diabetes or cancer, our unhelpful attitudes about addiction are starting to change. Addiction has nothing to do with a lack of morals or character, and people certainly shouldn’t be blamed for having an addiction any more than you would blame them for having cancer. But prejudices fade slowly. Even progressive people with the best intentions can still have implicit bias toward people suffering from substance use disorders who are returning to their workplace.

What can I do to support my coworker?

A good first step toward successfully supporting a person in recovery is to honestly examine your own beliefs and feelings about addiction, and to make sure that your response to the colleague you are about to welcome back isn’t hampered by any hidden negative attitudes. If you find yourself uncomfortable with the idea of working with an addict, there are many ways you can learn more about addiction to become more comfortable and educated about the subject.

It is critically important to try to understand what your colleague might be experiencing as they reenter the workforce. Most people who are early into their recovery process suffer from guilt, embarrassment, and shame, and it takes a lot of courage for them to walk through the front door on their first day back at work. They most likely feel quite vulnerable and fragile, and it is helpful to be sensitive to their state of mind, and to be as open and welcoming as possible.

There is no fixed formula for how to help someone who is returning to work after suffering from a substance use disorder. It partly depends on your relationship to them, both personally and professionally. It also depends on a keen reading of the returning person’s personality, as some people are going to want everything out in the open from day one, and others are going to feel more comfortable being discreet. If you are comfortable offering a listening ear, then be receptive to any overtures they might make to discuss their addiction. You can welcome any discussions they might start about their experiences, their addiction, struggles they may be having, and help they might need, including the possibility that they are struggling with a relapse. Colleagues can be a critical source of strength and support, and it’s important not to miss any opportunities that arise where you can help.

What can we learn from people in recovery?

As more people with substance use disorders recover and return into the workforce, it will be increasingly understood that recovery from addiction is about far more than not taking drugs. Recovery is about learning to listen, having humility, and connecting with other people. These are ideal traits that foster a healthy and productive work environment. Rather than being a burden, the employee who is recovering from addiction can very likely be a role model for other workers, and should be welcomed with open arms to any job in today’s economy, where communication and being a team player are highly valued. I predict that today’s stigma will give away to tomorrow’s embrace.

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My Health - February and the heart: More than Valentine’s Day

Today is Valentine’s Day and many of us turn our thoughts to hearts and love. But there is more than one day this month to think about the heart and heart health.

February is Heart Month, and with it, I hope many people make a commitment to getting heart healthy. As a cardiologist, many well-intentioned people will come to my office seeking guidance, especially about weight loss. While January sees an uptick in gym memberships, by the time February rolls around, dedication to working out becomes challenging. Exercise is, of course, heart healthy and everyone should make an effort to stay physically active. But, few people can lose weight with exercise alone, and for weight loss, this dreaded phrase still rings true: count your calories.

After a decade of devising many approaches to help motivate my patients, it turns out that perhaps the simplest plan has been our most successful. Sharing is caring, as my father-in-law used to say, so here we go.

Three simple steps toward weight loss and a healthier heart

1.   Picture a plate as a peace sign (or Mercedes sign if you prefer), with three equal sections. If you have trouble picturing thirds, then I recommend buying a set of sectional plates for the house. They work for those under the age of 10 as well, should you have picky eaters (also known as children). Now, place a different food group or item in each section. I am friendly with many of my patients, so the smart alecks will sometimes ask: does splitting a burger into thirds count? (It doesn’t.)

2.   No seconds. It’s really that simple. Mindful eating is an exciting method that is catching on, generally with people who already are into a healthy lifestyle. I myself took a class in it. While it is fun in the moment … it is very hard to teach others. However, if family and friends are partaking in “seconds” while you are at the table … slowing down your pace and enjoying your food is your only defense. “No seconds” breeds mindful eaters.

3.   Have three bites of anything yummy and delicious. Whether you have a sweet tooth or it’s the savory items that excite you, three bites is the limit. The first bite is because you want it. Enjoy it. The second bite is an act of defiance. Revel in it. The third bite is the last and should be savored the most. It is the last one because you respect yourself and have a laudable goal that you will achieve. Some people have asked whether we could stretch that out to five bites. A few thoughts. In five bites, I could finish a large slice of pumpkin pie (and this is in fact a diet). We don’t like calling it this, but in essence we are curbing calories. So no. Three bites it is.

Finding your plan for a healthy weight and a healthy heart

This plan may not work for everyone. For those who can afford dieting systems with prepared foods, or are facile with calorie-counting apps, those may be better. But for the average person, who just wants to see some progress in his or her weight loss, this might be for you. Some people hear this and think it will be easy, until they start. Others are concerned that it seems too restrictive, but the process is actually easier than they thought. Most people are able to stick with it long enough to see some small gains (actually, losses J), which is sometimes all the motivation you need to dedicate yourself to the plan for a bit longer. Whatever your plan, make it approachable, stick with it, and forgive yourself if you stray — but get back on board quickly.

Happy Valentine’s Day to all, and here’s to a healthy and well-moderated New Year.

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My Health - This Valentine’s Day, 14 ways parents can show love for their children

Follow me on Twitter @drClaire

Valentine’s Day — a day we associate with love. Usually we think of the day in terms of romantic love, with cards and flowers for our partner, but it can also be a day to show love for our children and to think about how we can better make our children feel loved all year round.

When children feel loved, it not only builds happiness, but confidence and resilience, both of which can make a lifelong difference. That’s why the American Academy of Pediatrics suggests these 14 tips for this February 14^th

1.   Be positive and encouraging when you talk with your children. Skip the sarcasm and put-downs, even if you are joking. Think about the “Golden Rule.” Treat your children the way you’d like to be treated.

2.  Say things like “please,” “thank you,” and “I’m sorry.” Be kind and polite. Not only does it show respect and kindness to your children, it sets a good example about how to talk to people generally.

3.  Respond promptly to your children’s physical and emotional needs, even if it’s not the best time for you. Put aside what you are doing, turn off the TV or computer, and listen or help. It sends the message that your children matter more than anything. Ask them about their day — and pay attention to the answer.

4.  When your children are angry or just in a bad mood, instead of getting angry or in a bad mood yourself, try giving them a quick hug or other sign of affection they respond to — and talking to them about it when they’re feeling better instead of in that moment.

5.  Use nonviolent forms of discipline. All hitting does, besides making children upset and afraid, is teach them that it’s okay to hit, which isn’t a great lesson to learn. Discipline works best when it’s started early and done consistently. From an early age, set rules about behavior, and stick to them — and remember to reward children for following the rules instead of just punishing them for breaking them.

6.  Spend alone time with your children on a regular basis, doing something they enjoy. If you have more than one child, make sure that each one gets some one-on-one time with you.

7.  Spend time together as a family, like family game night, or family outings, and turn off your devices during those family times.

8.  If you can, get a pet. Having a pet can be not just fun but can help children learn lessons about caring for someone and being responsible. If it’s a dog that needs walking it can make them more active. And no matter what it is, it gives them another friend.

9.  Cook and eat together. Cooking together teaches children about good food choices and gives them cooking skills they can take into adulthood. Eating family meals brings families together and can be a great opportunity to connect and hear about each other’s lives and ideas. Turn off all phones during meals (including yours).

10.  Speaking of devices… don’t let them take over your children’s lives. Read to your children and encourage reading as they grow. Limit the amount of “screen time,” both by having time limits but also by having other things to do, like arts and crafts, building toys, and other things that encourage creativity and imagination (and are fun).

11.  Take your children to the doctor regularly for checkups — and listen to your doctor’s advice about healthy diet, safety, sleep, and physical activity. Follow that advice yourself, too, so you are setting a good example.

12.  Help your children build positive relationships with siblings, friends, and others. Set a good example by inviting friends and neighbors to share a meal, and by joining community activities.

13.  Help your children learn their strengths — and learn to believe in themselves. This involves not just supporting them but giving the independence they need to become competent and capable — and learn from their mistakes.

14.  Don’t forget to say, “I love you.” Not just now, but for the rest of their lives.

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My Health - Calcium, vitamin D, and fractures (oh my!)

When I saw the headlines about this recently published study on bone health saying “Vitamin D and calcium supplements may not lower fracture risk” I thought: Wait, that’s news? I think I remember seeing that headline a few years ago.

Indeed, in 2015, this very blog reported on similar studies of calcium supplements, noting that calcium supplements have risks and side effects, and are not likely indicated for most healthy community-dwelling adults over 50. These folks are not in a high-risk category for vitamin deficiencies, osteoporosis, and fractures, and we usually advise them to get their calcium from food. Dietary sources of calcium are everywhere, including milk and yogurt, but also include green leafy veggies like collard greens, legumes like black-eyed peas, tofu, almonds, orange juice… the list goes on (and you can check it out here).

What’s new with this most recent study?

This research found that taking vitamin D supplements did not protect against fractures in people over 50. The authors examined 33 research studies including over 50,000 people for their analysis. However, and it’s a big however, study investigators note several times that their research included only healthy people out in the community, and that their findings do not apply to elderly people living in nursing homes who may have a poorer diet, less sun exposure and mobility, and who are at particularly high risk for fractures. Indeed, the original recommendations for calcium supplementation were based on a study of elderly, nursing-home bound women with vitamin deficiencies and low bone density, for whom calcium and vitamin D supplements did significantly reduce fracture risk.

What is the takeaway?

Well, simply, not much has changed. My advice to my healthy patients is still to get calcium from foods, and the best diet for this is a Mediterranean-style diet rich in colorful plants, plenty of legumes, and fish. This plus high-protein, low-fat, and low-sugar dairy (yogurt is ideal) can supply plenty of calcium. As far as vitamin D, well, vitamin D supplementation continues to be a topic of lively and livid debate among everyone, including competing guideline-authoring endocrine experts (see my Harvard Health Blog post on this). I hesitate to wander into that minefield again. But here goes…

The scoop on vitamin D deficiency

There is a large group of people who are likely to be deficient in vitamin D. It includes people with eating disorders; people who have had gastric bypass surgeries; those with malabsorption syndromes like celiac sprue; pregnant and lactating women; people who have dark skin; and those who wear total skin covering (and thus absorb less sunlight). In addition, people with or at risk for low bone density (perimenopausal and postmenopausal women, people diagnosed with other skeletal disorders, or who take certain medications), should discuss whether they need supplements and to have blood levels of vitamin D monitored.

Many New England-dwelling (and Northern hemisphere) residents are at risk for a dip in vitamin D levels during the long, dark winter months. In my own practice I do consider that a risk factor, and I advise a vitamin D supplement of 1,000 IUs daily. For people who would rather avoid a supplement but may need a boost of vitamin D, it is also found in some common foods, including sardines, salmon, tuna, cheese, egg yolks, and vitamin-fortified milk. I will add that, for those who fall into the “healthy community-dwelling adult” category, a supplement of anywhere from 400 to 2,000 IUs of vitamin D daily is not likely to cause harm. Yes, vitamin D toxicity is a thing, usually seen at levels above 80 ng/ml, which causes excessive calcium to be released into the bloodstream. This is rare, but I have seen it in patients who took high-dose vitamin D supplementation of 50,000 IUs weekly over a long period of time.

Other important and effective ways to protect your bones

There are other methods that may be more effective at maintaining bone health and reducing fracture risk. One that we can likely all agree on is regular physical activity. Weight-bearing exercise like walking, jogging, tennis, and aerobics definitely strengthens bones. Core exercises like yoga and Pilates can improve balance. All of this can help reduce falls and fracture risk.

And so, in the end, I am recommending what I always end up recommending: a Mediterranean-style diet rich in colorful plants, plenty of legumes, fish, plus low-sugar, low-fat dairy and plenty of varied physical activity throughout your entire life… and maybe calcium and/or vitamin D supplementation for certain people, following a discussion with their doctors.

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My Health - 10 Best Natural Ways To Treat Diarrhea Fast

10 Best Natural Ways To Treat Diarrhea Fast

Health and Fitness Tips
Health is the level of functional and metabolic efficiency of a living organism. In humans it is the ability of individuals or communities to adapt and self-manage when facing physical, mental, psychological and social changes with environment.

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My Health - A doctor answers 5 questions about dry skin

In the winter months, I wash my hands regularly and use a squirt of hand sanitizer from time to time in an effort to ward off colds. It may be a good health habit, but it also pretty much guarantees that I’m plagued by dry, cracked skin and tiny cuts around my fingers until spring.

Dry skin in the winter months is common, partly because people ramp up their hand washing, but the combination of cold air and the lack of humidity also plays a role. Your skin spends the winter months fighting to retain moisture, not to mention fending off other insults from cold-weather staples like scratchy wool clothes and crackling wood fires.

How can your skin survive the season? We asked Dr. Barbara Gilchrest, senior lecturer on dermatology at Harvard Medical School, to weigh in with her best tips to help you protect your skin from winter dryness.

1.  What’s the most common winter skin problem?

For most people, it’s dry skin and itching, says Dr. Gilchrest. You can blame cold air and low humidity for stripping the water away from the surface of your skin. Instead of lying flat and smooth and then shedding from the surface inconspicuously, dead skin cells from the many layers that make up our protective skin barrier form small but visible partially attached clumps that make your skin feel dry and rough.

Eczema craquelé is another problem to watch for in the winter months. It’s essentially an extreme manifestation of dry skin, usually occurring on the lower legs. With this condition, the dryness actually causes cracks in the top layer of skin, known as the stratum corneum. Blood may rise up beneath the skin, appearing as squiggly red lines, which give the skin a mottled appearance. Some people with this condition experience itching and stinging.

2.  How can you prevent dry skin in the winter months?

Combating the problem starts with keeping your home environment moist. Use a humidifier if you can. But the most effective strategy is to use skin moisturizers, which slow water loss and also physically smooth the skin, making it feel less rough, says Dr. Gilchrest.

3.  Do you have any tips for choosing a moisturizer?

Choose the heaviest moisturizer that’s comfortable to wear, and use more on your lower legs and hands, which are most prone to dryness. After a bath or a shower, pat the skin dry and immediately apply a moisturizer. Reapply as needed throughout the day, says Dr. Gilchrest.

4.  Do expensive, brand-name moisturizers work better than lower-cost options?

“It doesn’t have to be expensive to work,” says Dr. Gilchrest. “To my knowledge, while there are some extremely expensive moisturizers, there are none that are proven to be magically better.” But if you can, she says, look for moisturizers with alpha hydroxy acids, also called fruit acids, such as lactic acid or glycolic acid. Creams with alpha hydroxy acids tend to hold moisture in the skin longer than other moisturizers. You can get them at fairly high concentrations, she says. Use small amounts until your skin gets used to them, so you can apply them and they don’t sting.

5.  Any other winter tips you can offer?

Keeping the outer skin barrier well hydrated is crucial. Also keep your skin covered in cold temperatures, and don’t forget to wear gloves when you’re out, says Dr. Gilchrest. For people with Raynaud’s syndrome, where blood vessels in the fingers overreact to cold temperatures, gloves help prevent fingers from becoming painful and turning white, which happens more often in the winter. Keeping the hands warm can also ensure healthy nail growth during the colder months, she says.

In addition, as cozy as it may be, it’s best to avoid sitting next to a fire or a radiator all day, because that type of direct heat can be damaging to your skin. Avoid super-hot baths for the same reason, says Dr. Gilchrest. Whenever possible, try to wear soft fabrics. Wool is warm, but it can scratch and irritate the skin. If you do wear wool when you go outside, be certain to remove it as soon as possible when you go back inside, or layer it over softer fabrics.

With a little extra care, you’ll be able to protect your skin from the effects of winter’s chill.

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My Health - Expert advice on how to quit smoking

Okay, everyone knows smoking is bad for you, the number one cause of preventable death in the US and the world, a direct cause of lung and heart disease and cancer… et cetera. So let’s get right down to the nitty-gritty: quitting smoking is tough. What can people do to quit?

To answer this question, I spoke with my colleague Nancy Rigotti, MD. Dr. Rigotti is director of the Massachusetts General Hospital Tobacco Research and Treatment Center. She has extensively researched nicotine and tobacco, evaluated public policies on tobacco, contributed to US Surgeon General’s Reports, and authored clinical guidelines on smoking cessation.

“It’s never too late nor too early to quit,” she emphasizes. Research shows that even people who quit after age 65 can enjoy a longer, healthier life span.

Two-pronged approach is best

Behavioral strategies can help, medicines can also help, but what’s best is a combination of both. Behavior strategies can include counseling from a healthcare provider, self-help from websites or text message services, and/or social support. If someone has an underlying psychological issue like depression, anxiety, alcohol, or another substance use disorder, addressing those issues at the same time makes it more likely they can successfully quit smoking. As far as hypnosis or acupuncture, there is not a lot of evidence showing that they work.

Medicines that can help people quit include nicotine replacement therapy and the oral medications varenicline (Chantix) and bupropion (Zyban, Wellbutrin). Each is recommended for about 12 weeks.

Nicotine replacement (“the patch” and others)

Forms of nicotine replacement therapy (NRT) include patches, gum, lozenges, inhaler, and nasal spray. Dr. Rigotti points out that it’s safe to use more than one type of NRT at the same time. Combination NRT is a patch (which is long-acting) plus a short-acting agent (like gum, lozenges, inhaler, or nasal spray), and is more effective than a single form of NRT alone. “In addition, smokers are able to adjust nicotine intake to avoid both nicotine withdrawal and nicotine overdose, as they have done this throughout their years as cigarette smokers.”

When considering NRT, smokers need to consider what dose of each product they may need. For example:

Using nicotine patches. For the long-acting patch, someone who is smoking more than 10 cigarettes per day should start with the highest-dose patch (21 mg/day) for at least six weeks. However, those who smoke less than 10 cigarettes per day or weigh under 99 pounds should start with the medium-dose patch (14 mg/day) for six weeks, followed by 7 mg/day for two weeks.

How one applies the patch is also important. Change the patch site daily to avoid skin irritation, a common side effect. If leaving the patch on overnight causes insomnia and vivid dreams, take it off and replace it the next morning (smoking quit rates are the same whether the patch is left on for 24 hours or taken off at night). If the patch is removed at night and morning nicotine cravings occur, use the gum or lozenges while waiting for the new nicotine patch to take effect.

Using gum and the lozenges. For the nicotine gum, someone who is smoking more than 25 cigarettes per day should use the 4-mg dose. Those who smoke less than that should use the 2-mg dose. Chew one piece of gum whenever there is an urge to smoke (up to 24 pieces of gum per day) for at least six weeks, then taper off.

For best results, Dr. Rigotti recommends the “chew and park” method: “Chew the gum until the nicotine taste appears, then “park” the gum between your teeth and inner cheek until the taste disappears, then chew a few more times to release more nicotine. Repeat this for 30 minutes, then discard the gum, because by that time all nicotine has been released.”

Smokers with dental issues or who use dentures may do better with the nicotine lozenge. Smokers who smoke within 30 minutes of awakening should use the 4-mg dose, while smokers who wait more than 30 minutes after awakening to smoke should use the 2-mg dose. Place a lozenge in the mouth for 30 minutes. Let it melt, no need to chew. Use up to one lozenge every hour or two for six weeks, with no more than five lozenges every six hours or 20 lozenges per day, and then gradually taper.

Medications that can help you quit

Many studies have shown that 12 weeks of the prescription medications varenicline and bupropion are effective and safe in patients who want to quit smoking. A recent, large, high-quality study helped alleviate concerns about varenicline and psychiatric or cardiovascular side effects; the FDA removed that black box warning in December of 2016. Although one 2017 study [insert link or add to references?] suggests a risk, the methods have been called into question. Smokers are at significantly increased risk for CV events as it is, and it is difficult to correct for this using the methods this most recent study used. Dr. Rigotti emphasizes that varenicline “is our most effective agent and no riskier than any other agent, even in patients with psychiatric issues. This message needs to get out to patients and doctors.”

She explains that NRT can be used with either varenicline or bupropion. One other medication worth mentioning is nortriptyline, an older antidepressant that is also used for chronic pain. It is modestly effective, but is associated with side effects such as dry mouth, constipation, and weight gain. As with any medication, doctors and patients need to consider medical history, current medications, and personal preferences.

To increase your chances of success, Dr. Rigotti suggests taking the medication for at least one week before you even try to quit. In fact, for people who want to quit but are not ready to set a quit date, varenicline or NRT can help them smoke less, and can actually improve their chances of quitting successfully. “Encouraging smokers who are not ready to quit to try meds anyway is a new idea with increasing data,” she points out.

I asked Dr. Rigotti about e-cigarettes. While these are not FDA-approved for smoking cessation, experts agree that, for smokers unwilling or unable to attempt to quit, they are almost certainly safer than continuing to smoke cigarettes. However, anyone switching from cigarettes to e-cigarettes must do so completely. You should not use both together.

If you are even casually considering the idea of quitting, there are a ton of free resources available through 800-QUIT-NOW. Free text messaging and other supports and resources are available at www.smokefree.gov.

Resources

Primary Care Office InSite: Tobacco Treatment. Wynne Armand, MD, Nancy Rigotti, MD, and Susan Moran, MD.

UpToDate: Pharmacotherapy for Smoking Cessation in Adults. Nancy A. Rigotti, MD, along with section editors: James K. Stoller, MD, MS; Mark D. Aronson, MD; Deputy Editor: Judith A. Melin, MA, MD, FACP.

21st-century hazards of smoking and benefits of cessation in the United States. New England Journal of Medicine, January 2013.

Nicotine replacement therapy for smoking cessation. The Cochrane Database for Systematic Reviews, 2002.

Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet, June 2016.

Efficacy and safety of varenicline for smoking cessation in patients with cardiovascular disease: a randomized trial. Circulation, January 2010.

Efficacy and Safety of Smoking Cessation Interventions in Patients with Cardiovascular Disease: A Network Meta-Analysis of Randomized Controlled Trials. Circulation: Cardiovascular Quality and Outcomes, January 2017.

Safety and effectiveness of transdermal nicotine patch in smokers admitted with acute coronary syndromes. The American Journal of Cardiology, April 2005.

Combination varenicline and bupropion SR for tobacco-dependence treatment in cigarette smokers: a randomized trial. JAMA, January 2014.

Effect of varenicline on smoking cessation through smoking reduction: a randomized clinical trial. JAMA, February 2015.

Is a combination of varenicline and nicotine patch more effective in helping smokers quit than varenicline alone? A randomised controlled trial. BMC Medicine, May 2013.

In the clinic. Smoking cessation. Annals of Internal Medicine, March 2016.

Clinical practice. Treatment of tobacco use and dependence. New England Journal of Medicine, February 2002.

Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet, November 2013.

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My Health - Vaccinations: More than just kid stuff

Follow me on Twitter @RobShmerling

This is the time of year when it’s important to think about flu vaccinations. And there’s good reason for that! The flu causes thousands of preventable hospitalizations and deaths each year.

But what about other vaccinations? Do you think of them as something for kids? You aren’t alone. And it’s true, a number of vaccinations are recommended for young children as well as preteens and teenagers. These vaccinations have provided an enormous benefit to public health by preventing diseases that were common and sometimes deadly in the past, including polio, rubella, and whooping cough.

But there are several vaccinations recommended for healthy adults as well. And over time, these recommendations change. Here is a quick rundown.

Vaccinations for adults

According to the CDC, adults should consider receiving vaccinations to prevent

• influenza (during the fall and winter)
• tetanus
• a certain type of bacterial pneumonia (called pneumococcal pneumonia)
• shingles

In addition, adults should have vaccinations to prevent a number of infections if they were not received during childhood. Examples include the MMR vaccine (for measles, mumps, and rubella), HPV (human papilloma virus), chickenpox, and hepatitis.

Additional or earlier vaccinations may be recommended if you have certain medical problems, such as having an immune system weakened by illness or medications.

New recommendations

Mumps

In recent years, cases of mumps have spiked in the US. In 2015, there were about 1,300 cases reported. In 2016, the number jumped to more than 6,300. And as of November 2017, more than 4,600 cases were diagnosed. College campuses have been particularly prone to outbreaks. Mumps threatened to disrupt graduation at Harvard University in 2016, and recently Syracuse University, the University of Missouri, SUNY New Paltz, and Tufts University have reported outbreaks. We haven’t seen numbers like this since routine measles-mumps-rubella (MMR) immunizations began in the 1970s.

Although mumps is usually more of an annoyance than a serious illness, in some cases it may cause hearing loss, encephalitis (inflammation of the brain), and even death.

The rise in cases of mumps is not necessarily due to people not getting recommended vaccinations. The fact is, protection provided by vaccinations tends to wane over time. As a result, an expert panel has recommended that those at high risk for mumps get a booster shot. This includes anyone who has been in contact with someone who developed mumps. Others at higher than average risk include young adults ages 17 to 21 who spend time in close quarters, such as college students, church groups, and sports teams.

Shingles

Shingles is a re-activation of chickenpox, so anyone who had chickenpox in the past is at risk. Many who don’t recall having chickenpox have been exposed to the virus that causes it and are at risk as well.

Symptoms of shingles include an itchy, burning rash over a patch of skin lasting up to 10 days. Complications include vision loss (if the skin near the eye is affected), pneumonia, and chronic pain in the area of the rash (called post-herpetic neuralgia). Shingles tends to occur in older adults, affecting an estimated one in three people over a lifetime.

Since 1995 a vaccination has been available for chickenpox, so the incidence of shingles should fall dramatically in future generations. But in 2006, a vaccine was approved to prevent shingles for those who already had chickenpox. More than 20 million people have received this vaccine.

In October 2017, a new and more effective shingles vaccine called Shingrix was approved, leading an expert panel to recommend that people over age 50 get this new shingles vaccine even if they’ve already had the old one. As a next step, the CDC will review this recommendation and issue its own guidelines. Health insurance coverage for this new vaccine may vary, so it’s worth checking on that before getting it.

How to keep track of your vaccinations

It can be hard to remember which vaccinations you’ve had and when. Your primary care doctor should keep a running list in your medical record. But it’s a good idea to keep your own list. Each time you get a vaccination, put it in your smartphone or keep an updated record on your computer. There are apps and programs that can make it easy, but I just enter each vaccination I receive in my cellphone’s Contacts list under “Health Information.”

Keep in mind that no matter how hard you try to follow recommendations regarding adult vaccinations, the recommendations may change over time. So, at your routine checkups, ask your doctor if you should receive any vaccinations. It might be the most important thing you can do for your health.

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My Health - 4 things all parents should do to help prevent sexual abuse

Follow me on Twitter @drClaire

The trial of Larry Nasser, the physician who sexually abused female gymnasts, has been deeply disturbing. It’s hard to fathom how he managed to abuse hundreds of girls for so many years. Sadly, this can happen with sexual abuse. Very often, the perpetrator is someone known to the family, someone they may even trust. Very often, victims don’t understand that what is happening to them is abuse — and very often, talking about it is hard because of shame and fear.

As a society, we need to do a better job of protecting our children. But there are also lessons that parents can teach their children that can help keep them safe. Here are some suggestions from the American Academy of Pediatrics:

1.  Teach children the names of their body parts. It can feel awkward, as we sometimes think of words like “penis” or “vagina” as words that shouldn’t be used in regular conversation — and words we don’t want our preschoolers saying to other children at the playground. But by teaching them the actual names of all of their body parts, including their genitals, we do two important things: we give them the proper words to use to tell us should something happen, and we let children know that you are allowed to talk about all of your body parts, including your genitals.

2.  Make sure children know that not only are genitals “private,” but that nobody should touch them in a way that makes them feel uncomfortable. Another way of thinking of this is as “good touches” and “bad touches.” Any touch anywhere that is unwelcome, or feels inappropriate for the situation, is something that children should tell their parents about. This is important because often sexual abuse can begin in insidious ways, with perpetrators showing affection that isn’t sexual — extra hugs, touching an arm or a leg, a kiss.

This does not mean that every touch on the arm from a grownup is bad. The vast majority are perfectly fine. But it’s important to help children listen to their instincts and to teach them to let parents know about any touches. Parents, too, need to listen when a child tells them about a touch that made them uncomfortable. Never brush it off. Always take it seriously, ask questions, and understand what it was that made it uncomfortable.

3.  Teach children that it’s not okay for a grownup to ask them to keep a secret. Okay, maybe they shouldn’t tell Mommy what Daddy has planned for her birthday. But in general, it’s not a good idea, and as with touches, secrets can start as small and seemingly innocent.

4.  Create an environment where it’s okay to talk about sex. Sometimes what keeps a child from saying anything is that it feels awkward and shameful. Teaching the appropriate names for body parts is a start, but as children grow, keep up the conversation. Talk about body changes, body image, sexuality, and healthy relationships. When there are sexual images or messages in the media, instead of ignoring them, use them as conversation starters. And when there are events in the news such as the Nasser case, use them as an opportunity to reiterate messages around good/bad touches and secrets. Let children know that these are topics that you are happy to discuss.

In general, talking about sex is hard for parents. We want our children to stay innocent. But by allowing and encouraging conversations, not only do we set our children on a path toward healthier relationships, but we also help keep them safe.

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My Health - Top 10 Health Benefits Of Jogging Everyday

Top 10 Health Benefits Of Jogging Everyday

Health and Fitness Tips
Health is the level of functional and metabolic efficiency of a living organism. In humans it is the ability of individuals or communities to adapt and self-manage when facing physical, mental, psychological and social changes with environment.

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My Health - “Me time” sounds good, but when exactly?

I got a new doctor last year and at my first exam, he asked the standard, “What do you like to do for fun?” I laughed at him. I said that I have a 6-year-old and 3-year-old, mumbled something about poker games, and then my answer stopped. I’m not complaining, at least not much. I like my family and they require time. I don’t mind giving it, though I also work at home, a personal choice that comes with great benefits. But I can’t completely disappear, so sometimes, it just feels like an unending amount of time. My friends with older kids try to be supportive, saying that my wife, Jenny, and I are in the deepest part of the hole and it will soon get better, but they said that last year, and maybe the year before — I don’t really remember.

I know that I should squeeze in something like listening to music, reading, or doing nothing. It just never tops the priority list. I feel guilty spending time or money on anything that isn’t family-related. Jenny feels the same. We’re not pioneers with this mindset. As Dr. Beth Frates, assistant professor of physical medicine and rehabilitation at Harvard Medical School, says, it’s almost a default. “If you’re not working or taking care of another relative, you’re giving kids 100% of your attention.”

Why taking a break is important (and why it’s so hard)

The problem, she explains (and which isn’t surprising), is that parenting is a drain. It requires CEO-like thinking that happens in the prefrontal cortex, the place for self-control and rational decisions. That takes stamina, and if — check that — when you’re exhausted, you’ll shift into the amygdala, the emotional part of the brain that fights or flights, which is good against a bear attack, not so much against your child. Point is, a break every so often isn’t the worst thing.

Great. I’m still all for it. One question: when and how exactly does this magic happen?

The first step, Frates says, and it’s a big one, is acknowledging that personal time isn’t a luxury. The airplane oxygen mask analogy — put on yours first so you can better help your child — is the classic, but she prefers the idea that you can’t pour from an empty cup; with nothing there, there’s nothing to give.

The practical realities of “me time” — even a little bit can help a lot

If you can accept the concept, it becomes about identifying the daily possibilities. Ideally, she says, it’s a range, from 30 minutes to the occasional 24 hours. At minimum, it’s taking five. Even  that might feel undoable, but any type of screen time is a good place to look for time that can be better spent. And if it’s just the five, Frates likes deep breathing. She did it when her kids were young. She’d be in a chair with them in the room. They eventually understood not to bother her. She got her break and they got to witness the habit.

Ultimately, there’s no list of best things to do. The main requirement is that you look forward to whatever it is to get the reward of being fully absorbed, of losing your sense of time, and forgetting that you actually have bills, deadlines, or even children. It sounds simple, and it is to a degree, but if kids are involved, few things are simple. It takes teamwork to pull off. As a supportive partner, “What can I do to help?” is never a bad opening question. Often the person knows; now there’s an opening to brainstorm and strategize. Sometimes, if you know it’s not overstepping, you can take the initiative and buy something like a prepaid yoga classes card. The free time now almost has to happen.

“Me time” done just right

My wife took that route. I recently turned 50 on a Monday, and she woke me the morning before, holding a bottle of sports drink and telling me that this was my present. Where my head was at, I thought, “I have to get another colonoscopy?” She told me that at noon, I was playing tennis with a buddy.

I got to do something that I love — I think I stammered tennis out to the doc as well — with the person I like to hit with the most. But where Jenny crushed it was setting the whole thing up. She knew that if she gave me an open-ended coupon, it wouldn’t have happened. She just told me to go and enjoy myself.

I listened to my wife on this one. For two hours, I didn’t have to watch my language or answer the same question 10 times. My biggest responsibility was hitting a ball back over a net and breaking a sweat. It was great. I felt unburdened. I felt more energized and positive, and, at some point on the drive back, I remembered that I had two children.

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