My Health - Intermittent fasting: Surprising update

There’s a ton of incredibly promising intermittent fasting (IF) research done on fat rats. They lose weight, their blood pressure, cholesterol, and blood sugars improve… but they’re rats. Studies in humans, almost across the board, have shown that IF is safe and incredibly effective, but really no more effective than any other diet. In addition, many people find it difficult to fast.

But a growing body of research suggests that the timing of the fast is key, and can make IF a more realistic, sustainable, and effective approach for weight loss, as well as for diabetes prevention.

The backstory on intermittent fasting

IF as a weight loss approach has been around in various forms for ages, but was highly popularized in 2012 by BBC broadcast journalist Dr. Michael Mosley’s TV documentary Eat Fast, Live Longer and book The Fast Diet, followed by journalist Kate Harrison’s book The 5:2 Diet based on her own experience, and subsequently by Dr. Jason Fung’s 2016 bestseller The Obesity Code. IF generated a steady positive buzz as anecdotes of its effectiveness proliferated.

As a lifestyle-leaning research doctor, I needed to understand the science. The Obesity Code seemed the most evidence-based summary resource, and I loved it. Fung successfully combines plenty of research, his clinical experience, and sensible nutrition advice, and also addresses the socioeconomic forces conspiring to make us fat. He is very clear that we should eat more fruits and veggies, fiber, healthy protein, and fats, and avoid sugar, refined grains, processed foods, and for God’s sake, stop snacking. Check, check, check, I agree. The only part that was still questionable in my mind was the intermittent fasting part.

Intermittent fasting can help weight loss

IF makes intuitive sense. The food we eat is broken down by enzymes in our gut and eventually ends up as molecules in our bloodstream. Carbohydrates, particularly sugars and refined grains (think white flours and rice), are quickly broken down into sugar, which our cells use for energy. If our cells don’t use it all, we store it in our fat cells as, well, fat. But sugar can only enter our cells with insulin, a hormone made in the pancreas. Insulin brings sugar into the fat cells and keeps it there.

Between meals, as long as we don’t snack, our insulin levels will go down and our fat cells can then release their stored sugar, to be used as energy. We lose weight if we let our insulin levels go down. The entire idea of IF is to allow the insulin levels to go down far enough and for long enough that we burn off our fat.

Intermittent fasting can be hard… but maybe it doesn’t have to be

Initial human studies that compared fasting every other day to eating less every day showed that both worked about equally for weight loss, though people struggled with the fasting days. So I had written off IF as no better or worse than simply eating less, only far more uncomfortable. My advice was to just stick with the sensible, plant-based, Mediterranean-style diet.

New research is suggesting that not all IF approaches are the same, and some are actually very reasonable, effective, and sustainable, especially when combined with a nutritious plant-based diet. So I’m prepared to take my lumps on this one (and even revise my prior post).

We have evolved to be in sync with the day/night cycle, i.e., a circadian rhythm. Our metabolism has adapted to daytime food, nighttime sleep. Nighttime eating is well associated with a higher risk of obesity, as well as diabetes.

Based on this, researchers from the University of Alabama conducted a study with a small group of obese men with prediabetes. They compared a form of intermittent fasting called “early time-restricted feeding,” where all meals were fit into an early eight-hour period of the day (7 am to 3 pm), or spread out over 12 hours (between 7 am and 7 pm). Both groups maintained their weight (did not gain or lose) but after five weeks, the eight-hours group had dramatically lower insulin levels and significantly improved insulin sensitivity, as well as significantly lower blood pressure. The best part? The eight-hours group also had significantly decreased appetite. They weren’t starving.

Just changing the timing of meals, by eating earlier in the day and extending the overnight fast, significantly benefited metabolism even in people who didn’t lose a single pound.

So is this as good as it sounds?

I was very curious about this, so I asked the opinion of metabolic expert Dr. Deborah Wexler, Director of the Massachusetts General Hospital Diabetes Center and associate professor at Harvard Medical School. Here is what she told me. “There is evidence to suggest that the circadian rhythm fasting approach, where meals are restricted to an eight to 10-hour period of the daytime, is effective,” she confirmed, though generally she recommends that people “use an eating approach that works for them and is sustainable to them.”

So here’s the deal. There is some good scientific evidence suggesting that circadian rhythm fasting, when combined with a healthy diet and lifestyle, can be a particularly effective approach to weight loss, especially for people at risk for diabetes. (However, people with advanced diabetes or who are on medications for diabetes, people with a history of eating disorders like anorexia and bulimia, and pregnant or breastfeeding women should not attempt intermittent fasting unless under the close supervision of a physician who can monitor them.)

4 ways to use this information for better health

1. Avoid sugars and refined grains. Instead, eat fruits, vegetables, beans, lentils, whole grains, lean proteins, and healthy fats (a sensible, plant-based, Mediterranean-style diet).
2. Let your body burn fat between meals. Don’t snack. Be active throughout your day. Build muscle tone.
3. Consider a simple form of intermittent fasting. Limit the hours of the day when you eat, and for best effect, make it earlier in the day (between 7 am to 3 pm, or even 10 am to 6 pm, but definitely not in the evening before bed).
4. Avoid snacking or eating at nighttime, all the time.

Sources

Effect of Alternate-Day Fasting on Weight Loss, Weight Maintenance, and Cardioprotection Among Metabolically Healthy Obese Adults: A Randomized Clinical Trial. JAMA Internal Medicine, May 2017.

Alternate-day fasting in nonobese subjects: effects on body weight, body composition, and energy metabolism. American Journal of Clinical Nutrition, January 2005.

The Obesity Code, by Jason Fung, MD (Greystone Books, 2016).

Intermittent fasting interventions for treatment of overweight and obesity in adults: a systematic review and meta-analysis. JBI Database of Systematic Reviews and Implementation Reports, February 2018.

Metabolic Effects of Intermittent Fasting. Annual Review of Nutrition, August 2017.

Early Time-Restricted Feeding Improves Insulin Sensitivity, Blood Pressure, and Oxidative Stress Even without Weight Loss in Men with Prediabetes. Cell Metabolism, May 2018.

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My Health - Rethinking the screening mammogram

Doctors and patients want and need tests that detect disease while that disease is still treatable — ideally, while curable. Even better, we want screening tests that can accurately detect “pre-disease,” not just detect it once present. An example is colonoscopy, which can detect certain types of polyps that degenerate into colon cancer. And of course, we want tests that actually improve longevity or quality of life.

On the other side, we don’t want too many false alarms (or “false positive” results) — these are results that suggest disease when, in fact, no disease is present. This is especially true if those false alarms lead to unneeded surgery or other risky procedures.

Even when risky treatments are avoided, there’s another downside to false alarms: worry. If you’re told your screening test for cancer is abnormal, the time it takes to figure out that it’s a false alarm can be terribly frightening. And it can seem like forever.

Assessing the value of the screening mammogram

In a previous blog, I wrote about how we have relatively few time-tested and reliable medical screening tests that deliver on their promise. A 2016 study questions the value of one of those tests: the mammogram.

This study analyzed data from women over 40 and compared the size of breast cancers at the time of diagnosis detected in the 1970s (before mammography became common) with the size of tumors detected between 2000 and 2002, when screening mammography was routine. Treatments and rates of death due to breast cancer 10 years after the diagnosis were also analyzed. The study found that:

• As more women underwent routine screening mammograms, more small breast cancers were detected. Many of these tumors were restricted to the ducts within the breast (called ductal carcinoma in situ), and even without treatment would never threaten the health of the woman.
• The detection of larger, more aggressive breast cancers was unchanged in frequency between the pre-mammogram and more recent time periods. This is important since, if screening mammograms caught these cancers earlier, in theory, the frequency of detecting these more dangerous tumors should be falling.

Are there benefits of a screening mammogram?

The study’s authors did not suggest that mammography is useless. They estimated that about 20% of women with small tumors that could only be detected with a mammogram received therapy that might be lifesaving. But the other 80% of women did not benefit. Similarly, estimates suggest that about two-thirds of the reduction in breast cancer deaths in recent years is due to better treatments, not better detection. Some additional reduction may be related to falling rates of post-menopausal hormone replacement; but the contribution of mammography to this trend may be relatively small.

The authors suggest that the benefits of mammography have been overestimated and, as a result, many women may be receiving medical and surgical treatments that are unnecessary. It’s not surprising that this new study is controversial. A number of experts have criticized its conclusions and worry that such research will discourage women from having mammograms that could save their lives.

Debate on the value of screening mammograms has happened before

This isn’t the first time questions have been raised about the usefulness of mammography. A 2012 study also raised the concern that unimportant tumors were being detected, leading to unnecessary treatment for large numbers of women. There has also been controversy about when women should start having them and how often they should be repeated. For example, the US Preventive Services Task Force suggests that routine screening mammograms should begin at age 50 and be repeated every two years until age 74. But the American Cancer Society says that women should begin at age 45, have them yearly until age 55, and then every two years.

So, what’s a woman to do?

While the message of this new study is clear — mammography may not be as good as we thought — it isn’t at all clear what women should do with this information. It’s likely that in light of these concerns, recommendations will change in the future. But how?

Optimal recommendations regarding mammography will depend on:

• Developing better ways to distinguish breast cancers that pose a threat to health and warrant aggressive therapy from those that don’t
• Understanding the individual factors that affect the usefulness of mammography. For example, family history, genetic factors, use of hormonal therapy, breast density, obesity, and reproductive history all can affect the risk of breast cancer or the usefulness of mammography.
• Reaching a consensus regarding an acceptable level of accuracy for screening tests. As screening tests for breast cancer evolve — including better mammograms, ultrasound, and MRI — the accuracy of diagnosis should improve. But since no test is perfect, we have to accept that some breast cancers will be missed and false alarms will happen, even with the best available screening methods.

For now, it’s important to talk to your doctor about this important study. My guess is that he or she will continue to recommend mammograms as before.

Still, it’s worth a conversation. There is a real possibility that screening tests such as mammography can cause harm — and that’s worth understanding before you have the test.

Follow me on Twitter @RobShmerling

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My Health - Losing weight: Mindfulness may help

One of the hardest parts about losing weight isn’t choosing what to eat. You know you should focus on fresh, lower-calorie foods and steer clear of sugary, fat-laden treats. Often, the real challenge is more about changing how and why you eat. One strategy that just might help is the practice of mindfulness, according to a recent review in Current Obesity Reports.

One of the main benefits of mindfulness approaches for weight loss is to help people recognize emotional eating, says mindfulness expert Ronald D. Siegel, assistant professor of psychology at Harvard Medical School. “Very few of us eat solely based on hunger cues. We also eat to soothe anxiety, sadness, or irritation,” he says. That’s a recipe for mindless eating: You’re operating on automatic pilot, without paying attention to how you really feel, emotionally or physically.

Mindfulness practices help you notice these common patterns, which are similar to what happens with many types of addiction, says Dr. Siegel. Most human behaviors are based on conditioned patterns of seeking pleasure and avoiding pain. Those behaviors we refer to as addictions have good short-term consequences (the pleasure of eating a piece of chocolate cake) but bad long-term consequences (becoming overweight).

Self-awareness for losing weight? Notice your cravings

Addictive behaviors are prone to what addiction expert G. Alan Marlatt called the abstinence violation effect. For example, you might have a plan to eat healthfully, but then you see a chocolate cake. “You break down and eat a piece, but then feel so horrible about your lack of self-control that you feel a desperate need to self-soothe — and end up eating the rest of the cake,” says Dr. Siegel.

Once you become aware of these patterns, the next step is finding a way to cope with cravings. Simply avoiding tempting foods is difficult, because tasty treats are widely available nearly everywhere you go. Mindfulness can help you notice the craving and recognize that you can deal with the discomfort, which may be accentuated by unhappy emotions. By turning your attention to those feelings and practicing self-awareness, you can notice that the feelings come and go. “Urges and cravings comes in waves, and we can ride them out,” says Dr. Siegel.

Self-acceptance and defusion

Another aspect of mindfulness training is self-acceptance. If you do give in to a craving, forgive yourself and move on. “None of us is perfect, you don’t have to torture yourself,” says Dr. Siegel. Four of the 12 studies in the recent review article focused on acceptance-based behavior training, which relies on mindfulness strategies to identify emotions rather than avoid them.

In one small study of people with heart disease, participants were encouraged to recognize that eating healthfully and exercising is really challenging, and that pretending that it isn’t just makes it all the more distressing. Instead, they were taught a practice called defusion, in which you distance yourself from unhelpful thoughts, feelings, and beliefs. This helped them tolerate the distress of trying to make heart-healthy behavior changes. Participants gave high marks to the program and made positive changes in their diet and exercise habits.

Another promising strategy noted in the review includes different types of mindfulness meditation, such as an eating-focused practice in which people were taught to acknowledge their hunger levels, emotions, thoughts, motivations, and eating environment with acceptance but without judgment. The practice was most effective when combined with self-compassion, which involved repeating phrases of good will and benevolence for oneself and others.

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My Health - Teens are getting less sleep which raises heart disease risk

Teens are getting less sleep these days — and it could make them more likely to have heart disease as adults.

Over the past 20 years, the amount of sleep that teens get has dropped significantly. Only about half of them regularly get more than seven hours of sleep, with older teens sleeping less than younger ones — which, given that the recommended amount is eight to 10 hours, is bad news.

This is bad news for all sorts of reasons. Our bodies need sleep. When we get less sleep, not only are we cranky, we are less able to learn new information, our reaction times are longer, we may have behavioral changes or mental health problems — and it affects our health.

In a study just published in the journal Pediatrics, researchers looked at the sleeping habits of 829 adolescents between the ages of 12 and 16, with a mean age of 13. They found that a third of them slept less than seven hours every night, and nearly half of them were fully asleep for less than 85% of that nightly sleep time.

But here’s where it gets worrisome. The researchers found that those who got less sleep were more likely to have a high “metabolic risk score.” They were more likely to have belly fat, high blood pressure, and abnormal blood lipids, as well as insulin resistance, something that increases the risk of diabetes.

So not only are sleep-deprived teens more likely to do poorly in school, be depressed, and get into car crashes, they are also more likely to have heart disease when they are adults.

While homework, other activities, and early school start times certainly contribute to teens getting less sleep, the biggest culprit seems to be electronic devices. The blue light emitted from them can wake up the brain, making it harder to fall asleep (the “Night Shift” setting on the phones does not entirely take care of this problem) — but more commonly, teens simply stay up late using them.

This demands action. We can’t just sit back and say that “teens will be teens” when it comes to sleep — not when their future health is at risk.

Here’s what parents can do:

• Make a rule that electronic devices get turned off an hour before their teen needs to fall asleep (meaning eight to 10 hours before they need to wake up). It’s best if they are charged outside the bedroom, so that there is no temptation to respond to alerts. A second choice is to have phones on “Do Not Disturb,” which quiets all alerts except alarms (although buying an alarm clock is a viable alternative that many people forget about these days).
• Enforce this rule.
• Prioritize sleep. Sit with your teen and look at how their time is spent, and map out the day so that they can get to bed on time. If their homework and other activities make it impossible to get at least eight hours of sleep, then something needs to give. Physical and mental health needs to be more important than whatever it is they are doing instead of sleeping.
• Support community efforts to have later high school start times. Teens are biologically wired to fall asleep late and sleep late, and when we make them get up really early for school, we are only making everything worse.

We want our kids to have a good future. That’s why we talk to them about avoiding tobacco, drugs, and alcohol, about working hard in school and staying out of trouble. And it’s why we need to talk to them about sleep.

Follow me on Twitter @drClaire

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My Health - Probiotics for bipolar disorder mania

Bipolar disorder can be a debilitating disease. Dealing with this illness is quite difficult for patients, family, and friends. The manic phases can profoundly disrupt people’s quality of life. The cost is another reason for concern, as patients can be hospitalized for days until their symptoms are well controlled. After discharge there is a high risk of relapse, so careful observation is important to prevent rehospitalizations. But what if a simple supplement could help manage these serious flare-ups?

Bipolar disorder and gut health

There is growing evidence that mood disorders may be related to overall inflammation and to changes in the microbiome, the bacteria that live in our digestive tract. We have learned that probiotics may help improve a variety of health conditions, in part due to an anti-inflammatory effect.

Researchers from Johns Hopkins University School of Medicine designed an interesting study to determine if probiotics could help people discharged from the hospital after a manic flare-up avoid rehospitalization. The study randomized 66 patients with bipolar disorder who were hospitalized for mania and divided them into two groups of 33 patients. They gave a probiotic combination of Lactobacillus and Bifidobacterium species to one group and a placebo to the second group. They asked all patients to continue taking their regular medications for bipolar disorder and followed them for a total of 24 weeks. Before the start of the study, the researchers identified which patients had higher markers of inflammation (that is, people with more overall inflammation in the body).

What this study on probiotics and mania showed

The results were striking. The rates of rehospitalization were 51.1% in the placebo group and 24.2% in the group who took probiotics. On average, the reduction in readmission was 74% lower in the probiotic combination compared with the placebo arm of the study. The most significant finding was an almost 90% reduction of hospitalization in the group with the highest inflammation score who took probiotics. Additionally, patients who took probiotics and were rehospitalized stayed in the hospital on average 2.8 days, compared with 8.3 days for those taking placebo.

The microbiome and mood disorders beyond bipolar

This study adds to the data that suggest gut flora has an effect on psychiatric diseases. We still do not know if an intestinal microbiome disarray is the cause of mania and bipolar disorder. However, this research supports an assertion that overall inflammation is associated with gut inflammation, which in turn can modulate mood disorders, or at least severe cases of mania for bipolar patients. The evidence of a “gut-brain axis principle” is more robust, especially after some studies showing that the type of bacteria that live in our bowels could cause brain inflammation. This most recent research indicates that we could potentially manage the symptoms of severe cases of bipolar disorder merely by changing the makeup of our microbiome.

What now?

A few words of caution before you buy probiotics to address mood changes. The study was small, and the selected patient population had a more severe form of bipolar disorder. Similar studies for patients with milder symptoms of depression and schizophrenia found little to no effect when comparing probiotics to standard treatment. We need a lot more data from high-quality research to change what we currently recommend for the treatment of other psychiatric illnesses.

Yet, this research still has the potential to change practice after patients with bipolar disorder get discharged from the hospital for mania. Adding probiotics to the regular medication regimen is simple, cheap, has no side effects, and appears to be highly effective.

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My Health - Physician burnout can affect your health

There is a severe and worsening epidemic of physician burnout in the United States, which threatens the health of doctors and patients alike. What is burnout? How does it affect doctors? And, how can this affect patient care? Finally, what can be done about this issue, to breathe life and energy back into the field of medicine?

What does physician burnout look like?

Burnout among doctors is generally described in terms of a loss of enthusiasm for one’s work, a decline in satisfaction and joy, and an increase in detachment, emotional exhaustion, and cynicism. It manifests in disproportionately high rates of depression, substance abuse, and suicide. Annually, approximately four hundred physicians take their own lives in the United States.

A 2016 study published by the Mayo Clinic showed a high and increasing rate of physician burnout. Of the almost 7,000 physicians who responded to the survey, 54.4% “reported at least one symptom of burnout in 2014 compared with 45.5% in 2011.” Satisfaction with work-life balance also declined, but this is no huge surprise given that, as a whole, physicians are working more and earning less. In other words, more than half of US physicians are experiencing at least some degree of burnout.

Moreover, many doctors are leaving medicine mid-career, which, among other things, causes patients to have to start all over again with a new doctor. Other physicians are cutting back their hours, which makes it more difficult for patients to obtain timely appointments. These developments are expected to worsen the projected shortage of physicians that our country will be facing over the next few decades, estimated to be up to 100,000 doctors by 2030, according to a study commissioned by the American Association of Medical Colleges.

Why are doctors so burned out?

The causes of physician burnout are complex, but have to do in part with increasing workload, constant time pressures, chaotic work environments, declining pay, endless and unproductive bureaucratic tasks required by health insurance companies that don’t improve patient care, and increasingly feeling like cogs in large, anonymous systems. Parasitic malpractice lawyers are always circling, which causes us to waste an enormous amount of time with defensive documentation. The transition from paper charts to electronic medical records, which seemingly were designed to maximize revenues instead of clinical care, has created a technological barrier between doctor and patient, and between doctors.

Physician burnout compromises patient care

There is good evidence that physician burnout results in more expensive healthcare and less satisfied patients. Demoralized doctors can suffer from impaired memory and attention, and poor decision-making. They can be distracted, and their communication with both patients and peers deteriorates. They feel less empathetic and engaged in the outcomes of their day-to-day decisions. Their bedside manner worsens. They can make mistakes, sometimes devastating. While this is a difficult phenomenon to measure, a 2014 study of intensive care doctors showed that emotional exhaustion among physicians predicted a higher mortality rate among the patients they cared for. And according to a research review in the British Medical Journal from 2017, “there is moderate evidence that burnout is associated with safety-related quality of care.”

What can we do to address physician burnout?

Sadly, hospitals and other medical institutions have tended to address the problem of physician burnout merely by giving their doctors inspirational talks about “resilience,” patting them on the shoulder, and then sending them back into their deteriorating clinical lives with no material change in circumstances. Sometimes they throw in a yoga mat. The physician then continues to suffer in silence, leaves medicine, or encounters some other tragic endpoint.

Recently, there appears to be more awareness of, and concrete attention being paid to, this issue. Some medical schools and hospitals have started including physician wellness in their curriculums, and even dedicating some faculty time to help monitor and ensure the well-being of their staff physicians.

The problem of physician burnout is complex and there is no easy solution in sight. In my personal experience as a primary care physician over the last 20 years, the insurance companies won’t flinch at wasting a doctor’s time, even deliberately, if it will increase their profits. Hospitals will choose a medical record system that prioritizes their revenues, and which has the doctor facing the screen and pecking away, over one that allows for doctors and patients to speak with each other, comfortably, face to face. As with most things, it comes down to the bean counters, and the bottom line.

Addressing the human cost of physician burnout

The losers in all this, equally, are the doctors and the patients. If you are receiving substandard care from a seemingly burnt-out or distracted doctor, you obviously need to report it, and advocate for your own care. However, it is also critically important to remember that doctors are people too, not robots. As with most things in life, empathy is a two-way street. Doctors and patients need to put their heads together and try to find a way to regain what is being lost in terms of the once strong doctor-patient bond. We need to reclaim healthcare, for the good, and the safety, of us all.

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My Health - Sun protection: Appropriate sunscreen use

Summer holidays are here and the sunny, warm weather is in full swing. Now is not the time to get lazy about sun protection!

Sun: The good and the not-so-good

Sunlight is essential for many important bodily functions, including producing vitamin D and maintaining your circadian rhythm and mood. Yet too much sun exposure can also be harmful. Ultraviolet (UV) radiation may result in short-term and long-term skin damage, including sunburn, signs of aging, and even skin cancer. Approximately one out of five people in the United States may develop skin cancer in their lifetimes.

Approximately 95% of the UV radiation reaching our skin is ultraviolet A (UVA) light, which is primarily responsible for chronic effects such as photoaging, wrinkling, and age spots. Ultraviolet B (UVB) rays make up a smaller percentage but may be potentially even more harmful, as they are the primary cause of sunburns. Both UVA and UVB may cause skin cancer.

Even with all of these risks, many people still head to the beach with nothing more than their bathing suits, hoping to get tan. For some,  a  lobster-red burn is considered a badge of a successful beach day. This is absolutely not recommended. Any prolonged UV light exposure can put you at risk even if it isn’t summer, such as if you are out skiing in the winter with the sun reflected from the snow, or if you are indoors but using a tanning bed. So what can you do to protect yourself from these harmful rays?

There are many types of sunscreens available. Sunscreens work because they contain filters that reflect, scatter, or absorb UV radiation that otherwise would reach your skin. There are two main types of sunscreens available, separated into “organic filters” (aka chemical sunscreens) and “inorganic filters” (aka physical sunscreens).

Sun protection with chemical sunscreens (organic filters)

Organic filters absorb UV radiation and convert it into a small amount of heat. In the ingredients listed on the bottle, you may notice compounds such as oxybenzone, avobenzone, and octocrylene. Oxybenzone and avobenzone are relatively good filters for UVA radiation; however, they may be paired with other agents such as octocrylene, homosalate, and octisalate to stabilize them and provide UVB protection. In other countries, newer compounds including Tinosorb M/S, Mexoryl SX, and Mexoryl XL have been developed that are now being used as broad-spectrum sunscreens.

Sun protection with physical sunscreens (inorganic filters)

Inorganic filters are mineral compounds such as zinc oxide and titanium dioxide that theoretically work by reflecting and scattering UV light to protect your skin. However, some studies have shown that these compounds actually work by absorbing UV radiation and converting it into heat. These sunscreens tend to offer more broad-spectrum protection against both UVA and UVB light. They also tend to be the formulations used in children’s sunscreens, as they are easier on sensitive skin. These sunscreens tend to go on thicker and may appear whiter.

Use it correctly for effective sun protection

We recommend that everyone use sunscreen with sun protection factor (SPF) of 30 or higher when you spend time outdoors. SPF 30 will protect against approximately 97% of UVB rays. Sunscreens with SPF greater than 50 provide only a very small increase in protection against UV radiation.

Everyone, regardless of skin color, should wear sunscreen, because we are all at risk of the adverse effects of UV radiation and can benefit from protection. However, it is even more important for those with lighter skin shades who are more susceptible to these effects to wear sunscreen. The American Academy of Pediatrics recommends avoiding the use of sunscreen in children younger than six months, and instead emphasizes minimal sun exposure and to ensure adequate clothing and shade.

We recommend applying sunscreen using the “teaspoon and shot glass rule”: 1 teaspoon of sunscreen to the face and neck, and enough to fit a shot glass (approximately 1 ounce) for exposed areas of your body. You should apply sunscreen 15 to 30 minutes before sun exposure, then wait for 10 to 20 minutes before getting dressed. We recommend re-application of sunscreen at least every two hours, or after every water exposure or sweating even if they are labeled water-resistant.

In addition to wearing sunscreen, always wear appropriate protective clothing such as wide-brimmed hats, long-sleeved clothing, and pants when possible. Seek shade, wear sunglasses to protect your eyes, and avoid tanning beds. Remember to stay hydrated, and sunscreen up!

And what if you do get a sunburn?

If you get a sunburn, it is important to treat it right away. Seek shade and avoid being in the sun for any prolonged time.

One of the most important things in sunburn care is to drink extra water. When you have a sunburn, you actually lose more water from your body because the sunburn draws fluid to the skin surface, and the extra heat leads to increased evaporation. Topical therapies that may help with your symptoms include cool baths, gentle moisturizers, and even over-the-counter hydrocortisone cream, which may help ease the discomfort. If you have significant discomfort, you can also take aspirin or ibuprofen as directed. As always, if you ever have concerns, talk to your doctor.

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My Health - Dietary rut? 5 ways to snap out of it

Why is it that despite so many interesting foods in the world, we sometimes fall into dietary rut? For busy working families, lapsing into a boring menu routine may be due to a lack of time, planning, or know-how. Years ago, when I anchored the local TV news at dinnertime, my husband Jay made noodles with takeout meatballs so often that our three kids (even the baby) would tease him about it. “I didn’t know how to cook and I didn’t give much thought to dinner until everybody was hungry,” remembers Jay, my prince who would work all day, pick up the kids, and feed them before I got home. “We’d have leftovers of whatever you’d made or I’d go with the old standby.” (It could have been worse; Jay’s specialty in college was chili from a can.)

Unfortunately, a lack of variety and a reliance on convenience foods come with unappetizing pitfalls.

The risks of a dietary rut

Eating the same foods frequently deprives you and your kids of the flavors and textures that make meals adventures and turn your kids into healthy eaters. It also limits nutrient intake. “You need a wide variety of vitamins and minerals. In order to get them, you need to eat different types of fresh foods every day,” says Teresa Fung, adjunct professor in the nutrition department at the Harvard T.H. Chan School of Public Health.

Those nutrients should come from fresh vegetables and fruits, lean proteins, legumes (beans and lentils), nuts and seeds, healthy fats (avocados, olive oil), and low-fat dairy products.

Relying on prepackaged food or takeout meals can subject you to unhealthy ingredients like refined carbohydrates; saturated or trans fats; high amounts of salt; and lots of calories, preservatives, and additives. An unhealthy diet is associated with an increased risk for many chronic conditions, such as high blood pressure, heart disease, obesity, and cancer.

Easy ways to bust the dietary rut

Fortunately, breaking out of a dietary rut isn’t hard. Fung offers these suggestions:

1.   Get variety elsewhere. “A lot of grocery stores have a good number of healthy, prepared foods, and you can pay by the ounce,” Fung says. She recommends preparing the protein at home (like fish or chicken) and buying the side dishes — vegetables, whole grains, or salads — to bring home. “Make it something you wouldn’t normally eat,” she says.

2.  Be adventurous. “Try something unusual at least every other week. Make it yourself or get it from a restaurant,” Fung suggests. Caution: focus on vegetables or protein, and avoid anything with a lot of butter or cream. Need ideas? Pick a country and look up traditional dishes and recipes on the Internet.

3.  Try a subscription meal kit. You choose the menu on a website, and the premeasured, fresh ingredients arrive at your door. “Go for something with lots of vegetables and whole grains, and a chunk of protein,” Fung says. There are many meal kit services. Two of the biggest are Hello Fresh and Blue Apron. Prices per person, per meal, range from $10 to $12.

4.  Cook in batches. Cook once or twice a week and eat leftovers in between. Make a large entree (like white bean soup), broil several chicken breasts, or cook a few side dishes (like brown rice, quinoa, or cooked spinach) that can be eaten throughout the week. “It’s easier to cook 14 carrots in one day than two carrots per day for seven days in a row,” Fung points out.

5.  Get your kids in on it. They’ll be more inclined to eat it if they helped prepare it.

A few more tips

Jay and I finally realized that the key to variety in our family meals was planning. Now, in about half an hour on the weekend, we come up with healthy, interesting menus and shopping lists for the week.

We take turns making dinner, and we batch-cook a lot of meals.

Our other secret weapon: a gorgeous gas grill. It was a gift from Jay’s loving mom, and it turned my hubby into an inspired cook who can grill everything from salmon and veggies to dessert peaches. So there’s no more teasing about noodles when Jay makes dinner; you’ll only hear compliments to the chef!

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My Health - Separating children and parents at the border causes lifelong damage

There is an important scientific fact that we need to be aware of as the political drama at the border unfolds: when children are separated from their parents, they can be damaged for the rest of their lives.

Research shows that when children face strong, frequent, or prolonged adversity without adequate support from adults, it causes a stress response that can have terrible consequences. This “toxic stress” affects both the mind and the body.

It disrupts normal brain development, leading to not just emotional problems, but problems with thinking and learning. Children who are exposed to toxic stress have a higher risk of depression and substance abuse. They are more likely to drop out of school, engage in risky behaviors, and commit suicide.

The health risks are serious as well. When the physical stress response of the body — the “flight or fight” response — is turned on for prolonged periods of time, it causes damage to body organs. Children who are exposed to toxic stress have a higher risk of heart disease, obesity, diabetes, cancer, stroke, and lung disease, among other problems — and are more likely to die early.

The earlier in life the stress starts, the worse it is for children. Not only are young children more fragile, their brains are still developing. In order for young brains to develop normally, they need ongoing nurturing interactions with adults, something called “serve and return.” When these interactions don’t happen, it can literally and permanently change the architecture of the brain. The damage can be devastating, and it can’t be undone.

Remember, these are children who have already endured toxic stress — not just the stress of the journey to our border, but the poverty or violence or both that caused their parents to make the journey. They need us to help when they arrive, not make things worse.

Taking children away from their parents at the border and putting them into detention centers or foster care isn’t just sad. It can cause harm that lasts forever, even if they are ultimately reunited with their parents. It can change their future — and shorten their lives. That goes beyond sad: it is cruel.

It is clearly wrong to use children as pawns in any battle, especially a political one. But what is happening at the border goes beyond using children as pawns. The science is clear. We are literally ruining their lives. And the only reason we seem to be doing it is to make a point.

This is more than wrong. It’s unconscionable.

Follow me on Twitter @drClaire

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My Health - Lyme disease: Resolving the “Lyme wars”

It’s finally getting warm here in New England, and most of us have plans to enjoy the beautiful weather. And that’s why the Centers for Disease Control and Prevention (CDC) recently released a report raising awareness about how to prevent the tickborne infections that typically occur during this time of the year. Lyme disease is probably the most well-known, and the one for which diagnosis and treatment are most controversial.

What is Lyme disease?

Several countries around the world, especially in the Northern Hemisphere, and all 50 states in the US have already reported cases of Lyme. The disease is caused by bacteria called Borrelia, and it is spread by ticks. One of the biggest controversies surrounding Lyme is determining whether or not someone has the so-called persistent or chronic Lyme disease. The CDC and most specialists prefer to use a different term, post-treatment Lyme disease (PTLD).

What is post-treatment Lyme disease (PTLD)?

Most people diagnosed with Lyme do very well after taking a prescribed course of antibiotics. They can go on with their lives, and they never have any long-term complications. However, doctors noticed a subset of patients who develop symptoms that can last for months and even years after treatment. PTLD symptoms are vague and other illnesses present in a similar way: fatigue, brain fog, numbness, tingling, palpitations, dizziness, aches, and pain. There are a few case studies in the medical literature describing people who continued to have evidence of infection despite adequate treatment, but in most cases there is no laboratory proof the bacteria is still present.

Conventional medicine has a hard time treating something we cannot see or isolate. However, we cannot ignore that people’s lives changed after the diagnosis of Lyme disease. Their suffering is real. And the frustration is widespread. On one side, we have distressed patients tired with the lack of answers; on the other side, we have doctors who cannot find a biological proof of what is happening. Finally, we have an economic system where insurance companies regulate payment concerning how we diagnose and treat diseases. Physicians typically must see a patient every 15 to 20 minutes and find solutions that fit their goals, with little time to listen and address vague complaints. Lyme disease is the poster child for the disconnect we have in our current healthcare system. This scenario led a group of patients and clinicians to get together to seek solutions for this problem.

The main controversies surrounding Lyme disease

The blood test the CDC recommends to diagnose Lyme checks for an immune response to the bacteria, not for the Borrelia itself. That’s why the test can be negative if the disease is present for less than a month. It takes at least a couple of weeks to mount an immune response that would turn the test positive. It is easier to diagnose Lyme if you have the classic bull’s-eye rash that shows up a few days after the tick bite. In these cases, testing is not even necessary. But the rash only shows up in 80% of cases.

If making a diagnosis can be complex, the controversy about the treatment is so intense that some have even coined the dispute “Lyme wars.” The clash emerged from doctors’ offices, and spread to public hearings in statehouses around the country. One of the main points of contention is the duration of antibiotic treatment — not only for acute Lyme but also for PTLD. The evidence to recommend a specific length of antibiotics treatment is scarce. Most physicians follow the two- to-four-week treatment the CDC recommends. Some studies funded by the National Institutes of Health did not show any benefit when patients used several months of antibiotics. However, there is anecdotal evidence from a few patients who improved after months of antibiotic treatment. The naysayers believe this is probably due to a placebo effect.

A reasonable approach to post-treatment Lyme disease

If you are being treated for PTLD, there is no magic bullet to treat this problem, but here are some important steps to consider:

• Choose a doctor you trust and who can work closely with you.
• If your doctor agrees to start antibiotics for several months, make sure you talk about the risks and cost, as this can be dangerous and expensive.
• Make sure not to rely solely on antibiotics. The evidence for a benefit from antibiotics is weak, and we rely mostly on physicians’ clinical experience and interest in the disease to design a personalized therapeutic plan. For some, a more holistic approach may be the way to go.
• If you try supplements, ask about their source and purity, as they are not FDA-regulated.
• Consider looking for services in medical school hospitals or clinics where they may have programs with ongoing research on how to diagnose and treat Lyme.

I know there are many people who have experiences to share. This dialogue is vital to spark an open conversation in the medical community. We have to understand and provide more comprehensive and better care to patients. I see the “Lyme wars” as an advance in health care. Patients affected by a disease got organized, and together with like-minded doctors rallied to shed light on what works best for them. It reminds me of the progress in treating HIV/AIDS. In the 1980s and ‘90s a similar community spurred a drive to fund more research. Because of that research, although we still do not have a cure for HIV/AIDS, it is no longer a death sentence. I am hoping in the years to come more research drives better answers for Lyme the same way it did for HIV.

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My Health - Swimming lessons: 10 things parents should know

Before going any further, here’s the main thing parents should know about swimming lessons: all children should have them.

Every day, about 10 people die from drowning. Swimming lessons can’t prevent all of those deaths, but they can prevent a lot of them. A child doesn’t need to be able to swim butterfly or do flip turns, but the ability to get back to the surface, float, tread water, and swim to where they can stand or grab onto something can save a life.

Here are some other things parents should know as they think about swimming lessons:

1.   Children don’t really have the cognitive skills to learn to swim until they are around 4 years old. They need to be able to listen, follow directions, and retain what they’ve learned, and that’s usually around 4 years old, with some kids being ready a little earlier.

2.  That said, swim lessons between 1 and 4 years old can be useful. Not only are some kids simply ready earlier, younger children can learn some skills that can be useful if they fall into the water, like getting back to the side of a pool.

3.  The pool or beach where children learn must be safe. This sounds obvious, but safety isn’t something you can assume; you need to check it out for yourself. The area should be clean and well maintained. There should be lifeguards that aren’t involved in teaching (since teachers can’t be looking at everyone at all times). There should be something that marks off areas of deeper water, and something to prevent children from getting into those deeper areas. There should be lifesaving and first aid equipment handy, and posted safety rules.

4.  The teachers should be trained. Again, this sounds obvious — but it’s not always the case. Parents should ask about how teachers are trained and evaluated, and whether it’s under the guidelines of an agency such as the Red Cross or the YMCA.

5.  The ratio of kids to teachers should be appropriate. Preferably, it should be as low as possible, especially for young children and new swimmers. In those cases, the teacher should be able to have all children within arm’s reach and be able to watch the whole group. As children gain skills the group can get a bit bigger, but there should never be more than the teacher can safely supervise.

6.  There should be a curriculum and a progression — and children should be placed based on their ability. In general, swim lessons progress from getting used to the water all the way to becoming proficient at different strokes. There should be a clear way that children are assessed, and a clear plan for moving them ahead in their skills.

7.  Parents should be able to watch for at least some portion. You should be able to see for yourself what is going on in the class. It’s not always useful or helpful for parents to be right there the whole time, as it can be distracting for children, but you should be able to watch at least the beginning and end of a lesson. Many pools have an observation window or deck.

8.  Flotation devices should be used thoughtfully. There is a lot of debate about the use of “bubbles” or other flotation devices to help children learn to swim. They can be very helpful with keeping children safe at the beginning, and helping them learn proper positioning and stroke mechanics instead of swimming frantically to stay afloat, but if they are used, the lessons should be designed to gradually decrease any reliance on them.

9.  Being scared of the water isn’t a reason not to take, or to quit, swimming lessons. It’s common and normal to be afraid of the water, and some children are more afraid than others. While you don’t want to force a child to do something they are terrified of doing, giving up isn’t a good idea either. Start more gradually, with lots of positive reinforcement. The swim teacher should be willing to help.

10.  Just because a child can swim doesn’t mean he can’t drown. Children can get tired, hurt, trapped, snagged, or disoriented. Even strong swimmers can get into trouble. While swimming lessons help save lives, children should always, always be supervised around water, and should wear lifejackets for boating and other water sports.

The Centers for Disease Control and Prevention website has helpful information on preventing drowning.

Follow me on Twitter @drClaire

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My Health - “What ifs”: An underappreciated side effect of addiction

Shortly after our son, William, died of an accidental heroin overdose at age 24, I stumbled upon this unflinching reflection of addiction as a family disease: “Addiction isn’t a spectator sport. Eventually the entire family gets to play.” It is a disease that can yield many symptoms, many different forms of expression, not just the physical symptoms and silent longings suffered by the person whose system is under the thrall of the substances they’ve come to crave. It is not a disease family members get to choose. We may try to deny its existence, but even that “choice” is a symptom of the disease.

For family members another symptom of the disease can linger, sometimes tucked away until it suddenly manifests itself again, sometimes staring us down daily. I call it the “what ifs”: a repetitive and exhausting review of all the intersections where some action, imagined or real on a survivor’s part, might — I stress might — have led to a different outcome.

Since William’s death, my wife Margot and I have been introduced to many brave people who have lost family members to addiction. People whose lives, like ours, are scarred with the collateral consequences of addiction. People who, like us, ask themselves over and over, “What if?” In our case, what if William had not been released from inpatient rehab “against clinical advice” after a mere 10 days, because his insurers would not approve any further treatment? What if any one of four different hospital emergency rooms had recognized that William’s repeated overdoses made him a danger to himself and entertained the notion, indeed assumed the responsibility, of assessing him for a dual diagnosis? What if, when he arrived at a hospital of his own volition, with his bag packed (including two books, George Carlin’s When Will Jesus Bring the Pork Chops? and John Medina’s Brain Rules), his request for inpatient detoxification was considered medically necessary, rather than a denial of treatment four days before he fatally overdosed? What if, despondent, he hadn’t overdosed in a Starbucks bathroom within hours of being denied, then been treated and released from a hospital, all in less than a day’s time and without our knowledge? What if we’d happened to look into our living room where he was “watching TV” just a few minutes sooner, before I discovered him slumped over, a needle on the floor, in or about to be in cardiac arrest?

Artists and scientists use “What if?” to search for the truth in their work. For them too, the question that prompts the quest can be agonizing, as they struggle to employ their imagination in order prove a hypothesis or illuminate a story in the name of truth. Yet once their work is proven, or created, they are free to move on. Those of us afflicted with the “what ifs” of addiction find ourselves trapped in a repetitive cycle. The protective membrane in our imagination between health and disease, between discovery and repetition, is semi-permeable at best. Addiction drags imagination to the disease side off the membrane and locks us in.

I find myself inspired by the writer and lecturer Andrew Solomon when he says in his book Far from the Tree, “…we all have our darkness and the trick is making something exalted of it.” When the “what ifs” emerge from our dark places, as they invariably do, perhaps the most important thing we can do is to share them with others; to recall and then share the stories that prompted them, so that we can properly scrutinize the disease of addiction. Addiction thrives on the stigma composed in part of secrecy, shame, judgment, and darkness. Telling our stories brings healing light. What if we begin telling our stories more openly and more often? What if we use our stories to effect change? What if we strive toward the healing and the exalted?

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My Health - Exercise as part of cancer treatment

In a first, a national cancer organization has issued formal guidelines recommending exercise as part of cancer treatment, for all cancer patients. The Clinical Oncology Society of Australia (COSA) is very clear on the directive. Its recommendations are:

• Exercise should be embedded as part of standard practice in cancer care and viewed as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment.
• All members of the multi-disciplinary cancer team should promote physical activity and help their patients adhere to exercise guidelines.
• Best practice cancer care should include referral to an accredited exercise physiologist and/or physical therapist with experience in cancer care.

Lead author of the statement, clinical researcher and exercise physiologist, and chair of the COSA Exercise Cancer guidelines committee, Dr. Prue Cormie is also very clear in her statement to the press:

“If we could turn the benefits of exercise into a pill it would be demanded by patients, prescribed by every cancer specialist and subsidized by government. It would be seen as a major breakthrough in cancer treatment.”

The evidence on benefits of exercise during cancer treatment

On the research supporting the bold guidelines, Dr. Cormie states: “the level of evidence is really indisputable and withholding exercise from patients is probably harmful.”

She is correct. There are hundreds of studies showing real, tangible benefits of exercise for patients with a variety of different cancers and at different stages.

Exercise specifically as an additional therapy for patients undergoing cancer treatment has been well-studied and associated with many benefits. In one analysis of 61 clinical trials of women with all stages of breast cancer, those who underwent an exercise program during treatment had significantly improved quality of life, fitness, energy, and strength, as well as significantly less anxiety, depression, and lower body mass index and waist circumference compared with the regular care groups. In another major analysis of 28 trials involving over 1,000 participants with advanced cancers (including leukemia, lymphoma, multiple myeloma, lung, breast, GI, and prostate), an exercise program during treatment was associated with significantly improved physical function, energy levels, weight/BMI, psychosocial function, sleep quality, and overall quality of life.

COSA’s prescription for exercise during cancer treatment

The COSA statement advises that people with cancer should:

Avoid inactivity and be as physically active as they are able, with the goal of:

• at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise (e.g. walking, jogging, cycling, swimming) each week; and
• two to three resistance exercise (e.g., lifting weights) sessions each week involving moderate- to vigorous-intensity exercises targeting the major muscle groups.

Their care team should:

• tailor exercise recommendations to the individual’s abilities, anticipated disease trajectory, and health status
• consult with accredited exercise physiologists and physical therapists as the most appropriate health professionals to prescribe and deliver exercise programs to people with cancer
• promote these recommendations throughout treatment;

Finding a way to include exercise as part of cancer treatment

More research will help us understand exactly how much exercise is optimal for people with specific cancers. For now, COSA’s exercise prescription translates to about 21 minutes per day of exercise, plus a couple of muscle-building sessions per week.

I asked experienced nurse practitioner and cancer survivor Eileen Wyner what she thought about these guidelines, and she was unequivocal in her enthusiasm: “I think that is a terrific idea.” Though she is four years in remission from lymphoma, she remembers her chemotherapy treatments well. “I was in very good physical shape when I got sick, but I got weak fast. I would walk the hospital hallways with my IV pole when I could, because I knew from being a healthcare provider how important it was to stay as active as I could. But I did not do anything for my arms at all.” The new guidelines call for some kind of resistance training twice weekly, and Wyner feels that could have been helpful to her: “At one point, after my chemo treatments were over, I was home and I decided to get something out of a lower cupboard in my kitchen. It was so shocking to me when I realized I could not get up. For the life of me, I could not push or pull myself off of that floor. I couldn’t get to a phone, to a window… I was stuck there. I realized how weak I was, how weak my arms were… I’m lucky someone was able to help me, or I would have been in real trouble.”

What you can do

If you are being treated for cancer, the exercise recommendations can certainly sound overwhelming, but it’s important to remember the idea is to individualize the activity plan. Wyner suggests a little stretching and strengthening class during chemo infusions. “We were there all the time anyways, why not do something formal right then and there? It could be something basic and easy, modified for where the patients are at. It could really help people.”

The idea is for patients to do whatever they can manage, as they will reap the benefits, from conditioning to emotional well-being to relapse prevention.

Sources

A systematic review and meta-analysis of the safety, feasibility and effect of exercise in women with stage II+ breast cancer. Archives of Physical Medicine and Rehabilitation, May 2018.

Efficacy of exercise interventions in patients with advanced cancer: A systematic review. Archives of Physical Medicine and Rehabilitation, May 2018.

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My Health - Skin serum: What it can and can’t do

Many things improve with age; unfortunately, your skin is not one of them. Wrinkles, brown spots, and general dullness often start to creep in as the years tick by. To reverse these problems many women are turning to a skin serum. Serums are light, easily absorbed oil- or water-based liquids that you spread on your skin. They typically come in small bottles with a dropper, and you only need a few drops to treat your whole face. A skin serum is not a moisturizer, like a lotion or cream, says Dr. Abigail Waldman, instructor of dermatology at Harvard Medical School. Rather, they are highly concentrated formulations that are designed to sink into the skin quickly, delivering an intensive dose of ingredients that can address common skin complaints. “I definitely recommend serums for anyone who is concerned about aging. It’s a really good way to get extra anti-aging effects, more than your typical moisturizer and sunscreen,” says Dr. Waldman.

How do you choose and use a skin serum?

Serums are typically applied to skin after cleansing but before moisturizing, says Dr. Maryam M. Asgari, associate professor in the department of dermatology at Harvard Medical School. Some serums have one main ingredient, while others, including those that target the signs of aging, are combination formulas. “I use and recommend serums that have a combination of vitamin C, vitamin E, and ferulic acid,” says Dr. Waldman. “There is good literature that shows that vitamin C in particular can prevent brown spots, reverse damage from ultraviolet rays, and stimulate the growth of new collagen.”

Other good skin serum options to target wrinkles are those with antioxidants including tea polyphenols and resveratrol. Retinol, which reduces inflammation, is another good option, as is niacinamide.

If you are looking to fight blotchiness and discoloration, look for formulas that can brighten and lighten dark patches, including kojic acid and glycolic acid. If your skin is dry, tight, and flaky, find a skin serum that contains vitamin E, niacinamide, and glycolic acid. Also look for ceramides, which are fatty molecules that help hold the skin together and keep moisture from escaping. Other good options are serums that contain hyaluronic acid, or those with collagen peptides, epidermal growth factors, or stem cells.

Are all skin serums created equal?

Not all serums work the same. How well they work depends on the active ingredients, the formulation, the vehicle, and the stability of the compound, says Dr. Asgari. The prices of serums vary from less than $20 to hundreds of dollars. “To be honest, I don’t think price makes a difference,” says Dr. Waldman. More important than price are the ingredients in the serum — so the best practice is to read labels to find the best formulation for your needs.

Caveats when using a skin serum

“Powerful ingredients can irritate sensitive skin,” says Dr. Asgari. “Always test a small area before you apply a skin serum widely.” And use caution when combining acid-containing serums with other products that also contain acids. For example, your skin may get irritated if you use a serum with vitamin C (which is acidic) and as well as a retinol cream, or if you use a retinol serum along with a prescription retinol cream.

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My Health - Dogs and health: A lower risk for heart disease-related death?

Are you a “dog person”? You know, one of those people who talks about their dogs all the time, shares photo after photo online (or, worse, in person), and considers their dog as a semi-human member of the family? (In the interest of full disclosure, I am a dog person.)

If you are, here’s a medical news story that may confirm what you’ve suspected all along. And if you aren’t a dog person, this may confirm your suspicion that researchers can prove just about anything they want. According to a recent study, your risk of having a cardiovascular event such as stroke or heart attack, and your risk of death, are lower if you have a dog. Some of the proposed explanations for this might surprise you.

Research finds a new connection between dogs and health

This new study reviewed the health and death records of more than 3 million people in Sweden ages 40 to 80 over more than a decade, and found that:

• Compared with people in multi-person households without dogs, people living in multi-person households with dogs had a risk of death that was 11% lower, and risk of death due to a cardiovascular cause that was 15% lower.
• These findings were even more dramatic for those living alone. Risk of death was 33% lower among dog owners, cardiovascular deaths were lower by 36%, and the risk of heart attack was 11% lower.
• The benefit was greater for owners of certain breeds of dogs, such as retrievers and terriers.

Why might dog ownership come with health benefits?

The most obvious explanation for why dogs might provide their owners with certain health advantages is that dog owners tend to be more active. For many people, taking their dogs out of the house or apartment several times a day to “do their business” and walking their dogs is far more physical activity than their dogless neighbors. And this could explain why more active dog breeds (such as retrievers) are associated with the greatest benefit, and why single people (who must shoulder all of the “burden” of walking the dog) benefit the most.

But there are other potential explanations that researchers have considered, including:

• Improved immune function. Believe it or not, having a dog that brings dirt and germs into the home could improve how the immune system functions and reduce harmful inflammation in the body.
• Modifying the microbiome. The huge number of bacteria in our digestive tracts changes not only with changes in diet, but also with pet ownership. It’s possible that having a dog alters the types of bacteria we harbor, which in turn could affect inflammation in the body and resultant cardiovascular risk.
• Social impact. Dog owners must, to at least some degree, focus outside themselves, which can promote social interaction. In addition, dog owners tend to bond with one another as their dogs play together and check each other out. Past research has found that social contact is linked with lower cardiovascular risk and rates of death.
• Improved mood. Some have proposed that the unconditional affection and companionship of dogs can improve mood, and through this effect improve health.

Will getting a dog extend your life?

Not so fast. This study only found that dog owners tend to live longer and have fewer heart attacks than those without dogs. But that does not prove dog ownership itself it the reason. Maybe healthier, more active people get dogs more often than sedentary people, and it’s that self-selection that accounts for the observations of this latest research. It’s also possible that economic factors play an important role. Dog ownership can be expensive, and those who can most afford to own a dog might receive better healthcare, have better health insurance, or have healthier lifestyles. While the researchers tried to account for some of these possibilities, excluding some contribution from other “non-dog” factors is challenging.

We’ll need to have a better understanding of whether dog ownership itself truly provides health benefits and just how it works. Naturally, similar questions will arise regarding cats and other pets. Until we know more, the apparent health benefits of dog ownership should be encouraging to dog people everywhere. And if you aren’t a dog person, this latest research might convince you to become one.

Follow me on Twitter @RobShmerling

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My Health - Prescription monitoring programs: Helpful or harmful?

The crushing toll of the opioid crisis is daily news, including stories about ways to “fix” it. A wide array of initiatives has been brought forward in an attempt to curb this epidemic and the damage it causes. Prescription monitoring programs (PMPs) are one of them. The goal of PMPs is a good one — to identify patients who are being prescribed multiple medications by multiple clinicians. It is a means to introduce some stewardship for preventing overuse and misuse of prescription drugs.

How prescription monitoring programs work

Prescription monitoring programs are state-based electronic databases that provide a way to track prescriptions, specifically controlled substances including opioids, benzodiazepines, and amphetamines. They are intended to support access to legitimate medical use of these drugs, and to help identify and deter drug misuse and diversion (when medications are not used by the person for whom they were prescribed). Currently 49 states, the District of Columbia, and Guam have PMPs, and in many states providers must access the PMP before prescribing a controlled substance.

PMPs have had some success, with several states demonstrating an overall decrease in prescription opioid overdose after implementation. At the same time, there are several challenges hindering effective use of prescription monitoring programs, including issues of lag time, state to state variability, and important privacy concerns. These issues need to be addressed as this tool is used more and more frequently.

Prescription monitoring programs in medical practice

I work in emergency medicine, and the emergency department (ED) is on the front line of this epidemic in many ways. Not only do we treat people who overdose, but many patients who come through our doors are in pain and need our help. But there are some patients who come to the ED with the sole intention of getting a prescription for an opioid pain medicine, either for illicit use or with the intention of selling it. These same individuals may go to multiple EDs, obtaining several prescriptions in a single day. The ED isn’t the only place this sort of thing happens; some patients are prescribed the same opioid medication by two or sometimes even three different doctors.

The PMP should help “weed out” patients with this risky behavior, and allow the prescriber to identify such individuals and ideally get them help. Good intentions aside, there are some unintended and negative consequences of PMPs. The PMP can incorrectly target some patients. And for those people the system may actually do more harm than good, including taking away much needed medications. The results include poorly managed pain, inadequate palliative therapy, and in some cases driving patients to turn to illicitly obtained prescriptions or street drugs like heroin and fentanyl.

Unintended harms of prescription monitoring programs

I like to use a case as an example. I had a young woman who came to my ED one day with thoughts of self-harm. She said that she felt hopeless and lost. She had suffered from a chronic, painful condition for many years. A small daily dose of oxycodone managed her pain and allowed her to live a normal life. Other treatments hadn’t worked for her and she had never misused this drug. When she changed primary care doctors, her new doctor, who had accessed the PMP, stopped the prescription. While the concerns were legitimate, that left the patient in pain and this eventually led her to buying oxycodone from friends, then on the street, and eventually she started using heroin. She was now homeless, addicted, and contemplating suicide. This example is extreme, but illustrative. As we navigate the opioid epidemic, we must attend to appropriate use as well as misuse. Opioids have a place, such as when treating people with cancer pain or those receiving palliative or end-of-life care. The deep concerns among prescribers about misuse and diversion are completely justified, yet we must make sure that the pendulum doesn’t swing too far and cause harm to those patients who need these medications.

Beyond prescription monitoring programs: Prescribing stewardship

The PMP is a valuable tool, and it has helped to identify patients who may need help with substance misuse. However, as with any tool it needs to be used with caution. Not every patient who gets an opioid is misusing it, and there are many for whom opioids mean the difference between suffering and being able to manage pain. There is certainly a lot of room for prescribers to do a better job addressing pain, discussing both drug and nondrug options as well as early referral to pain clinics. Prescribers, policy makers, and the public need to ensure that these medications are available to the people who truly need them, for the short or long term. The opioid epidemic is a crisis, and we need to develop strategies to reduce harm and the loss of life. At the same time, we need to be vigilant that our approach doesn’t cause unintended harm.

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My Health - Music and heart health

What’s your “cheer up” song? That question popped up on a recent text thread among a few of my longtime friends. It spurred a list of songs from the ‘70s and ‘80s, back when we were in high school and college. But did you know that music may actually help boost your health as well as your mood?

Music engages not only your auditory system but many other parts of your brain as well, including areas responsible for movement, language, attention, memory, and emotion. “There is no other stimulus on earth that simultaneously engages our brains as widely as music does,” says Brian Harris, certified neurologic music therapist at Harvard-affiliated Spaulding Rehabilitation Hospital. This global activation happens whether you listen to music, play an instrument, or sing — even informally in the car or the shower, he says.

Make my heart sing

Music can also alter your brain chemistry, and these changes may produce cardiovascular benefits, as evidenced by a number of different studies. For example, studies have found that listening to music may

• enable people to exercise longer during cardiac stress testing done on a treadmill or stationary bike
• improve blood vessel function by relaxing arteries
• help heart rate and blood pressure levels to return to baseline more quickly after physical exertion
• ease anxiety in heart attack survivors
• help people recovering from heart surgery to feel less pain and anxiety.

Notable effects

Like other pleasurable sensations, listening to or creating music triggers the release of dopamine, a brain chemical that makes people feel engaged and motivated. As Harris points out, “An exercise class without music is unimaginable.” Sound processing begins in the brainstem, which also controls the rate of your heartbeat and respiration. This connection could explain why relaxing music may lower heart rate, breathing rate, and blood pressure — and also seems to ease pain, stress, and anxiety.

What music resonates for you?

But preference matters. Research suggests that patient-selected music shows more beneficial effects than music chosen by someone else, which makes sense. According to the American Music Therapy Association, music “provokes responses due to the familiarity, predictability, and feelings of security associated with it.”

In the cardiac stress test study (done at a Texas university), most of the participants were Hispanic, so the researchers chose up-tempo, Latin-inspired music. In the artery relaxation study, which tested both classical and rock music, improvements were greater when classical aficionados listened to classical music than when they listened to rock, and vice versa. Someone who loves opera might find a soaring aria immensely calming. “But quite frankly, if you don’t care for opera, it could have the opposite effect!” says Harris.

There’s no downside to using music either to relax or to invigorate your exercise routine, provided you keep the decibel level in a safe range. You might even consider using your heart health as an excuse to splurge on a new sound system.

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My Health - Genealogy testing–Prepare for the emotional reaction

The availability of home genealogy testing has made exploring genealogy popular and easy to do. This has led to many interesting stories of people meeting long lost relatives, learning that their heritage is not what they thought, and even discovering that they are not genetically related to people they thought were blood relatives.

While much has been written about privacy concerns related to DNA genealogy testing and how that information is shared, it seems there is little attention paid to preparing people for the emotions they may experience in reaction to what they may discover. This preparation includes considering what people’s expectations are for the testing, and how best to handle surprising results (“good” or “bad”).

Genealogy testing and family connections

Discovering “new” family members through DNA genealogy testing can trigger a wide range of emotions, including happiness, anxiety, sadness, or even anger. In fact, the emotional experience may be so intense that many genealogy sites state they are not liable for any “emotional distress” that may result from using the service.

If you are considering consumer  genealogy testing, think carefully about your motivation for your search. What do you hope to learn? What are you curious about? What will you do if you receive unexpected results (for example, your DNA suggests that your roots are not in Ireland as you thought, or that it is unlikely that you are biologically related to your family)? Do you anticipate trying to connect with relatives you never knew you had? What will you do if you can’t make those connections? What will you do if you can? How will these new people fit into your life and the family you’ve always known?

What happens if the results are disappointing?

Don’t go genealogy testing alone

Whatever you hope to learn, ground your search in the life you have. Consider talking with family members about your interest in testing before you take the plunge. Share your goals for exploring your family tree, and invite family members to share their thoughts as well. Provide space for family members to express their worries and fears as well as curiosity. This conversation offers the opportunity to explore family history in a new way. Be prepared for it to also raise information that was previously undisclosed or difficult to talk about.

Prepare for genealogy testing results

It can take weeks to months to process the test and get results, so think about how you will manage the time waiting for the results. You may choose to spend the time gathering data about your family. Continue to reflect on the reasons for your interest in your family history, and plan ahead for how you will view the results. Alone? With family? With friends?

Take time to consider whether or not you want your results to be shared with others on the genealogy site. Think about whether or not you would like to be contacted by strangers with whom you may share some DNA, and whether you would want to reach out to others.

Proactively make a plan to cope with potential strong emotional responses. Plan how much time you will allocate when you log on to the genealogy site. Make sure you have other activities scheduled for your day, and do not ignore other plans you have made to spend additional time on the genealogy site.

Getting (and acting on) the results of genealogy testing

Once you receive your results, you may at first find the amount of data you receive overwhelming. For example, you might receive information about your ethnicity, and hundreds (or thousands) of people with whom you share a significant amount of DNA. Make a point to tend to the emotions you experience. Are you happy? Anxious? Sad? Is this what you expected to find? If it starts to feel like too much to process, take a break from mining the data. Update family and friends on how you are doing, and let them know if you need support.

For some people, the results of genealogy testing prompt them to reach out to strangers with whom they share DNA. This may lead to a new and positive connection. This may also lead to a connection that is disappointing. And perhaps it may be hardest to cope with no response. Some people you attempt to contact on the site will not write back to you. Consider how many times you will reach out to someone who does not respond.

Moving forward after genealogy testing

DNA genealogy testing can yield information about your heritage that you never knew and never even thought about. This can be exciting and can broaden your thinking. It can also be disconcerting to learn about discrepancies between what you thought you knew about your family and what the results from the testing provided. And for some people, it may not bring the insight and direction they had hoped for, or may raise issues around family relationships that are hard to handle.

In the end, the results of genealogy testing do not change who you are as a person. But it may provide interesting information about your family tree and result in a powerful emotional experience. Be prepared with a plan and a support system.

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My Health - Secondhand marijuana smoke and kids

For years, we’ve talked about the danger to children of secondhand tobacco smoke. It makes asthma worse, increases the risk of respiratory and ear infections — and even increases the risk of sudden death in infants. We’ve had all sorts of educational campaigns for parents and caregivers, and have made some progress: between 2002 and 2015, smoking among parents of children less than 18 years old dropped from 27.6% to 20.2%. But now there is a new problem: secondhand marijuana smoke.

Studies show that when you are around someone who is smoking marijuana, the smoke gets into your system too. How much of it gets in depends on how close the person is, how many people are smoking and how much, how long you spend near them, and how much ventilation there is in the space. But research is clear that cannabinoids, the chemicals that cause the “high,” get into the bodies of people nearby — including children.

During the same time period that cigarette smoking around children came down more than 7%, marijuana smoking around children went up nearly 5%. With more and more states legalizing marijuana for recreational use, that number is likely to continue going up.

This is not good. Besides the fact that we don’t want children getting high, or exposed to the dangers of inhaled secondhand marijuana smoke, there is the additional concern about long-term effects on the brain. While research is still ongoing, there is evidence to suggest that when youth and young adults (whose brains are still developing) are exposed to marijuana, it may have permanent effects on executive function, memory, and even IQ.

This is not what we want for our children.

All the advice we give to parents who smoke tobacco applies to parents who smoke marijuana, including:

• The best thing for you and your child is to not smoke at all. Talk to your doctor about ways to quit.
• If you do smoke, don’t smoke around your child, ever.
• Even if your child isn’t around, don’t smoke somewhere they will be, like your home or your car. Smoke lingers.
• After you smoke, change your clothes and wash up. Again: smoke lingers.

As legal use of marijuana grows more common, we need to create the same kinds of rules and laws we’ve created to protect people from secondhand tobacco smoke.

Just because something is legal doesn’t mean it’s safe. And when we make choices that have risks, it’s not fair to impose those risks on other people — especially children, and especially when they could literally be harmed for the rest of their lives.

Follow me on Twitter @drClaire

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My Health - When your child ends up in the emergency room

I recently wrote about a walk I took with my sons, where I slipped, falling onto my youngest who fell onto a rock, which cut his forehead and meant a trip to the emergency room for four stitches.

It wasn’t our first visit, but thankfully, it’s never been for anything dire. My kids have just run into and jumped off a variety of things, so there’s been broken bones, forehead cuts (they have matching pairs), along with spiked temperatures that invariably happen when the pediatrician’s office isn’t open.

I’m pretty good at keeping my head, but I’m not at my best in an ED. I end up being too polite and deferential. In essence, I say, “Stop this bleeding now, and in exchange, I won’t bug you with more than two questions. Promise.”

How to advocate for your child in the emergency room

It’s not a winning formula. Doctors have skill, but they’re just people. They’re often rushed and can’t know everything about my child. They will fail to cover everything that worries me and my wife. Bottom line: they need help, and that means, because I’m the biggest expert on my child — side note: remember that I’m the biggest expert on my child — I need to ask questions, share relevant information, and, occasionally, be a pain.

But before I resort to that last part, I want to work with you, doc, and to do that, I’ll try to be clearheaded and give you useful information up top.

Help the emergency room doctor help your child

It’s not close to an exhaustive list, but Dr. Vincent Chiang, Harvard Medical School associate professor of pediatrics and emergency medicine and emergency room physician at Boston Children’s Hospital, has some suggestions of what to share:

• Your child’s ability to cope with any part of a medical visit. Do not equivocate. “He does not like … shots, blood, being sick, pain, lying still, anything doctors” is all helpful. Some hospitals have child life specialists that can help reduce the stress. It would be stellar if the doctor mentions it and calls for one. If not, ask if someone’s available.
• “This is our first time dealing with this.” For the doctor, most stuff registers as routine, but it’s not for parents, and saying this should be enough of a reminder to explain everything slowly, fully, and clearly. If it’s not, repeat it.
• “She never complains” or “He complains about everything.” It tells the doctor two things: something is different, and that worried you enough to come in. It can be hard to pinpoint, but try to verbalize your big concern (“My uncle had a headache and it turned out to be a tumor”). The doctor can possibly address it, so you’re not unnecessarily sitting with it.

None of this guarantees quick answers, Chiang says. Some conditions only fully reveal themselves over time. Sometimes tests are needed. If so, ask if they’re being done to rule out things or to look for something specific. More pointedly, ask the doctor if there’s anything that’s worrisome. And then ask when you two will have the next discussion, since all of this entails waiting, and that’s often the most stressful part.

Four things to know when you leave the emergency room

It’s understandable to forget questions and not mention every relevant detail. But before you leave the hospital, Chiang says to know these four things:

• The diagnosis. It’s simple, but you want to be clear on what the doctor decided your child was being treated for.
• The treatment plan. It needs to address the medical problem and the comfort measures. Example: Sprained ankle. Rest, ice, compression, elevation. If there’s pain or nausea or other discomfort, know your options for relief.
• The follow-up plan. It could be meeting with your pediatrician or a specialist, but it’s rare that there would be nothing to do. At the least, let your pediatrician know what happened as soon as possible and make sure that the follow-up plan makes sense. You cannot assume that the hospital will provide the information.
• The reasons to return. Most often, when you leave the emergency room, follow-up happens outside of the hospital, but you want to know what signs and symptoms suggest urgent care is needed again. You also want to know when things should start to go back to normal.

Make sure you’re clear on the treatment plan

Of the above four, Chiang says that the treatment plan causes the most confusion, because when you’re hearing it, you’re also hearing that your child is going home. You naturally become relaxed and the doctor might start moving on to a different patient. But there are still things to know, like if your kid can play sports or go to school/daycare, and, if not, when. There’s also the medication. Be sure of the dosing and timing, and why your child is taking it. Ask if there are interactions with other medications or additional precautions (for example, avoiding the sun, a side effect we recently experienced with an antibiotic), and how soon the first dose has to be taken, double-checking if it was already given in the hospital.

One good move is to take the time read the discharge instructions before you leave, and if the doctor hasn’t asked you to repeat back what you’ve heard about the treatment plan, then say, “This is what I understand. Am I correct?” It comes down to getting your questions answered, and that sometimes means pulling out the option of being a pain. It might feel unnatural or uncomfortable, but there’s no benefit in keeping anything to yourself. As Chiang says, “I don’t know about the question you don’t ask me.”

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