My Health - Fertility and diet: Is there a connection?

Here are some headlines on fertility and diet that caught our attention:

The ultimate fertility diet: We reveal what to eat and what to avoid

Here’s what to eat if you’re trying to get pregnant

Trying to get pregnant? Foods to eat and avoid to boost fertility

Wow! Who knew that your choices at tonight’s dinner buffet could transform you into a parent? Not so fast — let’s look at the new study that’s causing all the fuss.

A new study of fertility and diet

Researchers from the Harvard T.H. Chan School of Public Health and Harvard Medical School have just published a review of past studies that examined the impact of diet on fertility. Here’s what they found.

For women trying to become pregnant naturally (without “assistive reproductive technologies” such as in vitro fertilization), the following vitamins and nutrients were linked to positive effects on fertility:

• folic acid
• vitamin B₁₂
• omega-3 fatty acids
• healthy diets (such as the Mediterranean diet)

On the other hand, antioxidants, vitamin D, dairy products, soy, caffeine, and alcohol appeared to have little or no effect on fertility in this review. Trans fat and “unhealthy diets” (those “rich in red and processed meats, potatoes, sweets, and sweetened beverages”) were found to have negative effects.

Studies of men have found that semen quality improves with healthy diets (as described above), while the opposite has been linked with diets high in saturated or trans fat. Alcohol and caffeine appeared to have little effect, good or bad. Importantly, semen quality is not a perfect predictor of fertility, and most studies did not actually examine the impact of paternal diet on the rate of successful pregnancies.

For couples receiving assisted reproductive technologies, women may be more likely to conceive with folic acid supplements or a diet high in isoflavones (plant-based estrogens with antioxidant activity), while male fertility may be aided by antioxidants.

So what does this mean if you’re trying to get pregnant?

Considering the average couple trying to become pregnant naturally, this review seems less of a bombshell than the headlines might suggest. Yes, eating a healthy diet is a good idea for men and women. Extra folic acid, B₁₂, and omega-3 fatty acids might be helpful for women, but healthy diets are already recommended to everyone, and a prenatal vitamin (which includes folic acid and vitamin B₁₂) is already recommended for women trying to get pregnant. Folic acid supplementation has long been known to reduce the risk of developmental neurologic problems in the developing fetus.

Unanswered questions about diet and fertility

Even if we accept these findings as important enough to direct our dietary choices, we still need to answer some basic questions:

• How much folic acid or B₁₂ is best? Is there an advantage to taking a supplement rather than relying on dietary sources?
• Which sources of and how many servings of dietary omega-3 fatty acids are best? How should a woman balance the risk of fish contamination with toxins such as mercury?
• Are there some people who need to pay more attention to these dietary recommendations than others?
• What about other components of the diet? Fear not, researchers are hard at work looking at this question. For example, consider the results of three other recently published studies:
  • Consumption of sugar-sweetened beverages (especially sodas or energy drinks) was linked to lower fertility for men and women, while drinking diet soda and fruit juice had no effect.
  • Women who consumed high amounts of fast food and little fruit took longer to become pregnant than those with healthier diets.
  • Couples eating more seafood were pregnant sooner than those rarely eating seafood. Most pregnant women consume far less than the recommended 2 to 3 servings of lower-mercury fish (such as salmon, scallops, and shrimp) per week.

You can probably come up with more questions. Hopefully, researchers are already busy trying to answer them.

In the meantime…

Until we know more, the take-home message of this new research is not so different than before it was published. If you’re a man or a woman trying to become a parent, eat a healthy diet.

Many doctors recommend that women of childbearing age who are not using contraception take a prenatal vitamin daily. At the very least, women who are planning a pregnancy should take a prenatal vitamin at least a month before trying to conceive. A higher than usual dose of folic acid may be recommended for certain women, depending on the medications they take and other medical conditions they have. Doctors also recommend the following to maximize the chances of a healthy pregnancy:

• Try to maintain a healthy weight prior to conception. Obese women have a higher risk of complications.
• Avoid excessive vitamins before conception. Too much vitamin A, for example, can be bad for a developing fetus.
• Consider seeing your doctor for a “preconception” visit to review what you can do to optimize your chances of a successful pregnancy. For example, certain medications are harmful to the developing fetus and should be stopped well before planning a pregnancy.

And just in case it’s not obvious, don’t rely on research regarding diet and fertility to prevent pregnancy. An unhealthy diet and avoiding supplemental vitamins or omega-3 fatty acids is not a form of birth control.

Follow me on Twitter @RobShmerling

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My Health - Obesity is complicated — and so is treating it

Many people don’t think of obesity as a disease, but rather as a moral failing. But Dr. Fatima Cody Stanford, instructor of medicine at Harvard Medical School and researcher and practicing physician at the Massachusetts General Hospital Weight Center, points out that obesity is a complex, chronic disease. Stanford’s recent fascinating and informative presentation explains how the body uses and stores energy, and describes the complex interplay of the genetic, developmental, hormonal, environmental, and behavioral factors that contribute to obesity.

Obesity isn’t just “calories in versus calories burned”

Obesity isn’t just about energy balance, i.e., calories in/calories out. “That’s simplistic, and if the equation were that easy to solve we wouldn’t have the prevalence of obesity that we have today,” Dr. Stanford explains. She goes on to say that not only is the energy balance theory wrong, but the focus on that simplistic equation and blaming the patient have contributed to the obesity epidemic. Stigma, blame, and shame add to the problem, and are obstacles to treatment. Indeed, over 36% of adults in the United States have obesity, and the world is not far behind.

She describes her research and experience in the treatment of obesity, including several cases from her own clinic. These are the cases that capture my attention, as they demonstrate most clearly the effects of different treatment approaches (and combinations) to obesity: diet and lifestyle (i.e. behavioral), medications, and surgery. Stanford has seen remarkable, long-lasting positive results with all, but she always emphasizes diet and lifestyle change first and foremost. The program (called Healthy Habits for Life) offered at the MGH Weight Center is a huge commitment, but it can help reframe a person’s relationship with food, emphasizing a high-quality diet, and not calorie-counting.

The components of a successful treatment for obesity

Abeer Bader is a registered dietitian and the lead clinical nutrition specialist at the center. She described the program to me in more detail: it’s a 12-week group-based education and support program with a structured curriculum and frequent contact with patients. The classes are 90 minutes long and led by a registered dietitian, and cover everything from the causes of obesity to healthy eating to debunking popular diet myths, plus recommendations for dining out, grocery shopping, meal prep, physical activity, and more. “The goal of the HHL program is to provide patients with the education, support, and tools to lead a healthy lifestyle.”

The diet they promote is loosely based on the DASH diet and the Mediterranean diet, as these eating plans are rich in vegetables, fruit, lean protein, and whole grains. They use the Harvard Healthy Plate to illustrate a healthy, well-balanced meal.

But it’s also a highly individualized program. “We work closely with the patient to put together realistic goals. I think the most important part of approaching goal-setting and behavior change is to first determine what it is that they would like to improve. Often as providers we tell patients what they need to do, but when you allow the patient to highlight an area that they would like to work on, you may see better adherence,” says Bader.

Other similar comprehensive programs have been shown to help patients achieve lasting diet and lifestyle change, lose weight — and avoid diabetes. The Diabetes Prevention Program helps those with obesity and risk of developing diabetes lose 5% to 7% of their body weight, and decreases their risk of diabetes between 58% and 71%.

As Bader states, “I think it’s important to note that the diet that “works” is the diet that a person will adhere to for the rest of his or her life. We really emphasize the importance of lifestyle change versus short-term diet fix in order to have the greatest success in achieving a healthier weight.” This statement is evidence-based, as a recent review of multiple research studies looking at different weight loss diets found that all worked about equally as well.

Medications to treat obesity

What can surprise people (including doctors) is how helpful weight loss medications can be, though it can take some trial and error to figure out what will work for someone. “These medications affect the way the brain manages the body’s weight set point, and how the brain interacts with the environment. But sometimes there’s no rhyme or reason why one medication works for someone, but another doesn’t.” Unfortunately, as research shows, weight loss medications aren’t prescribed often enough.

In summary, obesity is a complex, chronic disease with many contributing factors. Primary care doctors and obesity specialists can guide treatments that include lifestyle approaches like diet, exercise, and addressing emotional factors that contribute to obesity. For some people weight loss surgery may be an option (a subject for another post).

Selected references

Centers for Disease Control Adult Obesity Facts.

Media and its influence on obesity. Current Obesity Reports, April 2018.

Assessing the evidence for weight loss strategies in people with or without diabetes. World Journal of Diabetes, October 2017.

The Centers for Disease Control and Prevention National Diabetes Prevention Program Information Page: The Research Behind the Program.

Safety and tolerability of new-generation anti obesity medications: A narrative review. Postgraduate Medicine, March 2018.

Low utilization of obesity medications. What are the implications for clinical care? Obesity: A Research Journal, September 2016.

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My Health - Teething-pain remedy dangers

Teething can be hard on babies. It can hurt as teeth break through the gums. While some babies weather it fine, others are downright miserable. It’s hard to watch a baby be miserable, so it’s understandable that some parents and caregivers reach for one of the products that contain benzocaine, which can numb the gums and soothe the pain.

Except that it’s a really bad idea.

The problem with benzocaine for teething

Benzocaine is found in products like Baby Orajel, Anbesol, or Orabase, as well as products marketed for sore throats such as Cepacol or Chloraseptic. But along with numbing pain, benzocaine can change hemoglobin into methemoglobin and cause a dangerous condition called methemoglobinemia.

Hemoglobin is the compound inside the red cells of the blood that gathers oxygen from the lungs and distributes it to the tissue. When the iron in hemoglobin is exposed to certain chemicals including benzocaine, it changes to a form that holds on to the oxygen instead of letting it go — which means that tissues in the body don’t get the oxygen they need.

Because babies and toddlers are smaller, with less blood volume, they are at higher risk for this side effect. So are people with heart disease or lung disease, or the elderly: their oxygenation and circulation is already not working perfectly, so an additional problem with getting oxygen to their body affects them even more.

Symptoms of methemoglobinemia include pale or blue skin, dizziness, headache, and other pain. As the amount of methemoglobin increases it can lead to seizures, coma, and even death. There is an effective treatment if the condition is recognized and the person is brought to a hospital.

The Food and Drug Administration has been warning about methemoglobinemia for a long time, but they are now taking the additional step of asking companies who make benzocaine-containing products to stop making them for children under the age of 2.

Methemoglobinemia doesn’t happen every single time a person takes something with benzocaine. Since 1971, there have been 400 cases reported; even though this is likely an underestimate of the total cases, as many more than 400 people have used benzocaine. But the question is: why use a product that can be dangerous when there are other options for managing pain?

Other ways to help teething pain (without benzocaine)

When it comes to options for managing teething pain, simple is best. Just chewing on a cold teething ring or other teething toy (or even a cold washcloth) can make a miserable baby feel better — as can a dose of acetaminophen or ibuprofen (for children under 2, it’s best to check with the doctor for the correct dose for the child’s weight). A little extra cuddling and TLC can be comforting too.

There are many products marketed as natural teething remedies, with many different ingredients. Before you use one, check with your doctor as to whether the ingredients are known to be effective — and whether they are safe for your child.

It’s hard to have a miserable baby, that’s true. But just say no to benzocaine. It’s not worth the risk.

Follow me on Twitter @drClaire

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My Health - Ticked off: America’s quiet epidemic of tickborne diseases

For most of us, springtime marks the return of life to a dreary landscape, bringing birdsong, trees in bud, and daffodils in bloom. But if you work for the Centers for Disease Control and Prevention (CDC), the coming of spring means the return of nasty diseases spread by ticks and mosquitoes.

The killjoys at CDC celebrated the end of winter with a bummer of a paper showing that infections spread by ticks doubled in the United States from 2004 to 2016. (Tick populations have exploded in recent decades, perhaps due to climate change and loss of biodiversity.)

Lyme disease

The most common infection spread by ticks in the US is Lyme disease. There were 19,804 confirmed cases of Lyme in 2004, compared to 36,429 in 2016. Because of incomplete testing and reporting, these numbers are almost certainly an underestimate. There may be as many as 329,000 cases of Lyme disease in the United States every year. New England, the mid-Atlantic states, and Minnesota and Wisconsin account for 95% of reported cases.

While Lyme disease may lead to fever, rash, meningitis, Bell’s palsy, and arthritis, it rarely kills. More worrisome are surges in deadly diseases spread by ticks, such as Rocky Mountain spotted fever, anaplasmosis, ehrlichiosis, and babesiosis.

Other serious tickborne illnesses

Rocky Mountain spotted fever (RMSF) is a misnomer. Although it occurs throughout much of the United States, including the Rocky Mountains, it is most common in southern Appalachia and the Ozarks; 60% of cases are diagnosed in North Carolina, Tennessee, Arkansas, Missouri, and Oklahoma. Reported cases of RMSF rose from 1,713 in 2004 to 4,269 in 2016. Patients with RMSF have high fever, headache, belly pain, and a rash with pinpoint red dots or red splotches. The rash may not be present early in the disease. Even with treatment, RMSF is fatal in up to 4% of cases.

Anaplasmosis and ehrlichiosis resemble RMSF, except that rash is less prominent (and is rare in anaplasmosis). Anaplasmosis is lethal in 0.5% of cases, while ehrlichiosis kills 1% to 2% of patients. Cases of these two diseases rose from 875 in 2004 to 5,750 in 2016. Anaplasmosis is most common in New York, New Jersey, New England, Minnesota, and Wisconsin, while ehrlichiosis abounds in the southeastern and south central United States.

Babesiosis is a tickborne disease that mimics malaria, leading to hectic fevers, headache, body aches, anemia, and liver and kidney damage. Cases rose from 1,128 in 2011, the first year it was a reportable disease, to 1,910 in 2016. In the US, it is most common in coastal New England and parts of New York, New Jersey, Wisconsin, and Minnesota.

As if that wasn’t enough to worry about, we are still discovering new infections spread by ticks, including Bourbon virus, which killed a man in Bourbon County, Kansas, in 2014, and Heartland virus, first diagnosed in two Missouri farmers in 2009.

Infections spread by mosquitoes

If infections spread by ticks have increased steadily, infections spread by mosquitoes tend to have more of a waxing and waning pattern. West Nile virus, which first came to the United States in 1999, has flared up multiple times in the continental US since then. Other exotic viruses, such as Zika, dengue, and chikungunya, have caused major outbreaks in Puerto Rico, American Samoa, and the US Virgin Islands, with occasional spillover into the continental US.

How to protect against ticks and mosquitoes

• Avoid walking in scrubby areas with shrubs, bushes, high grass, and leaf litter, where ticks abound.
• When walking in the woods, stick to the center of cleared trails.
• Tick repellents containing picaridin, IR3535, or at least 20% DEET will provide several hours of protection to exposed skin. Clothing and camping gear can be treated with sprays containing 0.5% permethrin.
• The Environmental Protection Agency (EPA) has a search tool to help you find safe and effective mosquito and tick repellents.
• Looking at your body in a full-length mirror and taking a bath or shower soon after you come inside will help you to identify and remove ticks.
• Ticks like to hide in protected areas. When checking their kids out for ticks, parents should pay special attention to the scalp and ears, the shoulder blades, the waist, belly button, and behind the knees and between the legs.
• Ticks are vulnerable to heat and dehydration. Washing your clothes in hot water, or putting them in the dryer on high heat, should kill ticks hiding in them.

What to do if you find a tick on your skin

• If you find any ticks attached to your body, use fine-tipped (jeweler’s) tweezers to remove them. Grasp them next to the skin and apply steady, gentle pressure. Do not yank or twist the tick, as this may cause its mouth parts to break off and stay embedded in your skin. Do not apply nail polish or petroleum jelly to the tick, or try to burn it off!
• Clean the bite site afterward with soap and water, iodine, or rubbing alcohol.
• If you develop a rash at the bite site or feel ill, see your doctor.

Follow me on Twitter @JohnRossMD

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My Health - Move more every day to combat a sedentary lifestyle

When I was in high school, I mowed my grandmother’s lawn once a week. Yet every time I arrived, she would have already mowed a small part of the back yard. I always told her she didn’t need to do that, but she insisted. At the time I didn’t understand why she felt compelled to do this every week, but now that I’m inching closer and closer to her age then, I get it: it was something she could do to stay active. She knew that to stave off the effects of a sedentary lifestyle, it is important to move more every day.

The older we get, the more likely we are to lapse into a sedentary lifestyle. In fact, an estimated 67% of older adults report sitting for more than eight hours per day, and only 28% to 34% of adults ages 65 to 74 are physically active, according to the Department of Health and Human Services.

Evelyn O’Neill, manager of outpatient exercise programs at the Harvard-affiliated Hebrew Rehabilitation Center, sees the consequences of too much sitting every day. “Sitting is the new smoking in terms of health risks,” she says. “Lack of movement is perhaps more to blame than anything for a host of health problems.”

The dangers of a sedentary lifestyle

A sedentary life can affect your health in ways you may not realize. For example, prolonged sitting, like spending hours watching television, can increase your chance of developing venous thrombosis (potentially fatal blood clots that form in the deep veins of the legs), according to a study of more than 15,000 people. In fact, people who watched television the most had a 70% greater risk of suffering from venous thrombosis compared with those who never or seldom watched TV.

On the flip side, squeezing in extra movement during the day can have a big impact. For instance, simply standing more can help you lose weight and keep it off, according to a review published in the European Journal of Preventive Cardiology.

Everyday activities that incorporate more walking also can build up your leg muscles, which may help you live longer. Researchers have found that loss of leg muscle strength and mass is associated with slower walking speeds among older adults. Slower speeds are linked to a lower 10-year survival rate for people after age 75.

Simple ways to move more every day

One way to combat the health risks of a sedentary lifestyle is to work small bits of exercise into your daily routine. There are many ways to do this, according to O’Neill. “Even if you aren’t sweating or feeling like you’re working hard, you are still moving your arms and legs, stimulating your muscles, and working your joints,” she says.

Focus on adding just 30 minutes of extra activity into your day, three days a week. “You can break it down into smaller segments, too, like 10 minutes in the morning, afternoon, and evening,” says O’Neill. What can you do during that time? Here are some strategies to help you move more every day:

• Walk for five minutes every two hours.
• Get up and walk around or march in place during TV commercials.
• Do a few sets of heel raises, where you stand on your toes. “Try it while you brush your teeth or make breakfast,” says O’Neill.
• Always stand or walk around when you’re on the phone.
• Do a set or two of push-ups against the kitchen counter. “Your body weight is always a good way to strengthen muscles,” says O’Neill.
• Use soup cans as dumbbells and do 10 to 20 reps of biceps curls.
• Perform up to 10 reps of stand-and-sit exercises, where you rise from a chair without using your arms and then sit down again to complete one rep.

“Also, look for opportunities to do extra movement during regular errands and chores,” says O’Neill. For instance, save some dirty dishes for hand washing, which works your hands and fingers. Wash your car instead of using the drive-through car wash, park farther away at the grocery store (or better yet, walk to the store and carry groceries home, if possible), sweep and mop more, and do simple yard work like weeding, planting pots, and raking.

“There’s a lot you can do to be more active,” says O’Neill. “Exercise doesn’t always have to be intense to be effective, and there are many opportunities in your daily life to sneak in extra movement. You just need to do it.”

That’s advice my grandmother faithfully followed until she passed away at age 100.

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My Health - Could medications contribute to dementia?

Alzheimer’s disease and other illnesses that cause dementia are devastating, not only for those affected but also for their friends and family. For most forms of dementia, there is no highly effective treatment. For example, available treatments for Alzheimer’s disease may slow the deterioration a bit, but they don’t reverse the condition. In fact, for most people taking medications for dementia, it may be difficult to know if the treatment is working at all.

Experts predict that dementia will become much more common in the coming years. We badly need a better understanding of the cause of these conditions, as this could lead to better treatments and even preventive measures.

New research links certain medications to dementia risk

A new study raises the possibility that certain medications may contribute to the risk of developing dementia.

The focus of this study was on medications with “anticholinergic” effects. These are drugs that block a chemical messenger called acetylcholine, which affects muscle activity in the digestive and urinary tracts, lungs, and elsewhere in the body. It’s also involved in memory and learning.

Many medications have at least some anticholinergic effects, and it’s estimated that up to half of older adults in the US take one or more of these medications. Common examples include:

• amitriptyline, paroxetine, and bupropion (most commonly taken for depression)
• oxybutynin and tolterodine (taken for an overactive bladder)
• diphenhydramine (a common antihistamine, as found in Benadryl).

In this new study, researchers collected detailed information from more than 300,000 adults ages 65 and older, and compared medication use among those diagnosed with dementia with those who were not. Those who had taken any medication with anticholinergic activity were 11% more likely to be eventually diagnosed with dementia; for those drugs with the most anticholinergic effects, the risk of dementia was 30% greater. The largest impact was found for drugs commonly taken for depression, bladder problems, and Parkinson’s disease; for antihistamines, and some other anticholinergic drugs, no increased risk of dementia was observed.

So should you be worried about your medications and dementia?

These findings are intriguing but they aren’t definitive, and they don’t mean you should stop taking a medication because you’re concerned about developing dementia.

First, this study found that use of certain medications was more common in people later diagnosed with dementia. That doesn’t mean these drugs caused dementia. There are other potential explanations for the findings. For example, some people develop depression during the early phases of dementia. Rather than antidepressants causing dementia, the medication might be prescribed for early symptoms of dementia that has already developed. This is called “confounding by indication” and it’s a potential flaw of studies like this one that attempt to link past medication use with future disease.

Another reason to be cautious about these results is that they cannot be used to estimate the impact of medication use on an individual person’s risk of dementia. This type of study looks at the risk in a large group, but individual factors (such as smoking or being sedentary) may have a much bigger impact on dementia risk.

Still, there is reason to be concerned about the possibility that anticholinergic drugs contribute to the risk of dementia. Acetylcholine is involved in memory and learning, and past research has demonstrated lower levels of acetylcholine in the brains of people with Alzheimer’s disease (the most common cause of dementia in the elderly). In addition, animal studies suggest that anti-cholinergic drugs may contribute to brain inflammation, a potential contributor to dementia.

What’s next?

Additional research will undoubtedly provide more information about the potential impact of medication use on dementia risk. In the meantime, it’s a good idea to review the medications you take with your doctor before making any changes.

And keep in mind that you may be able to reduce your risk of dementia by not smoking, getting regular exercise, and sticking to a healthy diet (that is rich in fiber, fruits, vegetables, and omega-3 fatty acids). Get your blood pressure and lipids checked regularly, and follow your doctor’s advice about ways to keep them in an optimal range.

The use of any medication comes with potential risks and benefits. This recent research linking certain medications with dementia risk reminds us that the risks of some medications are only uncovered years after their use becomes commonplace.

Follow me on Twitter @RobShmerling

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My Health - 6 reasons children need to play outside

Here’s something really simple you can do to improve your child’s chance of future health and success: make sure he spends plenty of time playing outside.

There are many ways in which this generation’s childhood is different from that of the last generation, but one of the most abrupt contrasts is the degree to which it is being spent indoors. There are lots of reasons, including the marked increase in time spent interacting with electronic devices, the emphasis on scheduled activities and achievements, concerns about sun exposure — and, for many families, the lack of safe outdoor places to play. It’s not just children; adults are spending less time outdoors as well.

Here are six crucial ways playing outside helps children:

1.   Sunshine. Yes, sun exposure — especially sunburns — can increase the risk of skin cancer. But it turns out that our bodies need sun. We need sun exposure to make vitamin D, a vitamin that plays a crucial role in many body processes, from bone development to our immune system. Sun exposure also plays a role our immune system in other ways, as well as in healthy sleep — and in our mood. Our bodies work best when they get some sunshine every day.

2.  Exercise. Children should be active for an hour every day, and getting outside to play is one way to be sure that happens. They can certainly exercise indoors, but sending them outdoors — especially with something like a ball or a bike — encourages active play, which is really the best exercise for children.

3.  Executive function. These are the skills that help us plan, prioritize, troubleshoot, negotiate, and multitask; they are crucial for our success. Creativity falls in here, too, and using our imagination to problem-solve and entertain ourselves. These are skills that must be learned and practiced — and to do this, children need unstructured time. They need time alone and with other children, and to be allowed (perhaps forced) to make up their own games, figure things out, and amuse themselves. Being outside gives them opportunities to practice these important life skills.

4.  Taking risks. Children need to take some risks. As parents, this makes us anxious; we want our children to be safe. But if we keep them in bubbles and never let them take any risks, they won’t know what they can do — and they may not have the confidence and bravery to face life’s inevitable risks. Yes, you can break an arm from climbing a tree — and yes, you can be humiliated when you try to make a friend and get rejected. But that doesn’t mean you shouldn’t try; the lessons we learn from failure are just as important as those we learn from success.

5.  Socialization. Children need to learn how to work together. They need to learn to make friends, how to share and cooperate, how to treat other people. If they only interact in very structured settings, such as school or sports teams, they won’t — they can’t — learn everything they need to know.

6.  Appreciation of nature. So much of our world is changing, and not for the better. If a child grows up never walking in the woods, digging in soil, seeing animals in their habitat, climbing a mountain, playing in a stream, or staring at the endless horizon of an ocean, they may never really understand what there is to be lost. The future of our planet depends on our children; they need to learn to appreciate it.

So try it. Do what our parents did: send your children outside. Even better, go with them. And do everything you can to be sure that every child can do the same.

Follow me on Twitter @drClaire

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My Health - Choosing life with a VAD (ventricular assist device)

Rain splattered, blurring my view of the Massachusetts state highway. The rental car’s wipers squeaked as they dragged across the windshield. Though I was briefly tempted to turn back, I kept driving. The man with the battery-operated heart had invited me to his home, and I didn’t want to be late.

I am a critical care doctor. Throughout the course of my training, I have learned how to manage a ventilator, how to treat sepsis, how to sort out the causes of renal failure. But what I didn’t learn is what comes after for those who do not die, whose lives are extended by days, months, or even years as a result of our cutting-edge treatments and invasive technologies, which is what led me to Van Chauvin — the man with the battery-operated heart — and his family that rainy Sunday afternoon.

I had met Van a few weeks before as he trundled through heart failure clinic, a sight in a camouflage vest to carry his battery packs, controller unit along his waist. His doctors had directed me to him. When I told Van that I wanted to learn more about life with a partial artificial heart (called a ventricular assist device, or VAD), he smiled incredulously and, with a chuckle, invited me to his home to see what living with a VAD was really like.

Later that day, I had talked with Van’s doctors. They explained to me that Van had initially undergone the surgery to place the VAD with the hope that the device would just be a step on the way to a heart transplant. But Van’s lungs, weakened by years of smoking, got sicker as he waited on the transplant list — and shortly before we met, Van had learned that he was no longer a candidate for a heart. This device, with all its cords and tradeoffs and the possibility of complications, would be the way Van would live until he died.

As I drove, I wondered what Van would tell me about what it had been like to learn that he wouldn’t get a new heart. Maybe he regretted the decision he had made to get the VAD, knowing now that he would never again be able to shower the way he liked, or to go fishing lest the machinery get wet. I wondered if he would be angry, resentful of his current reality.

So I was surprised when I walked into Van’s home (I finally made it, despite the rain and a few wrong turns) and found myself in the midst of what felt like a family gathering in the living room. Van’s sisters had stopped by, as had a niece, one of his daughters with her chubby-cheeked son, even his mother. They wanted to tell me about Van. I didn’t even recognize him at first, as he stepped out from the kitchen with a smile and a steaming tray of potatoes, chives, and sour cream he’d whipped up for the company. “Grab a plate!” he said, beckoning me in. First we would eat, and then we would talk.

Over the course of that afternoon and the many phone calls that followed, I came to understand that I had been wrong about Van. I met him because I wanted to learn what it was to live a life that I perceived as a state of limbo. I thought that the very obvious reminders of living with a battery-operated device — carrying battery packs and sleeping plugged into a wall socket — might have been untenable. But Van told me that he wasn’t angry at all. Once he learned that he was no longer a transplant candidate, he was able to come to terms with his life for what it was. And a big piece of that process of adaptation meant finding ways to do the things he enjoyed, even if he needed to bend the rules.

The summer after we met, which would be the last summer of Van’s life, he even fixed up a boat to take out on the lake near his home. His voice lifted when he told me about the afternoons he spent on the water, catching fish and enjoying the sunshine. In one of our last conversations, he’d invited me to come out with him. I had smiled and thanked him, thinking maybe next summer, assuming there would be time. Though I will never fish with Van, I will remember the lessons he taught me. Van had priorities other than survival, other than living as long as possible. And contrary to what I had assumed, as long as Van could find ways to regain the independent life that his heart failure had taken from him, he could tolerate the cord that connected him to the wall each night. Rather than feeling tethered, as I had assumed, Van found a way to be free.

Learn more about Van, and read other stories of men and women navigating life at the medical borderlands, in Daniela Lamas’s book, You Can Stop Humming Now: A Doctor’s Stories of Life, Death and In Between.

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My Health - PrEP: Protection against HIV in a pill?

HIV (the human immunodeficiency virus) weakens the human immune system and destroys the important cells that fight disease and infection. A person can get HIV when bodily fluids — including blood, semen, pre-seminal fluid, rectal fluids, or vaginal fluids of a person with the virus — come in contact with a mucous membrane or damaged tissue. HIV can be transmitted through breast milk, or when a contaminated needle or syringe comes into direct contact with the bloodstream.

There is no cure for HIV, but with proper medical care the virus and its effects can be controlled. HIV transmission can be reduced by consistent use of condoms and clean needles. However, another way to protect against getting HIV is pre-exposure prophylaxis, or PrEP.

PrEP is a pill that can help prevent HIV

PrEP is a combination of two antiretroviral medications, tenofovir and emtricitabine, that, if taken every day, can now prevent HIV. The pill (Truvada) is FDA approved. Truvada works by blocking an enzyme so that HIV cannot reproduce and establish infection in the body.

The pill is taken by mouth with or without food. It is best if taken at the same time every day, as this helps establish a routine. Skipping days isn’t recommended. If you forget a dose, take it as soon as you remember. If it is almost time to take the next dose, skip the missed dose and continue the regular dosing schedule. Truvada takes full effect seven to 20 days after starting the medication. It can be discontinued whenever the protection it offers is not necessary (for example, if your risk for HIV or preferences change). Do talk to your doctor when stopping or starting any medication.

Who should consider PrEP?

The following circumstances mean that PrEP may be a good choice and worth a conversation with your doctor:

• if you have had anal or vaginal sex with more than one partner and prefer to use condoms only sometimes or not at all
• if you are a sexually active adult male who prefers male partners, whose HIV status may not be known
• if you are in a relationship with an HIV-positive partner
• if you have recently had a sexually transmitted infection in your anus or vagina
• if you have had sex with people who inject drugs, or if you inject drugs yourself
• if you are trying to conceive with a known HIV-positive partner
• if you have used stimulants, poppers, cocaine, meth, ecstasy, or speed in the last six months.

What about condoms?

Condoms do provide protection against HIV. Unlike PrEP, they also protect against other sexually transmitted infections, and prevent pregnancy when used correctly and consistently.

Does PrEP have side effects?

Overall PrEP is very well tolerated. As with starting any medication, some people will experience side effects such as nausea, gas, or headache. In general, these side effects are mild and tend to improve with time if the medication is stopped. Kidney problems can occur infrequently, and so your doctor will monitor your kidney function with regular blood tests. Some people may experience a mild reduction in bone mineral density. The significance of this is not known, but it tends to stabilize or go back to normal over time.

PrEP does not interfere with most medications including suboxone, methadone, or oral contraceptives, and does not affect sexual performance. While this medication has been used extensively in pregnant and breastfeeding women who have HIV infection, the risk/benefit of using it for HIV prevention during pregnancy or breastfeeding needs to be individualized. Talk to your doctor if you are taking NSAIDs like ibuprofen or naproxen, or antivirals like valacyclovir or acyclovir.

What are the next steps if you think PrEP is right for you?

Make an appointment with your doctor and talk about why you think you would like to take this medication. Your doctor will run tests to check for HIV and other sexually transmitted infections as well as hepatitis A, B, and C, and check your kidney function before starting PrEP. Usually your provider will need to get prior authorization for the medication. Most insurances cover the cost. If your provider is uncomfortable prescribing this medication, ask to be referred to an HIV specialist in your area.

You will need to see your doctor initially after one month and then every three months, when HIV and sexually transmitted infection testing will be repeated. Your kidney health will be monitored via a blood test once within six months, and PrEP must be stopped if the kidneys are adversely affected.

References

Centers for Disease Control and Prevention, HIV Basics: About HIV.

Centers for Disease Control and Prevention, HIV Basics: PrEP.

World Health Organization, Guidance on oral pre-exposure prophylaxis (PrEP) for serodiscordant couples, men and transgender women who have sex with men at high risk of HIV.

US Public Health Service, Preexposure Prophylaxis for the Prevention of HIV Infection in the United States — 2014: A Clinical Practice Guideline (PDF).

Acknowledgements: Dr. Linda Shipton, MD, an internist and infectious disease specialist at Cambridge Health Alliance, for support during the preparation of this post.

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My Health - The psychology of Internet rage

Have you ever noticed that you tend to get a lot angrier on the road with other drivers than you do with people in the rest of your life? To a large degree, the experience of road rage is universal, and can be explained by the emotional distance that is created between drivers when there is both physical separation and a high potential for perceived slights and wrongdoing. The relative anonymity of driving leads to an exaggerated emotional response when feeling slighted or threatened, in part because all you may know of the other driver is that he or she just cut you off. It makes sense that you might react more angrily in that situation than if the same interaction occurred in another real-life setting.

Now if you accept the premise that separation and relative anonymity increase the potential for rage, imagine what the anonymity and dehumanization of the Internet does to virtual interactions. It is well documented that online comment sections too often become a hub for threats, heated arguments, and name calling.

Let’s explore why this might happen.

In 2016, FiveThirtyEight.com performed an extensive survey of 8,500 commenters to better understand the nature of their behavior. It found that commenters tended to be younger than 40 and predominantly male. Commenters also stated that they commented primarily in order to correct an error, add to the discussion, give their personal perspectives, and represent their views. Less often, they were trying to be funny, praise content, ask a question to learn, or share their own thoughts. So, we can acknowledge that there is a certain self-selection in the Internet commentary world that will lead to many comments being oppositional, even if most readers do not perceive the article this way.

But why do online commenters so often seem rageful in their opposition?

One explanation begins with the knowledge that the content most likely to elicit impassioned responses is on the very subjects that people feel affect them personally. The majority of Internet commenters know something about the topics being discussed, and often their personal experience does not align with the viewpoint of the author. Put another way, they may feel that this firsthand experience makes them more knowledgeable than the author, while the author may only have theoretical experience or none at all. Because commenters so often identify personally with the topic for this reason, the magnitude of their emotional response can be amplified, sometimes leading to stronger language than they would use in the real world. This is the case even when topics are written by so-called experts. This may be attributed to a principle in psychology known as the “backfire effect” — that is, people often become counterintuitively more entrenched in their position when presented with data that conflicts with their beliefs.

Even when commenters read entire articles, hostile comments are often formed out of defiance rather than ignorance of evidence presented by the author. The Dunning-Kruger effect may be at play here. This principle states that a person’s perception of what they have read and the content they’ve actually read often do not align well. In other words, a person may read an article whose focus is on one area, but become attentionally derailed by a strong emotional response provoked early in the piece. The provocative nature of Internet headlines are in fact designed to elicit such emotional responses in order to gain additional page views. One result is that many readers come away very quickly feeling attacked or misrepresented by information when that was not necessarily the article’s objective or focus. With the inherent anonymity and seclusion of Internet use, it is not hard to see how reasonable online decorum so often fails to hold under such circumstances.

There is little that you as an individual can do about the nature of the Internet, but you can choose how you interact with it. Good mental health around Internet use likely revolves around limiting your use to content arenas that promote your best self by allowing you to be productive and enjoy the time you spend on the web. If sites or posts seem to make you rageful, it may not be worth continuing to engage in this way. This is one aspect of online interactions where you have a lot of control.

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My Health - Fermented foods for better gut health

Naturally fermented foods are getting a lot of attention from health experts these days because they may help strengthen your gut microbiome—the 100 trillion or so bacteria and microorganisms that live in your digestive tract. Researchers are beginning to link these tiny creatures to all sorts of health conditions from obesity to neurodegenerative diseases.

Fermented foods are preserved using an age-old process that not only boosts the food’s shelf life and nutritional value, but can give your body a dose of healthy probiotics, which are live microorganisms crucial to healthy digestion, says Dr. David S. Ludwig, a professor of nutrition at the Harvard School of Public Health.

Not all fermented foods are created equal

The foods that give your body beneficial probiotics are those fermented using natural processes and containing probiotics. Live cultures are found in not only yogurt and a yogurt-like drink called kefir, but also in Korean pickled vegetables, called kimchi, sauerkraut, and in some pickles. The jars of pickles you can buy off the shelf at the supermarket are sometimes pickled using vinegar and not the natural fermentation process using live organisms, which means they don’t contain probiotics. To ensure the fermented foods you choose do contain probiotics, look for the words “naturally fermented” on the label, and when you open the jar look for telltale bubbles in the liquid, which signal that live organisms are inside the jar, says Dr. Ludwig.

Try making your own naturally fermented foods

Below is a recipe from the book Always Delicious by Dr. Ludwig and Dawn Ludwig that can help get you started.

Spicy pickled vegetables (escabeche)

These spicy pickles are reminiscent of the Mediterranean and Latin American culinary technique known as escabeche. This recipe leaves out the sugar. Traditionally, the larger vegetables would be lightly cooked before pickling, but we prefer to use a quick fermentation method and leave the vegetables a bit crisp instead.

• 2 cups filtered water
• 1 to 1¼ tablespoons sea salt
• 2 tablespoons apple cider vinegar
• 1 jalapeño or a few small hot chiles (or to taste), sliced
• 1 large carrot cut into ¼-inch-thick rounds or diagonal slices
• 1 to 2 cups chopped cauliflower or small cauliflower florets
• 3 small stalks celery (use only small inner stalks from the heart), cut into 1-inch-long sticks
• 1 bay leaf
• 1 cabbage leaf, rinsed

Warm the water (no need to boil). Stir in the sea salt until it dissolves completely. Set aside to cool (use this time to cut the vegetables). Add the vinegar just before using. The brine can be made ahead of time and stored in a sealed glass jar on the counter to use when ready to pickle.

Set a quart-size canning jar in the sink and fill it with boiling water to sterilize. Empty the jar and tightly pack the vegetables and bay leaf inside to within 1 to 2 inches from the top of the jar. Pour the brine over the vegetables to fill the jar to within 1 inch from the top. Wedge the cabbage leaf over the top of the vegetables and tuck it around the edges to hold the vegetables beneath the liquid.

Set jar on the counter and cover with a fermentation lid. (Alternatively, use a standard lid and loosen it a bit each day for the first few days, then every other day, to allow gasses to escape.) Let pickle for 3 to 5 days, depending on the indoor temperature. Check the taste after a couple of days, using clean utensils. Vegetables will pickle faster in warmer climates. Make sure the vegetables stay packed beneath the level of the liquid and add salted water (2 teaspoons sea salt dissolved in 1 cup warm filtered water) as needed.

When the vegetables are pickled to your liking, seal the jar with a regular lid and refrigerate. Vegetables will continue to slowly pickle in the refrigerator. They will keep for about 1 month. Taste for saltiness before serving and, if desired, rinse gently to remove excess salt.

Calories: 1 (per 1 tablespoon)

Carbohydrate: 0 g

Protein: 0 g

Fat: 0 g

Excerpted from the book Always Delicious by David S. Ludwig, MD, PhD, and Dawn Ludwig. Copyright © 2018 by David S. Ludwig, MD, PhD, and Dawn Ludwig. Recipe reprinted with permission of Grand Central Life & Style. All rights reserved. 

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My Health - 4 things to know about ticks and Lyme

As the weather gets better and school vacations begin, along with sunburns and water safety there is something else parents need to think about: ticks and Lyme disease.

Lyme disease is spread by the bite of the blacklegged tick. While there are cases in various parts of the country, it’s most common in the Northeast and mid-Atlantic states, as well as around the Great Lakes. The early symptoms of Lyme include fever, body aches, and a bull’s-eye rash. It’s very treatable with antibiotics, but if not caught and left untreated, it can lead to serious health problems.

Here is information from the Centers for Disease Control and Prevention on four things that everyone should know and do:

1.  Prevention is key

As is true with all health problems, preventing them in the first place is always best. Be mindful of where your children play, as brush and tall grasses are where the ticks hang out. As much as possible, try to keep to the center of paths. Use a repellent with DEET (at least 20%), picaridin, or IR3535 on exposed skin (the Environmental Protection Agency has a great online tool that can help you choose the best insect repellent), and spray clothing (including socks and shoes) and gear like backpacks with permethrin.

2. Do tick checks at the end of every day

Even if your kids were just playing outside in the yard, get in the habit of looking them over. Ticks like warm, moist areas like the armpits, groin, and scalp, so you should particularly check there. Be sure to look carefully, because the blacklegged tick often transmits when it’s in the nymph stage, and nymphs are really tiny.

If you find an attached tick, grab it at the base with a tweezer and pull it upward with steady pressure. You can get rid of a live tick by wrapping it tightly in something or flushing it down the toilet.

Along with checking your human family members, be sure to check pets that have been outside, as they can carry ticks inside with them. You should also check clothing. Anything that isn’t going into the wash can be thrown into the dryer for 10 minutes or so (when washing clothes, be aware that if they aren’t washed in hot water, they may need extra time in the dryer to kill any ticks on them).

3. Be on the lookout for symptoms

If you do tick checks at the end of every day you should be fine, because it takes at least 24 hours — more often 36 to 48 hours — for an infected tick to transmit Lyme. This is a really important point that many people don’t know.

The classic rash of Lyme is an expanding bull’s-eye rash at the site of the bite. The rash is present in 70% to 80% of cases. Of course, that means it isn’t present in 20% to 30% of cases, so if someone in your family had a tick on them for more than 24 hours, or if you live in an area where there are many cases of Lyme and there may have been a tick bite, you should call your doctor if the person has a fever, chills, aches and pains for no clear reason, along with swollen lymph nodes or swelling of one or more joints. While having these symptoms doesn’t mean for sure that a person has Lyme, it’s worth getting checked out, as early treatment generally leads to a complete cure.

4. Be a cautious consumer of information when it comes to testing and treatment of Lyme

As with many conditions, there is a lot of misinformation out there about Lyme testing and treatment. It’s important to use laboratories that use evidence-based norms and processes. There are many advertised tests for Lyme disease, but some of them are simply not reliable — and it’s really important to have reliable information when making a diagnosis. It’s also not recommended to do testing for Lyme in someone who does not have clear symptoms of Lyme disease.

Most people recover completely after treatment of Lyme, but there are some people who have chronic symptoms such as fatigue, pain, or joint swelling after Lyme disease. This is called post-treatment Lyme disease syndrome or post-Lyme disease syndrome. The cause of these syndromes is unknown. Prolonged use of antibiotics is not recommended. Studies have shown that it doesn’t help, and there can be serious health problems when antibiotics are taken for prolonged periods of time.

To learn more about Lyme and its treatment and prevention, visit the Lyme disease page on the Centers for Disease Control and Prevention website.

Follow me on Twitter @drClaire

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My Health - Knuckle cracking: Annoying and harmful, or just annoying?

Follow me on Twitter @RobShmerling

Knuckle cracking is a common behavior enjoyed by many. It can become a habit or a way to deal with nervous energy; some describe it as a way to “release tension.” For some, it’s simply an annoying thing that other people do.

If you’ve ever wondered why stretching the fingers in certain ways causes that familiar noise or whether knuckle cracking is harmful in some way, read on. Despite how common it is, there has been considerable debate regarding where the noise comes from. Fortunately — at least for those of us who are curious about it — knuckle cracking has been the subject of a fair amount of research.

Here’s some of what we know about knuckle cracking

• The “cracking” of knuckle cracking seems to be produced by increasing the space between finger joints. This causes gas bubbles in the joint fluid to collapse or burst. It’s a bit like blowing up a balloon and then stretching the walls of the balloon outward until it pops.
• The reason you can’t crack the same knuckle or joint twice right away is that it takes some time for the gas bubbles to accumulate again in the joint.
• Cracking the knuckles is probably harmless. Although there have been occasional reports of dislocations or tendon injuries from overly vigorous knuckle cracking, such problems seem very much to be the exception and not the rule.

How do we know that knuckle cracking is harmless?

One of the most convincing bits of evidence suggesting that knuckle cracking is harmless comes from a California physician who reported on an experiment he conducted on himself. Over his lifetime, he regularly cracked the knuckles of only one hand. He checked x-rays on himself after decades of this behavior and found no difference in arthritis between his hands. A larger study came to a similar conclusion.

There are rare medical reports of problems associated with this behavior that may relate to how much force is applied and one’s particular technique. For example, joint dislocations and tendon injuries have been described after attempts to crack knuckles. One study published in 1990 found that among 74 people who regularly cracked their knuckles, their average grip strength was lower and there were more instances of hand swelling than among 226 people who did not crack their knuckles. However, the incidence of arthritis was the same in both groups.

And a new study created a mathematical model of a knuckle that helped confirm that the noise comes from collapsing gas bubbles.

What about other sounds coming from the joints?

The origin of most joint noises, such as popping sounds or cracking of the knees when squatting, is uncertain. They may come from the kneecap rubbing on the bones below, or a tendon sliding across an irregular surface. However, in the absence of pain, swelling, or other joint symptoms, these sounds are probably nothing to be concerned about, and there is no reliable way to silence them.

The bottom line on knuckle cracking

If you want to crack your knuckles, it’s unlikely to cause you harm. But if you want someone else to stop cracking their knuckles, you’ll need a better reason than telling them they’re ruining their joints.

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My Health - 10 Tips How To Prevent Asthma Attack Naturally

10 Tips How To Prevent Asthma Attack Naturally

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 - The bacterial horror of hot-air hand dryers

Follow me on Twitter @JohnRossMD

If you’re the kind of person who avoids public bathrooms at all costs, you may feel validated, as well as disturbed, by a new study from researchers at the University of Connecticut and Quinnipiac University. They suspected that hot-air hand dryers in public restrooms might be sucking up bacteria from the air, and dumping them on the newly washed hands of unsuspecting patrons.

To test this theory, scientists exposed petri dishes to bathroom air under different conditions and took them back to the microbiology laboratory to look for bacterial growth. Petri dishes exposed to bathroom air for two minutes with the hand dryers off only grew one colony of bacteria, or none at all. However, petri dishes exposed to hot air from a bathroom hand dryer for 30 seconds grew up to 254 colonies of bacteria (though most had from 18 to 60 colonies of bacteria).

Were the bacteria multiplying inside the hand dryers, or were they being pulled into the hand dryers from the air inside the bathroom? To answer this question, the researchers attached high-efficiency particulate air (HEPA) filters to the dryers, which would eliminate most of the bacteria from the air passing through the dryer. When they exposed petri dishes to air from the hand dryers again, the quantity of bacteria in the dishes had fallen by 75%. As well, the researchers found minimal amounts of bacteria on the nozzles of the hand dryers. They concluded that most of the bacterial splatter from the hand dryers had come from the washroom air.

How did the bacteria get into the air in the first place? Unfortunately, every time a lidless toilet is flushed, it aerosolizes a fine mist of microbes. This fecal cloud may disperse over an area as large as six square meters (65 square feet). Aerosols from flushed toilets may be especially harmful in the hospital setting as a means of spreading Clostridium difficile.

Is there any good news from this study? Well, the vast majority of the microbes that were detected do not cause disease in healthy people, with the exception of Staphylococcus aureus. Some of the bathroom bacteria, such as Acinetobacter, only cause infections in people in the hospital, or in those with weak immune systems. The others that were found are relatively harmless. In addition, air from real-world bathrooms may contain fewer bacteria than the bathrooms in the study. The sampled restrooms were located in a university health sciences building, and at least some of the bacteria came from experiments going on in laboratories within the building.

So what’s a person to do to avoid picking up bacteria in a bathroom? You should still dry your hands, as not drying them after washing them helps bacteria to survive on them. Paper towels are the most hygienic way to dry your hands. For this reason, use of paper towels is already routine in health care settings. You may also wish to avoid jet air dryers, which have also been associated with the spread of germs in bathrooms. And remember that your chances of picking up a serious pathogen in a restroom are small. Direct contact with other people is much more likely as a means of acquiring infection.

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My Health - Memories: Learning, remembering, (not) forgetting

For 30 years, I have talked to people about their memories and, as a neuropsychologist interested in amnesia, I am very interested in brain areas that mediate learning and forgetting.

How memories work

A core brain structure for memory is the hippocampus. The hippocampus (the Greek word for seahorse) is shaped like its namesake. It plays a key role in the consolidation of new memories and in associating a new event with its context (e.g., where it took place, when it happened). For example, you might hear the name Princess Diana. The hippocampus may activate verbal associations (e.g., she was part of the Royal Family), as well as memories of particular images or experiences. When I hear the name Princess Diana, I recall my brother telling me of her death as I descended the stairs of his home on Cape Cod. I can picture that moment in my “mind’s eye.” Despite my age, my (relatively) intact hippocampus allows me to retrieve a complex set of images and ideas that remind me where I was and who I was with when I heard the sad news of Princess Di’s death.

Memories that last

Some memories seem to age well. Recall of specific “flashbulb” events, such as the death of John F. Kennedy, or where you were on September 11th, 2001, seems unblemished and unchanged over time. However, in reality all memories, even flashbulb events, are malleable; they change as a result of the passage of time. They shift each time you call a memory to mind, as they are affected by other memories that have overlapping elements. As a student of memory, I am just as interested in long-term forgetting as I am in remembering. I am particularly intrigued by changes that take place with regard to autobiographical memory. Autobiographical memory is the foundation on which we derive a sense of who we are, what we find rewarding, and how we define our world. It is integral to how we construct meaning and purpose in our lives.

Autobiographical memory as we grow older

As we age our personal memories become fragile. They become less accurate and lose context. People with neurodegenerative conditions such as Alzheimer’s disease are particularly vulnerable to the loss of personal memories, due to the combined effects of their neurological condition and the aging process. They no longer have the same access to important milestones that helped define them. The importance of autobiographical memory is often overlooked. People come to me to ask for assistance with memory skills. I teach them all I know about mnemonic techniques to enhance face–name associations. I review cognitive strategies for new learning. I rarely talk about old memories… their first day of school, their first kiss, music from teenage years.

Tending to autobiographical memory

More recently I shifted my focus in conversations with people who want to talk about memory. Together with a therapist colleague, I started the “memoir project.” Why? I want to help highlight the important role of personal memories in maintaining a strong sense of self. People, even those with mild dementia, are encouraged to review important life events by using personal timelines to identify, for example, key events, food, music, and people who contributed to their sense of self. They may contact childhood friends, college roommates, and family members to remind them of shared experiences and to augment past memories. They often receive memory “gifts” as a result of these conversations — filling in the gaps in a memory that was beginning to fade. And of course, documentation and journaling are critical strategies. The stories people have shared with me have been fascinating. More important is the joy of reminiscence they experience.

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My Health - Chondroitin and melanoma: How worried should you be?

Follow me on Twitter @RobShmerling

Chondroitin sulfate is among the most popular supplements in the world. It’s often taken in combination with glucosamine for joint disease — some take it for prevention, others to treat pain.

And yet, evidence that it actually works at all is limited at best. One review of the evidence suggested that of the few studies of chondroitin that were positive, nearly all were funded by makers of the supplement. Despite this, millions of people take it, many of my patients swear by it, and the lack of evidence doesn’t seem to be much of a concern to them. A frequent comment I hear is: “Well, I’m not sure if it’s doing much but it can’t hurt, right?” A new study suggests that maybe it can.

Can chondroitin increase melanoma risk?

Researchers publishing in the medical journal Molecular Cell are raising concerns that chondroitin sulfate may encourage the development or recurrence of melanoma, a potentially deadly form of skin cancer. Here’s what they found:

• The growth of human melanoma cells with a particular mutation (called V600E) that had been grafted onto the skin of mice was promoted when the mice consumed chondroitin sulfate. About half of human melanomas contain this mutation.
• Among mice fed chondroitin sulfate, these melanoma tumors were more resistant to an antitumor drug, vemurafenib, than those without the mutation.

Although this research did not actually study people with melanoma, the study authors speculate that for people with precancerous skin growths containing the V600E mutation, taking chondroitin might be a bad idea because it could speed up tumor growth. And if a person had melanoma in the past, taking chondroitin might make recurrence more likely.

The research linking chondroitin and melanoma is preliminary

It’s important to point out that this is preliminary research. Although the tumor cells studied came from humans, a link between chondroitin sulfate use and melanoma in humans has not yet been established. It’s possible that these results aren’t relevant to actual people — for example, the doses or metabolism of chondroitin sulfate may be so different in humans (vs. mice) that these results do not apply to humans. It is not rare that studies in animals do not translate directly to people.

Why does this matter?

Melanoma is not the most common type of skin cancer, but unlike many other skin cancers (such as basal cell cancers), simply removing the cancer doesn’t always cure it. It can spread quickly even years after apparent “cure.” Estimates are that more than 90,000 people learn they have melanoma each year, and more than 9,000 people die of the disease annually.

Here’s my take: this research is quite preliminary, and might turn out to have little relevance to human disease. But if chondroitin sulfate may promote melanoma growth — and it’s not clear that this supplement is particularly helpful anyway — I’d advise against its use, at least until we know more.

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My Health - Do we need to take tackling out of youth football?

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As we learn more about the frequency and effects of concussions in football, we are increasingly being forced to face the question: do we need to take the tackling out of youth football?

A study published in the Annals of Neurology definitely begs that question. Researchers from Boston University examined the brains of 246 deceased football players, 211 of whom were diagnosed with chronic traumatic encephalopathy, or CTE. They found that the younger the players started playing tackle football, the earlier they started showing symptoms of CTE such as neurological and behavioral problems. In fact, for every year before age 12 that the players started playing, they showed symptoms 2.5 years earlier.

That’s really sobering. That means that a child who starts Pop Warner football in kindergarten at 6 could have real problems 15 years earlier than someone who started in middle or high school.

Now, there are obvious limitations to this study. They didn’t have a control group, and it’s certainly possible that families of players with more serious symptoms were more likely to donate the players’ brains for study. But given what we know about the effects of repeated head injury, it makes sense. Given what we know about any repeated injury, it makes sense: when you injure a part of the body it can become weakened, and less able to heal completely from future injuries. When that part of the body is the brain, the ramifications are particularly worrisome.

It’s hard to imagine football without tackling — but you could argue that the real athleticism of football isn’t the part where people get knocked down. You could argue that it’s in the speed and agility, the ability to throw and catch with precision. You could argue that the successful teams aren’t so much the ones who are good at slamming into people, but the ones who are good at strategy and teamwork. If we took out the tackling, we’d still be teaching young athletes skills that are important not just for sports but also for life.

Of course, concussions happen in other sports besides football. Youth who play soccer, volleyball, lacrosse, and many other sports are at risk for concussion too. My daughter actually got two concussions in high school swimming from colliding with other swimmers. It’s important that parents and coaches of athletes in all sports be aware of the risks and do everything they can to lessen them.

Injuries are part of sports. We can’t prevent them all without stopping kids from playing sports completely, which we don’t want to do. But if we know that there is a particular aspect of a sport that puts kids at real risk, and that aspect of the sport isn’t necessarily crucial, then maybe we should think about making changes while players are young. When they are adults, or even teens, they can make their own choices. But when they are young kids, keeping them safe and getting them to adulthood in the best shape possible is, well, our job.

That’s really the crux of it. Knowing what we do about tackling, can we in good conscience let our kids keep doing it?

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My Health - Eat These 9 Foods To Protect Yourself From The Sunburn

Eat These 9 Foods To Protect Yourself From The Sunburn

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 - Take control of your health care (exert your patient autonomy)

Autonomy means being in control of your own decisions without outside influence — in other words, that you are in charge of yourself. It is considered an essential development step toward maturity. We all make decisions about how to live our lives, although sometimes we have less choice than we might like.

When it comes to your health care, how much autonomy is the right amount?

There’s lots of interest in what the term means. Here’s a definition from MedicineNet:

Patient autonomy: The right of patients to make decisions about their medical care without their health care provider trying to influence the decision. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.

This can be a hard line to navigate. In the past, physicians made all the decisions for their patients. They would plan the care, prescribe the treatment, and the patient would either comply or not. The word “comply” is itself pejorative. We have moved into a much more enlightened era of care, and many physicians seek to involve patients, to help them understand treatment options, and to work collaboratively to achieve goals of wellness.

When you and your doctor don’t see eye to eye on the best health care for you

But what if you and your physician don’t agree on the best course of care for you? What if your doctor insists that she knows best, and that your health will be at risk if you don’t follow her advice? Maybe your physician has discouraged you from researching your medical condition yourself. From the physician’s angle, most of us want our patients to understand their illness, be educated on goals of wellness, and be active participants in their own healthcare. But here’s where it gets tricky: physicians study for years to become doctors and bring their scientific knowledge and clinical acumen to the office and the bedside. Patients may not have those skills, but they know their own bodies, tolerance for treatment, and the manner in which they are comfortable receiving care.

Finding the right doctor

It’s sometimes hard to find a doctor you’re comfortable with, whether it’s for you or your child. Making a list of what’s important to you — whether you have a physician you like now, are uncomfortable in your current treating situation, or are in the process of looking for a new provider — can really help. Ask yourself these questions:

• What is my style about health care? Do I want my doctor to tell me what to do, list the options but give me the final choice, or let me describe the medication and plan that I have researched first?
• Would I like someone who is more relational or more boundaried? Do I want a physician who has the style of sharing his own life with me, asks about my life and tries to incorporate who I am as a person as well as a patient, or would I prefer a more businesslike approach? Do I want my physician to tell me if she has the same illness I do, and what it’s like for her, or would I prefer my doctor keep this to herself?
• How much do I want my doctor to know about me as a person? Is that important in the way I want to receive my health care?
• What might happen if I disagree with my doctor? Would that end the treating relationship right there, or could we work through a difference?

The right doctor will naturally support your patient autonomy

Figuring out how you want your physician to work with you lets you maintain your patient autonomy, whatever that autonomy might be. Receiving the kind of care that is comfortable for you is exercising your autonomy. There will always be blips along the way. One woman told me about a primary care doctor she had worked with for years who became enraged with her at a visit, seemingly out of the blue. She felt he was attacking her health care behavior without asking appropriate questions. She offered him several opportunities during the visit to re-evaluate his comments. When he couldn’t do so, she used her autonomy to fire him. Another patient described being told that if he did not take a specific medication, the outcome could be devastating for his health. This may have been true, but perhaps a more collaborative discussion would have allowed this patient to feel less bullied into a treatment. Feeling comfortable with your right to get the answers you need to understand your treatment reflects your patient autonomy. Make sure your doctor’s style matches your own. How the treating relationship works is an essential part of the treatment. If it works, everything is enhanced. If your autonomy is not respected, your health care will suffer.

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My Health - Should you carry the opioid overdose rescue drug naloxone?

The US Surgeon General, Dr. Jerome Adams, recently released an advisory on naloxone and opioid overdose. In his advisory, Dr. Adams writes:

For patients currently taking high doses of opioids as prescribed for pain, individuals misusing prescription opioids, individuals using illicit opioids such as heroin or fentanyl, health care practitioners, family and friends of people who have an opioid use disorder, and community members who come into contact with people at risk for opioid overdose, knowing how to use naloxone and keeping it within reach can save a life.

This was the first surgeon general advisory issued in 13 years. The previous one raised awareness about the dangers of alcohol use in pregnancy. But let’s look at this advisory and attempt to figure out if it will actually help solve the opioid epidemic.

What is naloxone?

Naloxone has been around since the 1970s and has been used as a mainstay treatment of opioid overdose since that time. Naloxone (often referred to by its trade name, Narcan) is a competitive antagonist of the “mu” opioid receptor. This receptor is responsible for the pain-relieving effect of opioids, but when overly activated can lead to a life-threatening decrease in respiratory rate. In my own practice in the emergency department, naloxone has been part of the “coma cocktail” that we consider giving to patients who are unresponsive, along with medicines like glucose for suspected low blood sugar. For years, naloxone was an inexpensive, generic drug that cost less than $1 a dose. But then, the opioid epidemic came.

The increase in demand for naloxone

With the increased number of deaths from opioids, there was an urgent need to expand access to the antidote. In the hospital, naloxone is typically given by an intramuscular shot or IV line, but the medication is also conveniently absorbed into the blood supply if given in the nose as well. Emergency medical technicians began using nasal naloxone by jerry-rigging the IV formulation with an adapter that atomizes the medicine and allows it to be sprayed in the nose. Eventually, protocols to use naloxone spread to other first responders like police officers and firefighters, who are frequently the first to reach an overdose victim. The final step was to empower bystanders and family and friends of opioid users to carry and use naloxone. A landmark study by Dr. Alex Walley and colleagues in 2013 demonstrated that communities where overdose education and nasal naloxone distribution occurred had lower rates of overdoses than those that did not.

The market for naloxone increases

With increased demand, the cost of naloxone skyrocketed. Two products were developed specifically for bystanders: brand name Narcan, which is a nasal spray, and a talking auto-injector called Evzio. Both of these products have been criticized because of their high list prices ($150 for a two-pack of the nasal spray and $4,500 for the auto-injector). Fortunately, most insurances do cover naloxone, so most people are only obligated to cover their copay. Still, even if the cost to consumers is low, finding a pharmacy that carries it can be challenging, even in New York City.

Back to the key question: “Should you carry naloxone?”

I would answer “yes” but with some qualifiers. As the Surgeon General wrote, naloxone is most effective for people taking high doses of opioids, who are misusing prescription opioids, or who are using illicit opioids. It makes sense to have naloxone on hand if you fall into one of these categories, or if you are a friend, family member, or community member who comes into contact with people at risk for overdose. You should also know that in most states, you can request naloxone at most pharmacies without a prescription.

But I do have one important criticism of the Surgeon General’s advisory. Naloxone should be considered a Band-Aid, but it is not the solution to the opioid crisis. Naloxone is only sufficient to save the life of a person who is actively overdosing. This antidote does nothing to prevent future overdoses, nor does it address the longer-term treatment needs of patients with substance use disorders. I don’t mean to downplay the importance of naloxone to save the life of an overdose victim but saving a person from an acute overdose is merely the first step.

Furthermore, unlike an EpiPen that people can self-administer if they are having a serious allergic reaction, naloxone is given when a person is unconscious and therefore must be given by someone else. That means if a person overdoses alone, which frequently occurs, naloxone will not help. There are other issues to consider, such as how to pay for many more naloxone kits with its expanded use and increased cost, and that the medication does expire and must be stored in a tight temperature range (it shouldn’t be allowed to freeze or be kept in a car on a hot day).

My hope is that this advisory is only a first step, and that federal and state governments will step up to make naloxone more affordable and provide the necessary and substantial resources required to address the treatment requirements of the underlying substance use disorders that lead people to suffer overdose in the first place.

Disclosures: Dr. Weiner completed a research study about opioid-induced respiratory depression that was funded by Kaleo, the company that makes the Evzio naloxone auto-injector. He also has ownership interest and is on the scientific advisory board of General Emergency Medicine Supplies Corp. (a company aiming to make public access naloxone stations) and Epidemic Solutions LLC (a company creating a wearable device that detects opioid overdose and calls for help).

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