My Health - 6 steps toward a successful exercise resolution

Here we are at the end of December, and some of us are contemplating another chance for a fresh reboot. The infamous New Year’s resolutions are a common topic. Last year I wrote a blog post about an overall view of how to be successful when thinking about reaching a goal. Changing behavior is all about learning a new skill. Ultimately, you are teaching your brain that you can do a specific job, creating a new habit that eventually will be part of your weekly or daily routine. In a similar way that’s how we learn how to cook, and even how you learned to speak or walk. Acquiring a new habit requires a plan, practice, and reflection on how to improve. Let’s harness the teaching mode to make this learned skill part of your life in 2019.

“Start exercising” is what most of my patients say when I ask them what could make them healthier. Here is an effective way to incorporate physical activity into your weekly routine moving forward.

Do not skip any of the six steps. Make sure you write them down. Remember, this is a process.

Step 1: Reflect on the feelings you might have toward exercise

For some people, just thinking about exercising creates undesirable memories and anxiety. Let’s first deal with the ingrained thoughts and emotions related to exercising. It will probably take you around 10 minutes to write this down. Writing is better than typing, so grab a piece of paper. Do you feel helpless? Do you feel you do not have any guidance? How did you feel when you were not able to follow through on your plans in the past? How do you feel about going to a gym? What did you learn from your past experiences? Reflecting on your feelings and emotions will help you deal with the barriers you may encounter. Failure to recognize and to be aware of these thoughts and feelings may be one of the reasons many have a hard time reaching their goals.

Step 2: Go deep into the reasons why you want to move more

It is not because you need to exercise, but instead pin down why you want to start exercising. Having the reason you want to exercise written down is what you will revisit when you cannot get off of the couch. Is it because you want to be fit? Do you want to look better? Is it because you want to go on a trip where you will be walking several hours a day? Is it because you want to have less anxiety, or maybe you want to lower your blood pressure? If you are not sure of the reason why you want to do it, I would recommend more reflection, talking to your family and friends, or to your doctor. If you are not ready to make the change, I would suggest asking why. Why is exercising not that important? If you don’t move more, how do you see yourself 10 or 20 years from now? What do you want your health for? How do you see yourself after you start working out? What will you do when you feel stronger and healthier?

Step 3: It’s time to come up with a plan

You can either write or type into a computer. If you type, make sure to print the program and put up in a place where you can see it every day. It can be your fridge, your office, a spot you pass frequently. Choose the exercise and how much time you will allot per week to do the task. Come up with a realistic plan to fit your schedule. Don’t create an unreasonable plan to work out an hour a day, five times a week starting January 1st if you are sedentary, have a full-time job, and still have to take care of your family when you get home. You are setting yourself up to fail. This is the biggest mistake I see when people are trying to incorporate a new habit. Failure can be very frustrating, and it is one of the main reasons New Year’s resolutions do not develop into habits. Take a look at your schedule and choose an exercise you enjoy and that is doable. It is okay to start walking at a fast pace 10 minutes twice a week, or do a seven-minute workout routine, but make sure you block out the time to do so.

Now that you have reflected on your emotions, written down the reasons why you want to start exercising, selected the type of exercise and the amount of time you will devote to get moving, let’s come up with a more detailed plan, so exercise is part of your routine in 2019.

Step 4: Develop a detailed plan based on time, rest, and intensity

Let’s say that you decided you will start walking at a fast pace for 20 minutes per week, two sessions of 10 minutes each. You eventually want to get to the standard recommendation of 150 minutes of moderate exercise per week, or 75 minutes of vigorous physical activity per week. You will do this very slowly, and it will take several months. To get there, you will adjust three variables: the amount of time per week (volume), the amount of rest you will have between sessions, and the intensity of the exercise. You will change only one variable at a time every two months. Remember that you are teaching your brain that you can do a particular activity. If you manipulate all three variables at the same time your brain gets confused. For example, if you want to change the volume (duration and distance), add 10% to 20% of the time to each of your two weekly sessions, walking at the same pace. Do not start to run (intensity) and add time all at once, for example. If you want to go a little faster instead, continue training twice a week for 10 minutes. If going faster is too subjective, consider buying a heart rate monitor and increase your heart rate by about 5% to 10% after each session. You could also reduce the amount of rest between your sessions, adding another 10-minute session in the middle of the week, using the same pace.

Step 5: Adapt your plan using four-session cycles

If you feel too tired midway through your exercise, there is a chance you are changing the variables too fast, and you could be overtraining. People who overtrain get injured and are less likely to continue the learning progress. You do not need to reach your goal too quickly; learning takes time. Slowly ramp up your routine, either increasing volume and intensity or reducing rest. After ramping up your workout for three sessions, just repeat the same workout for the fourth session. So for example. If on Day 1 you walk 10 minutes, Day 2 you go up to 12 minutes and Day 3 you walk for 14 minutes, on Day 4 just repeat the previous day, walking again for 14 minutes. That way you are teaching your brain that you know you can do that task well, without getting exhausted. For the fifth session, you can continue the ramp-up. Keep doing this system of four-session cycles where you increase one variable every three sessions and repeat the last one.

Step 6: After each workout, take the time to reflect on what you just did

Incorporate the sense of accomplishment and how rewarding it was to do it. Hold onto these positive feelings for 10 to 20 seconds after the workout. It’s helpful to think about this throughout the day. You could even journal about these emotions. The more you think about and feel that sense of accomplishment throughout the day, the more brain connections it creates. You are teaching your brain about the importance of exercise and that you can actually do it. Think about the reasons why you are exercising. Does this make you feel good about yourself? Is this helping you deal with some medical problems you might have? Is this making you stronger? Do you have more energy to go on with your day or play with your kids?

Bringing it together

It is through continuous practice and reflection that we learn everything in life. Being aware of your emotions, reflecting on your motivations, practicing the skill, making small changes, and improving what you already know is the recipe to make exercise part of your life moving forward. That’s how you adapt the brain to learn a new habit. That’s how you teach the brain to do that exercise for that amount of time at that specific intensity. Don’t give up — be aware of the feelings and emotions that might undermine your goals and objectives. January 1st is just another day in the calendar, you can try this any day of the year. Don’t wait for 2020 if your plan does not go as expected. Learning a new skill is a journey. Happy 2019 and best of luck.

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My Health - Give yourself an annual health self-assessment

I understand why people embrace New Year’s resolutions: it’s a chance to wipe the slate clean and set annual goals with new focus and enthusiasm. But are they focusing on the right areas of their lives? Instead of setting resolutions, a better approach may be to conduct a health self-assessment. It’s a way to take an in-depth look at where you are now, so you can identify the parts of your life that need the most attention. “A self-assessment gathers the vital information you need to begin thinking more about your life and how you want to live,” says Susan Flashner-Fineman, Vitalize 360 Coach at Harvard-affiliated Hebrew SeniorLife, a comprehensive wellness program that promotes healthy aging.

According to Flashner-Fineman, a complete analysis of your well-being should encompass five areas: physical, intellectual, social, financial, and spiritual. For each category, explore what you are you doing well and where you can improve. “This way, it’s not all about focusing on your shortcomings, but rather highlighting your strengths and building on them,” says Flashner-Fineman. Here is a look at the five categories for your health self-assessment.

1.   Physical. Instead of focusing on simply staying healthy, tailor your fitness to meet specific goals, says Flashner-Fineman. “Ask yourself, what level of activity do you want and what do you need to maintain it?” For instance, do you want to continue gardening, or have greater endurance to interact with grandchildren, or just improve your functional fitness so you can do daily chores and activities with less pain and risk of injury? “Connecting it with something you want to accomplish also can help you stay motivated and focused on your health going forward,” says Flashner-Fineman.

2.   Intellectual. Are you doing enough for your brain? It’s so easy to get trapped in the lull of repetitive activities that don’t work your memory and problem-solving skills. Learning something new is a great way to challenge your brain. For example, learn to play bridge, paint, or play a musical instrument. Interested in a particular subject? Take a class at your local college (many offer free tuition for older adults). You can also raise the bar on an existing skill. Love to cook? Try French cooking. Practice your public speaking at a Toastmasters club, or join a chess or book club.

3.   Social. How well do you currently connect with others like family, friends, and neighbors? And how often do you interact with them on a regular basis? “Think about how you can improve your existing relationships as well as make new connections,” says Flashner-Fineman. For example, make a point to call, write, or go out to lunch with a close friend once a week, or consider joining a club of some kind that has regular meetings and social events.

4.   Financial. Do you stress about money issues? A professional financial planner can help evaluate your current financial situation and devise a plan to prepare for the future. Lifestyle changes can ease financial strain and even make your life a bit easier. For instance, you could move into a smaller place that requires less maintenance and upkeep, buy everyday items more cheaply in bulk, or cut your cable and use the Internet for watching shows. “You don’t want to make changes that affect quality of life, but often we are afraid to make positive changes because we are used to a certain way of living,” says Flashner-Fineman. “But if you understand why the change is good — like freeing up more money to travel, for example — then it’s easier to do.”

5.   Spiritual. Studies have found that some level of spirituality and gratitude is associated with greater wellness. Some people do this through religion or a faith-based community, but others choose activities like meditation and interactions with nature.

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My Health - Surgeons are doing fewer knee surgeries

When knee arthroscopy became widely available in the 1980s, it represented a major advance. Today orthopedists evaluating and treating common knee problems often recommend arthroscopy, during which they insert an instrument into the joint and, with a light and camera on its tip, directly inspect the knee from the inside. While there, he or she can diagnose and treat common painful knee problems, such as arthritis or torn cartilage. The risks are much lower and recovery times much shorter than standard “open” knee operations.

As with any technology or other advance in medicine, years of research were required to understand when best to use it. Not surprisingly, arthroscopy turns out to be much more helpful for some conditions than others. For example, if you have a sports injury in which the medial meniscus (a crescent-shaped, shock absorbing wedge of cartilage) is torn and blocking the motion of the knee, arthroscopic surgery can provide dramatic relief in a short period of time.

But studies have demonstrated convincingly that for many other common causes of knee pain, including osteoarthritis and many instances of torn cartilage that do not block joint motion, medications and physical therapy may work just as well as arthroscopic surgery. Despite these recent data, some orthopedists continued to recommend arthroscopic surgery for these conditions. Now, that seems to be changing.

A new study says the number of knee arthroscopies is falling

Data recently published in JAMA Internal Medicine demonstrate that between 2002 and 2015, the rate of arthroscopic surgery in Florida

• decreased from 449 to 345 per 100,000 people (a 23% decline)
• dropped more among adults under age 65 (24% reduction) than among those over 65 (19% reduction)
• fell most dramatically after 2008 (after a second important trial showed no benefit of arthroscopy for osteoarthritis of the knee).

Is this a good thing?

Reducing the number of unnecessary operations is certainly a good thing, especially for one that is so common. However, we don’t know if the reduction in arthroscopies occurred for the right reasons: while it’s possible that the reduction was because orthopedists are recommending them more selectively (and more appropriately), it’s also possible that people are not getting the surgery due to lack of insurance, trouble finding an orthopedist, or because they just prefer not to have surgery. We don’t know about patients’ health or outcomes: are some people suffering because they didn’t have an arthroscopy they needed? How many had arthroscopies they did not need and had complications, or simply didn’t improve?

We also don’t know whether rates are falling in other states. Still, it’s reasonable to assume that knee arthroscopies are being performed less often because we better understand when they are likely to help and when they are not.

Why does change take so long?

At the risk of gross over generalization, doctors tend to avoid change. That’s true of many — but certainly not all — of my colleagues. Who else is still using beepers and fax machines on a daily basis? So, some of the reluctance of orthopedists to change their practice in the face of studies questioning the usefulness of knee arthroscopy may be this tendency to resist change. Another reason might be financial considerations: surgical procedures tend to generate a large income stream for the doctor and the hospital or surgical center.

But it’s also true that a single study is rarely enough to change medical practice — doctors are, with good reason, a skeptical bunch. Subsequent research must verify and confirm a new finding. Perhaps that’s why the rate of knee arthroscopy dropped most significantly after the publication of a second trial regarding knee osteoarthritis.

What’s next?

You can expect to hear much more about studies that challenge standard practice, especially when that practice is invasive (including surgery) and expensive. My guess is that the number of knee arthroscopies will continue to fall for some time, until only the most appropriate ones are being done.

When it comes to standard but treatments being called into question, the big question is, indeed, “what’s next?” The answers will come once high-quality research is performed by skeptical researchers willing to question the status quo.

Follow me on Twitter @RobShmerling

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My Health - Can exercise help conquer addiction?

As an athlete, I think regularly about the potential health benefits of exercise for my patients. Every week, I treat patients hospitalized at Brigham and Women’s Hospital with significant medical problems that are a direct result of severe addiction, ranging from seizures and strokes to heart valve and joint infections. I also care for outpatients at the Brigham and Women’s Faulkner Hospital Addiction Recovery Program. In both settings, I provide medication-assisted treatment (MAT) such as buprenorphine-naloxone for opioid use disorder, and extended-release naltrexone for both alcohol use disorder and opioid use disorder. I work closely with therapists and social workers who offer our patients counseling and referrals to additional programs. I frequently discuss mutual-help groups such as Alcoholics Anonymous and SMART Recovery with patients. I use motivational interviewing techniques to help enhance motivation and guide patients towards their recovery goals.

Suffice to say, I am a psychiatrist interested in pulling out all of the stops when it comes to treating addiction.

Despite increased national attention and numerous interventions to tackle the opioid epidemic, recent statistics are still alarming. Drug overdose deaths involving synthetic opioids increased by 87% annually from 2013 to 2016. This dramatic increase is attributed mainly to the illicit manufacturing of fentanyl, an opioid approximately 100 times more potent than morphine. In Massachusetts, where I practice, rates of overdose deaths from all drugs ranked eighth highest in the country in 2016.

Does exercise help people in recovery from addiction?

Combined with what we know about other treatments, exercise shows promise. Animal studies have shown that regular swimming reduces voluntary morphine consumption in opioid-dependent rats, and access to an exercise wheel reduces self-administration of cocaine in rats dependent on the drug. A small study in humans investigated an exercise program offered to 38 men and women who misused a variety of substances, including opioids, cannabis, amphetamines, and cocaine. Participants agreed to take part in group exercise three times a week for two to six months. Twenty people completed the intervention. When reassessed a year later, five reported abstinence and 10 reported that they had decreased their substance use.

In my experience, many patients with various substance use disorders have found that exercise helps to distract them from cravings. Workouts add structure to the day. They help with forming positive social connections, and help treat depression and anxiety in combination with other therapies.

Forging positive connections with others in recovery

Organizations promoting physical activity for people in recovery continue to grow. The Boston Bulldogs Running Club, which dates back to 2008, has broadened its mission to support people with addiction and their friends and families. This nonprofit organization also promotes wellness to children and teens to help prevent substance use disorders.

The Phoenix, another nonprofit organization, aims to build an active community of sober individuals through peer-led CrossFit, yoga, rock climbing, boxing, running, and hiking events. Created in 2006, it has expanded to offer free programming in a number of states. Phoenix events are open to anyone with at least 48 hours of sobriety, and to supporters of those in recovery. I recently worked up a sweat in a Phoenix CrossFit class in Boston. The camaraderie during the workout was palpable, and it was inspiring to witness the dedication of the coaches in recovery.

Is it best to combine exercise with other addiction treatments?

Medication-assisted treatment at least doubles the rates of opioid abstinence. Staying on long-term MAT is often recommended. Studies show a greater than a 50% chance of relapsing on illicit opioids just one month after discontinuing treatment with buprenorphine-naloxone. For people with opioid addiction, continuing to take methadone or buprenorphine-naloxone substantially lowers the risk of dying from an overdose. Consistently taking these medications also decreases the risk of death related to other causes.

Psychotherapy is often a recommended component of substance use treatment as well. No medication is perfect, and addiction has an impact on many dimensions of a person’s life.

In summary, I vote that yes, there is some evidence that exercise can help to conquer addiction. No treatment is infallible. Frequently, people with substance abuse disorders find that a variety of strategies is best, including MAT, psychotherapy, and mutual-help groups. More research is needed to clarify which types and amounts of exercise are potentially helpful in treating addiction. I look forward to watching organizations like The Boston Bulldogs and The Phoenix continue to grow, and I plan to continue recommending groups like these to patients.

Follow me on Twitter @clairetwarkmd

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My Health - Is a steady diet of social media unhealthy?

Asking if social media makes you lonely and depressed is a little like asking if eating makes you fat. The answer is yes, absolutely, but not always, not in everyone, and not forever.

Social media use is fine in moderation. But as with any diet that tilts heavily toward foods that lack nutritional value, an excessive intake of social media may be bad for your health.

When it comes to social media, think snack-sized portions

The latest research suggests that limiting social media use to 30 minutes a day “may lead to significant improvement in well-being,” according to a widely publicized University of Pennsylvania study published in the December 2018 issue of the Journal of Social and Clinical Psychology. Working with 143 undergraduates, researchers found that students who limited their use of Facebook, Instagram, and Snapchat to 30 minutes a day for three weeks had significant reductions in loneliness and depression as compared to a control group that made no changes to their social media diet.

Researchers noticed something else that happened when students self-monitored their time on social media. Just being mindful of screen time usage turned out to be beneficial. Students showed “significant decreases in anxiety and fear of missing out,” a side effect of increased self-monitoring, noted researchers. As one study participant put it, “I ended up using [social media] less and felt happier… I could focus on school and not [be as] interested in what everyone is up to.”

Successful strategies for a social media diet

The lesson from this new research is to be more mindful of how we use social media and the role it plays in our lives. It’s fine to do a quick check on what other people are doing, or to keep track of social events to attend. It is less healthy to monitor social media for what we’re missing out on. Be mindful of how — and how much — you use social media.

Being mindful means asking ourselves honestly why we are checking in on Facebook, Instagram, or Snapchat. Is this a replacement for something else you could be doing IRL (in real life)? Healthier substitute activities might include visiting with friends, reading a book, taking a contemplative walk in nature, or participating in arts such as photography, writing, or creative cookery. Be aware of what’s driving you to snack on social media. There are healthier options to satisfy those cravings.

Note also that not all social media is created equal. By its very nature, Facebook posts are highly comparative, and may have a “showoff” character that can’t help but make us compare our life with others. Instagram allows a bit more creative expression, especially for images. Twitter can be devastating when we are trolled by negative commenters, and yet it is also more conversational. Dating apps can be a gateway to a meaningful romantic relationship — or leave us reeling from too many swipe-left rejections. Choose a social media platform carefully. Stick to a social media outlet that helps develop authentic social connections and pulls you into a welcoming community. That is what social media was meant to do in the first place.

Finally, be mindful of who you are before reaching for that social media snack. Some populations, such as college students, are more vulnerable to loneliness. The stress of college can weigh heavily on students who lack a social network to help them battle negative thoughts. According to a 2017 survey of nearly 48,000 college students, some 64% said they had felt “very lonely” in the previous 12 months. If engaging in social media does not leave you with warm feelings, dial down usage.

That University of Pennsylvania study established a clear causal link between less social media use and improvements in loneliness and depression. But researchers also had this to say about social media: “It is ironic, but perhaps not surprising, that reducing social media, which promised to help us connect with others, actually helps people feel less lonely and depressed.”

When it comes to social media, less is more.

Follow me on Twitter @JeremyNobel1

The Foundation for Art & Healing

The UnLonely Project

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My Health - Alcohol use disorder: When is drinking a problem?

Over the past few months, a conversation about alcohol use has been center stage in the national news. Stories about underage drinking, blacking out, and harmful behavior associated with alcohol use are quite common in many families around the world. The rise of the opioid epidemic in the US has rightly caught our attention, but overshadowed a much more common problem. In the United States, from 2006 to 2010 alcohol-associated deaths accounted for 88,000 deaths annually, or almost 10% of all US deaths.

While many people are becoming aware that medication assisted therapy can help treat opioid use disorder, very few know that medication and counseling can significantly reduce alcohol use compared with trying to cut back on your own.

What is an alcohol problem, anyway?

In the US, 6.6% of adult population reported heavy alcohol use, and one in four people reported at least one episode of binge drinking. Binge drinking is defined as four or more drinks in a day for a woman and five or more drinks in a day for a man. I bet you probably know someone who binge drinks — if not daily, then at least on weekends.

Alcohol use disorder (AUD) and other substance use problems are considered diseases like any other, but are stigmatized as moral failure by many. The cause of AUD is a complex interaction between genes and environment, with a strong association with other health problems. In one study, 77% of the individuals with AUD carried another medical problem, either cancer, liver disease, pancreatitis, or other psychiatric diseases such as depression, anxiety, bipolar disorder, or schizophrenia. A history of trauma, physical, verbal, and sexual abuse is also highly prevalent in this population. Even though genetics play an important role, exposure to specific life events and situations can significantly increase one’s vulnerability to seek comfort and reward using alcoholic beverages.

Recognizing alcohol use disorder

The awareness that alcohol use may be causing a problem does not come so easily. Drinking is socially accepted in most places, and is frequently used as a social lubricant. I rarely see a patient coming forward on his or her own to talk about drinking behavior. The conversation is usually triggered by friends and family members who urge their loved ones to seek help, as many do not see their alcohol use as a problem. If you are unsure if you or someone you love may have a problem using alcohol, I would recommend asking one question: how many times in the past year have you had five (for men) or four (for women) or more drinks in a day? A response equal to or greater than “once” identifies, on average, eight out of 10 people with AUD. A positive answer should trigger a more thorough evaluation in a doctor’s office, or least stimulate a reflection about one’s drinking behavior.

Treating alcohol use disorder

As with many other chronic diseases, AUD treatment is not as straightforward as taking antibiotics for pneumonia. However, it may surprise you that there are several medications that can help patients deal with cravings and reduce drinking. Naltrexone, acamprosate, and disulfiram are among the current FDA-approved drugs to treat AUD. Other drugs that are used off-label to treat AUD include nalmefene, baclofen, gabapentin, and topiramate. Individual and group therapy may also help reduce binge drinking and increase abstinence.

For some people, drinking at night or on the weekend may feel like the only source of relaxation and comfort. It is not uncommon for people who suffer from anxiety and depression to drink to alleviate their feelings and emotions. The treatment of these psychiatric disorders may also help reduce the frequency and amount of drinking. Nonetheless, it may be hard to keep the motivation going. Relapses are a common part of the disease, and successfully overcoming AUD often depends on stability at work, adequate housing, hope for the future, and support from family, friends, and the health system.

Don’t be afraid to seek professional help if alcohol use defines who you are and is affecting your life and relationships. We now have several approaches that may lead to healing and recovery. A simple conversation with your doctor about whether or not you have a problem with alcohol use could be the first step toward a healthier and more fulfilling life.

Sources

Diagnosis and Pharmacotherapy of Alcohol Use Disorder: A Review, JAMA, August 2018.

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My Health - Benefits of a healthy diet — with or without weight loss

With the obesity epidemic at an all-time high in the US — close to 70% of Americans are overweight or obese — many people could benefit from losing weight. However, for numerous reasons, weight loss is challenging. In addition, some people are tempted to choose the “diet of the month” or a plan that they have read about online or heard about from friends and family. Unfortunately, these diets are oftentimes not the most nutritious, and even with some weight loss, may not ultimately improve health.

So, is there any benefit from improving the quality of one’s diet without weight loss? The answer is YES. Three randomized clinical trials (the gold standard in nutrition research) have shown that by improving what you eat, you can improve cardiovascular risk factors, such as high blood pressure, LDL (bad) cholesterol, and triglycerides, and improve your health.

Examining the evidence

One study examined the effect of the DASH (Dietary Approaches to Stop Hypertension) Diet on blood pressure. The researchers recruited 460 overweight and obese adults with borderline high blood pressure. They provided the participants with food according to DASH diet guidelines. The DASH diet is defined as: low in saturated fat and dietary cholesterol; rich in potassium, magnesium, calcium, and fiber; emphasizing fruits, vegetables, whole grains, and low-fat dairy products; including fish, poultry, nuts, and seeds; and limiting red meat, sweets, and sugary beverages. To prevent any effect from weight changes on the results, researchers regulated calories to prevent weight gain or weight loss. At the end of the 11-week study, the participants’ blood pressure was significantly reduced compared to their baseline blood pressure.

The second study looked at the already very healthy DASH diet and then added sodium limits. Study participants on the DASH diet who were assigned to the lowest sodium limit (1,500 milligrams per day) experienced drops in blood pressure similar to what a blood pressure medication would achieve.

The third trial examined whether changing a few components of the original DASH diet could result in even greater improvement in risk factors. This study, called OMNI Heart (Optimal Macronutrient Intake to Prevent Heart Disease) examined 164 overweight and obese adults with prehypertension or Stage 1 hypertension, and replaced some of the carbohydrates in the DASH diet with either healthy protein (from fish, nuts, beans, and legumes) or unsaturated fats (from olive oil, nuts, avocado, and nut butters). Again calories were kept neutral to avoid weight gain or loss. Results showed that substituting healthy protein or healthy fats for some of the carbohydrate lowered LDL (bad) cholesterol, blood pressure, and triglycerides even further than the DASH diet alone.

Putting it into practice

In summary, for overweight or obese people with borderline high blood pressure, following a DASH diet with a focus on daily consumption of vegetables, fruits, whole grains, low-fat dairy, nuts, and lean sources of protein could result in a reduction in blood pressure. Limiting high sources of sodium, including any canned, convenience, and processed foods, and high-sodium condiments such as salad dressing, pickles, and soy sauce, can produce even greater reductions in blood pressure. Substituting some healthy fat or healthy protein for some of the carbohydrates in your diet may improve your cardiac risk factors even more by lowering triglycerides and LDL cholesterol.

The bottom line is that for those who are overweight or obese, losing weight is not the only way to improve your health. Choosing healthy foods every day can make a positive difference.

The DASH Eating Plan
Food group	Goal servings	Example of one serving
Vegetables	4–5/day	1 cup raw, leafy veggies or 1/2 cup cooked
Fruit	3–4/day	1 cup berries, 1 medium apple
Whole grains*	4–6/day	1 slice whole-grain bread, 1/2 cup cooked
Low-fat or fat-free dairy	2/day	1 cup yogurt or milk
Nuts, legumes, seeds	4–5/week	1/4 cup nuts, 2 tbsp. nut butter, 1/2 cup legumes
Oils and fats*	3/day	1 tsp oil, 2 tbsp. salad dressing
Fish, poultry, or lean meats	6 or less/day	1 ounce fish, poultry, or lean meat, 1 egg
Sweets	5 or less/week	1 tbsp. sugar, 1/2 cup sorbet
For an OMNI Heart eating plan: Limit fruit to 3 servings per day and whole grains to 4 servings per day, and increase healthy protein (fish, legumes, beans, nuts, nut butters) OR increase healthy fats (olive oil, avocado, nut butters, nuts).

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My Health - Heart failure and salt: The great debate

“Let there be work, bread, water, and salt for all.”
— Nelson Mandela

Salt: without it, food can seem tasteless. It is the reason sea water burns our eyes and skin. Some people enjoy salt water baths. Is it good for us? Is it not? Do we really know?

In modern medicine, we tend to have a generally negative feeling about sodium, the element found in salt. Excessive sodium intake is linked to water retention, and it is also a risk factor for high blood pressure. Both excessive sodium intake and high blood pressure are major risk factors for developing heart failure, and for causing complications in those with existing heart failure. Given that 6.5 million American adults have heart failure, restricting salt intake might profoundly reduce risk for this major medical scourge.

Indeed, we advise our patients with heart failure to restrict the amount of salt they consume per day. For years we have been telling them to stay away from salty fries and Chinese takeout, which may have up to 7,000 mg of sodium in a single meal. We consign patients hospitalized for heart failure to a bland “low salt, heart healthy” diet until discharge. But what do we base the low-salt recommendation on? Is this just anecdotal? Or do we have evidence that guides our recommendations?

In the spirit of open-mindedness, let’s debate this question.

Point: Moderate sodium intake is harmful for people with heart failure

Sodium intake is associated with fluid retention, hence the puffiness and bloating that may follow a very salty meal. And excessive sodium intake may worsen high blood pressure, or hypertension. High blood pressure increases the risk of developing heart failure and can worsen existing heart failure. Hypertension may also lead to other types of heart disease, stroke, or kidney failure. A low-sodium diet may help lower or prevent high blood pressure, and may reduce the risk of such diseases.

High-sodium diets are also usually high in total fat and calories, which may lead to obesity and its many associated complications. Some studies also suggest that there may be a link between sodium intake and osteoporosis and stomach cancer. Additionally, consuming salty foods over a long period of time can accustom your taste buds to the taste, and in turn make you more likely to reach for saltier foods.

Counterpoint: Moderate sodium intake is not harmful for people with heart failure

Cardiologists tend to practice evidence-based medicine, yet many of our recommendations regarding sodium intake for people with heart failure are based on assumptions. Surprisingly, it is hard to say there is enough evidence to state beyond a shadow of a doubt that patients with heart failure should be restricted to the 2,000 mg of salt per day most physicians recommend. And realistically speaking, how many patients abide by this restriction remains unclear, because sodium is in almost everything we consume.

In a systematic review of nine studies recently published in JAMA Internal Medicine, only limited and inconsistent evidence was found supporting any benefit of salt-restricted diets for non-hospitalized people with heart failure. The evidence for salt restriction was inconclusive in patients admitted to the hospital for heart failure. This was a well-done study; only nine of 2,655 studies evaluated were rigorous enough to include in the review. So perhaps most importantly, this review illustrates that regardless of the conclusion, rigorous, evidence-based data regarding sodium restriction in heart failure are not available.

The lives of our heart failure patients are complicated enough as it is. It is imperative that whatever we recommend for our patients does not further worsen the quality of their already difficult lives. Since patients often struggle to maintain adherence to therapies in heart failure, our focus as physicians should be on stressing the things that are evidence-based. This includes adherence to guideline-directed medical therapies and favorable lifestyle interventions, such as more exercise, and care of other relevant medical conditions, such as diabetes.

The verdict: Until we have more evidence, it’s a draw

Take some of what we say with a grain of salt (pun intended). There is not yet enough evidence for either side of the great salt debate to win. And our discussion should not lead patients to consume salt in excess until we know for sure. Indeed, in the absence of good clinical data, one must accept the need for good clinical judgment: avoiding excessive amounts of sodium is a healthy move for all of us, including those with heart failure.

It’s also highly likely that some patients are more salt-sensitive than others. Thus, directing salt restriction to those most vulnerable might be better than a one-size-fits-all approach. Studies in this area are very much needed. Fortunately, clinical trials to address this question are ongoing, so stay tuned!

Follow Dr. Januzzi on Twitter @JJheart_doc and Dr. Ibrahim @IAmDrIbrahim

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My Health - Seasons of grief

While speaking as a panelist on substance use disorder (SUD), I felt it necessary to remind the audience that addiction is a family disease. While family members may not themselves be tethered to use of a substance, we all share in the anger, guilt, despair, and all too often grief that ripple back and forth in a family’s encounter with SUD. I learned early on, “Addiction isn’t a spectator sport, eventually the whole family gets to play.”

What may be harder for some to understand is that the “sport” gets played for a lifetime, even by generations to come. I am reminded of a line near the end of Robert Woodruff Anderson’s play I Never Sang for My Father, “Death ends a life, but it does not end a relationship, which struggles on in the survivor’s mind toward some final resolution, some clear meaning, which it perhaps never finds.”

The struggle to find some resolution to loss due to SUD may take the form of rotating graveside arrangements, memorial gardens or park benches, sponsored public talks, races, and fundraising benefits. These are but a few of the ways families devise to remember a loved one and contribute to the common good in their name.

Unfortunately, the struggle toward resolution can also result in blame, alienation, family disruption, and divorce. The disease has a way of finding its way into the weak spots of a family fabric and causing rot, unless and until the aftereffects are tended to and we find some way to make meaning from a loved one’s overdose death.

One disruption that is almost certain to appear is the alteration of a family’s calendar. While always a constant, grief finds a way to manifest itself in anniversaries new and old — certainly on birthdays, or with an empty chair at holiday tables (a practice some families observe not only in name but in deed), but also the memory of the day someone overdosed, or the last memory of sobriety. The scar of a horrifying discovery or a dreaded telephone call now mars Christmas Day, a wedding anniversary, or what would ordinarily be a celebratory family event.

For me the fall was always a happy time, ever since my early adolescence when I began to play soccer. I’ve played, coached, or been a referee every fall for 50 years. Exactly six years ago, even the same day of the week as I write this, I refereed a game on a bright October Saturday morning. That evening I discovered our son, William, overdosed in our living room. His last words to me as he shut the door were, “I’m going to watch some TV.” There was no mention of injecting heroin. Six weeks of comatose hospitalization followed before he died in our arms.

Every year since, the fall darkens not just with the loss of daylight, but also with the loss of a beautiful light in our lives. William’s November birthday, Thanksgiving, the day he died, the date of his memorial service — all combine to create a season of grief for our family. Nieces who will know him only through photographs and stories will sing him “Happy Birthday” on a day that is anything but happy for those who knew and loved William. Soccer, a sport I love, now competes with a deep seasonal gloom.

The philosopher Arthur Schopenhauer famously said, “All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.” Despite all the loss and suffering, all the beautiful memorials, and all the work of many grieving families and advocacy groups to enlighten us, I fear our society lingers too near stage one, ridicule. Ridicule prolongs shame and stigma, and serves to perpetuate our seasons of grief.

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My Health - The new exercise guidelines: Any changes for you?

It’s likely you already know that regular exercise helps prevent chronic disease, such as diabetes and heart problems, while improving your overall health, mood, and quality of life. It can sharpen mental function, boost concentration, and help you sleep. And the new exercise and physical activity guidelines issued by the federal government’s Office of Disease Prevention and Health Promotion show that the dose required to gain these benefits is not hard to achieve. The new guidelines are better tailored for age and ability, too.

What should your exercise goals be?

The amount of exercise and mix of activities recommended varies depending on age and ability, as described more fully below. It ranges from a high of three hours daily — for preschoolers, who tend to love activity — to 150 minutes a week.

Unfortunately, 80% of the population is not meeting the guidelines. Each year in the US, an estimated 10% of premature deaths and $117 billion in healthcare costs are associated with inadequate physical activity.

Besides saving money on healthcare, there are many personal benefits to staying active. The new guidelines highlight other new evidence-based findings related to physical activity and exercise.

What changed in the new exercise guidelines?

• Overall, move more, sit less. Work toward reducing the amount of time you spend sitting every day. If you have a desk job, get up to walk around regularly, or try chair yoga or a few desk exercises.
• All activity counts toward the recommended goals — not just 10-minute bouts of activity, as past guidelines recommended.
• Younger people and older people may benefit in different ways from exercise. It facilitates normal growth and development for preschoolers through teens, strengthening bones and muscles and improving cardiovascular health. Older adults who participate in regular exercise have better balance, and lower risks of falling and injury, thus improving their ability to remain independent.

The new guidelines base your dose of physical activity on relative intensity: how much effort a given exercise takes compared with your capacity for exercise. A brisk walk counts as moderate physical activity (think: fast enough so that you can speak comfortably, but not sing). The speed of this walk will be much faster for someone who is in shape than for someone who is just starting to exercise or getting back to activity after a break. But no matter where the starting line is, most people can safely improve their fitness and health. Begin with lower amounts of exercise and slowly increase duration, intensity, and frequency.

For example, if you:

• Have been bed-bound, start by walking two minutes every 10 to 15 minutes (during commercial breaks when watching TV or listening to the radio).
• Typically walk for exercise, try adding an extra block to your regimen once a week.
• Jog, try going at your regular pace for five minutes, then increasing it for one minute.

What stayed the same in the new exercise guidelines?

• Exercise is safe for almost everyone — even people with chronic disease and disabilities.
• Different types of exercise have complementary benefits:
  • Aerobic activity, like walking, running, or cycling, improves cardiovascular health. It involves movement of the large muscles of the body for sustained periods of time.
  • Muscle-strengthening activity, like resistance training with elastic bands or weight lifting, improves muscle strength, endurance, power, and mass.
  • Bone-strengthening activity, like running, playing basketball, resistance training, or jumping rope, improves bone health and strength.
  • Balance activity, like walking backwards, standing on one leg, yoga, and tai chi, can reduce fall risk.
  • Multicomponent physical activity, like running, dancing, or playing tennis includes at least two of the above types of activity.
• Rating the intensity of activities is simple. During:
  • Light activity, you don’t feel like you’re exerting yourself.
  • Moderate activity, you can talk comfortably, but not sing.
  • Intense activity, you can say a few words, but not full sentences. Within the guidelines, one minute of intense activity is roughly equivalent to two minutes of moderate activity.

New exercise recommendations by age and ability

• Preschool-age (3 through 5 years): physically active throughout the day with the goal of three hours of activity daily
• Children and teens (6 through 17 years): at least 60 minutes daily of moderate-to-vigorous physical activity; include vigorous activity, muscle-strengthening, and bone-strengthening activity three times a week
• Adults:at least 150 to 300 minutes weekly of moderate-intensity aerobic activity, or 75 to 150 minutes weekly of vigorous-intensity aerobic activity, or an equivalent combination of both, plus muscle-strengthening activities on at least two days a week
• Older adults:multicomponent physical activities that mix balance activities, aerobic activities, and strength training can help prevent falls and injuries; reduce overall sitting and replace it with light (or when possible, moderate) activity
• Pregnant and postpartum women:at least 150 minutes weekly of moderate-intensity aerobic activity
• Adults with chronic conditions or disabilities:follow adult guidelines as able, including both aerobic and muscle-strengthening activities

 

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My Health - Intimate partner violence and traumatic brain injury: An “invisible” public health epidemic

While studying brain injuries in the mid-1990s, I began volunteering in a domestic violence shelter. I noticed that the abuse and problems many women reported were consistent with possibly experiencing concussions. Women reported many acts of violence that could cause trauma to the brain, as well as many post-concussive symptoms. Shockingly, my search for literature on this topic yielded zero results.

When I decided to focus my graduate work on this topic, I was even more shocked by what I learned from women who had experienced intimate partner violence (IPV). Of the 99 women I interviewed, 75% reported at least one traumatic brain injury (TBI) sustained from their partners and about half reported more than one — oftentimes many more than one. Also, as I predicted, the more brain injuries a woman reported, the more poorly she tended to perform on cognitive tasks such as learning and remembering a list of words. Additionally, having more brain injuries was associated with higher levels of psychological distress such as worry, depression, and anxiety.

When I published these results, I was excited about the possibility of bringing much needed awareness and research attention to this topic. Unfortunately, over 20 years later — despite the plethora of concussion-related research in athletics and the military — concussion-related research in the context of intimate partner violence remains scant, representing a barely recognized and highly understudied public health epidemic.

What do we know about intimate partner violence-related traumatic brain injuries?

First, we need to understand that an estimated one in three women experience some type of physical or sexual partner violence in their lifetimes. IPV is not a rare event, and it traverses all socioeconomic boundaries. It is the number one cause of homicide for women and the number one cause of violence to women. For many reasons, including the stigma of being abused, many women hide their IPV — so the chances that we all know personally at least a few people who have sustained IPV are quite high.

Though we lack good epidemiological data on the number of women sustaining brain injuries from their partners, the limited data that we do have suggest that the numbers are in the millions in the US alone. Most of these TBIs are mild and are unacknowledged, untreated, and repetitive. Consequently, many women are at risk for persistent post-concussive syndrome with completely unknown longer-term health risks.

What are the signs and symptoms of IPV-related TBI?

A concussion, by definition, is a traumatic brain injury (TBI). All that is required for someone to sustain a TBI or concussion is an alteration in consciousness after some type of external trauma or force to the brain. For example, either being hit in the head with a hard object (such as a fist), or having a head hit against a hard object (such as a wall or floor), can cause a TBI. If this force results in confusion, memory loss around the event, or loss of consciousness, this is a TBI. Dizziness or seeing stars or spots following such a force can also indicate a TBI. A loss of consciousness is not required, and in fact does not occur in the majority of mild TBIs.

There are often no physical signs that a TBI has occurred. Recognizing that an IPV-related TBI has occurred will typically involve asking the woman about her experience following a blow to the head or violent force to the brain, and then listening for signs of an alteration of consciousness (such as confusion, memory loss, loss of consciousness). Within the next days or week, a range of physical, emotional, behavioral, or cognitive issues may indicate post-concussive symptoms that could include

• headaches
• dizziness
• feeling depressed or tearful
• being irritable or easily angered
• frustration
• restlessness
• having poor concentration
• sleep disturbances
• forgetfulness
• taking longer to think.

If a TBI is suspected, a woman should see a doctor if possible. Sustaining additional TBIs while still symptomatic will likely increase the time to recovery, and possibly increase the likelihood of more long-term difficulties.

What can we do?

An important component of addressing IPV-related TBI is to raise awareness and destigmatize intimate partner violence. IPV is unfortunately quite common, and some estimates suggest that millions of women may be sustaining unacknowledged, unaddressed, and often repetitive mild TBIs or concussions from their partners. Talking openly and honestly about this problem, especially in cases were abuse may be suspected, is critical. As we open up this conversation about the commonality of IPV with nonjudgmental acceptance of a woman’s experience, we will be in a better place to hear, understand, and support women who may be unknowing members of this invisible public health epidemic.

Follow me on Twitter @EveValera2‏

Resources

If you or someone you know is experiencing intimate partner violence, The Hotline is a 24/7 support service that has a wealth of resources, including access to service providers and shelters across the US.

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My Health - Smell disorders: When your sense of smell goes astray

We spend our days interacting with the world around us through our senses of sight, sound, and touch. But anyone who has developed complete nasal obstruction from an infection or severe allergies has experienced what it’s like to be without one of our most basic senses: our sense of smell.

The many functions of smell

In other animals, the sense of smell is absolutely crucial for survival, reproduction, and rearing of young. Although humans can survive without smell, research has shown that losing the sense of smell negatively impacts quality of life, even driving some people toward clinical depression. Just as other animals depend on the sense of smell as an alarm system for danger, we also depend on smell to warn us of the hazards of smoke from a fire, natural gas leaks in the home, and spoiled food.

On a daily basis, smell rounds out our experiences and is often an integral part of our memory of events from years gone by. Memories of a perfume worn by your spouse or the bread being baked at your grandmother’s house when you were a child last for decades, and are often intricately tied in with strong emotions.

The flavor of a meal depends heavily on the ability to smell, and without it, eating is just a bland means to dispel hunger. With so much of our social activity involving congregating at restaurants, bars, and cafes, it is understandable how someone losing the sense of smell can develop a sense of alienation.

Impact of smell disorders

Smell disorders affect 19% of the population over the age of 20 and 25% of the population over 53. If smell loss from aging alone is considered, one out of eight people between 53 and 91 will be affected over a five-year period. The detrimental effect of smell loss on flavor of food could significantly impact the elderly population, where diet and nutrition are already often a concern.

The sense of smell (olfaction) is dependent on millions of specialized nerve cells that are located in a deep protected recess high in the nasal cavity. Remarkably, these nerve cells normally die and are replaced throughout our lifetime. Therefore, the system has the capacity to repair itself after injury, but this isn’t always possible or complete.

The most common causes of prolonged smell loss occur as a result of upper respiratory infection, head injury, chronic sinus disease, and aging. However, other conditions such as Alzheimer’s disease, Parkinson’s disease, and tumors can be associated with smell loss.

In some cases, the loss of smell is complete (anosmia), while in other cases there is only a partial loss (hyposmia). In many instances where smell loss occurs, remaining smells are distorted. The distortions are either experienced as odors smelling dramatically different from what was remembered (parosmia) or smelling an odor that isn’t present (phantosmia).

Perhaps if they were pleasant, these distortions of smell might not be as distressful. However, in almost all instances, the experienced smells are unpleasant, with “smoke,” “swamp-like,” “musty,” “garbage,” or “chemical-like” among some very common descriptions. The odor is usually hard for people to describe, since it is not like anything they have experienced before.

Treating smell disorders

In cases where smell loss results from sinus disease, we have had some success in treating the condition. Oral and topical steroids often provide relief. Sometimes surgery is required to reduce the obstruction of odors to the sensory nerve cells. Sinus disease usually requires long-term management, and fluctuations in the ability to smell are common.

In contrast to chronic sinus inflammation, success in treating people with loss of smell resulting from head injury, upper respiratory infection, or aging is poor. The natural ability of the olfactory system to repair itself allows for some patients to regain the sense of smell after a respiratory infection-related loss or head injury. This recovery can take over a year, and can be so gradual that people have difficulty recognizing the change. Predicting whether recovery will occur in an individual is usually not possible, but overall any improvement that occurs within a one-year period increases the chances of recovery.

If you experience any persistent change in your sense of smell, visit your doctor for an evaluation. Some rare forms of smell disorders may result from tumors in the brain, neurodegenerative disease, or infection. These conditions should be diagnosed expediently for proper management and treatment. In addition, your doctor should talk to you about risks, such as depression and nutritional concerns that may stem from loss of smell.

Although therapies are currently lacking, there is hope for future breakthroughs. Ongoing scientific work is investigating how stem cells in the nose replace dying olfactory nerve cells. In the future, we will be able to add medication in the nose to trigger these cells to make more neurons, or replace missing stem cells to regenerate the neurons. Or we may be able to electrically stimulate a sensation of smell using an artificial implant. Continued research advances in this field will someday allow us to restore this important sensory system to those unfortunate enough to experience smell disorders, and provide them with the ability to once again fully experience the world around them.

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My Health - 8 Amazing Health Benefits Of Starfruit (Carambola) For Your Healthy

8 Amazing Health Benefits Of Starfruit (Carambola) For Your Healthy

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 - Holiday toys for kids: “Back to basics” is best

It’s the holiday season, time for buying toys for the children in our lives. As we do, the American Academy of Pediatrics (AAP) encourages us to think about buying toys that can actually help children as they grow and develop.

Play is the work of children. That doesn’t mean it can’t be fun; of course play should be fun. But play is at its best when it encourages learning and development, and when it encourages interaction with other people. So many gifts these days are full of bells and whistles and cool electronic gadgets, but don’t really help children (and are often quickly discarded). The AAP thinks that when buying gifts for children we should think more about getting back to basics, and suggests we think about toys from traditional toy categories:

• Symbolic/pretend play. These toys are the building blocks for imaginative play. They are things like dolls, animals, dollhouses, kitchen sets, tool sets, dress-up costumes, or puppets. Children can use them to create their own stories, doing it differently each time. Simple is best: toys don’t need to walk or talk or do anything, really. It’s better to leave that up to children.
• Fine motor/adaptive/manipulative. These are things like actual building blocks and other building sets, train sets, or puzzles. These are toys that not only encourage children to build and create, but also encourage fine motor skill development and early math (and even engineering) skills. There are apps that allow kids to build things digitally, but using their hands is best; nothing outdoes the three-dimensional approach.
• Art. Nothing encourages creativity and fine motor skills better than drawing, painting, and building with clay. So buy paper, crayons, markers, paint and paintbrushes — and modeling clay. They are inexpensive gifts that can keep children happy for hours. There is something very powerful for development when children have to start a project from scratch, like a drawing from a blank piece of paper.
• Language and interaction. This is where books come in — there is nothing better for learning new words, and appreciating words, than books. And when they are read aloud, in someone’s lap, they encourage interaction, which helps children flourish. Games encourage interaction too; traditional board games can be fun for everyone, and bring people together.
• Gross motor. In general, we are a sedentary nation — and most children do not get the recommended hour of physical activity every day. So make it easier for them. Buy them a bike or a trike, or a basketball and a net, or a soccer ball or a jump rope. Anything you do to get them moving not only builds strength and skills, it builds habits that can keep children healthy for the rest of their lives.

That’s the thing: when we get back to basics with toys, we not only give children hours of fun, but we’re helping them learn skills and strategies to grow into happy, healthy adults.

Follow me on Twitter @drClaire

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My Health - Kidney Infection Treatment Without Antibiotics

Kidney Infection Treatment Without Antibiotics

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 - Calm for the holidays

Are you heading home for the holidays, hosting relatives, or throwing parties? A strong dose of calm can help you enjoy yourself more and stress less. Here are a few ways to take holiday stress down a notch and invoke your calmest self.

Find your calm

Breathe deep: When your emotions run high, breathing speeds up, too. Deliberately slowing your breathing relaxes tense muscles, bringing shoulders down from ears, calms roiling emotions, and helps disarm the hormonal cascade within the body that feeds anxiety.

Try this: close your eyes and breathe in deeply through your nose while counting upward. Hold for a few seconds. Breathe out slowly through your nose while counting downward. Make each out-breath a few counts longer than each in-breath. Repeat for 5 minutes.

Or try a calming yoga breath, such as alternate nostril breath, described in a blog post by Marilyn Wei, MD.

A wide world of mindfulness apps for smartphones or tablets can show you many more ways to breathe deep and seek calm. Some are available for a one-time fee or by monthly subscription. Others allow you to tap samples for free.

Move fast: Investing time and effort in regular exercise helps people manage anxiety.  A systematic review of 15 randomized, controlled trials found that regular aerobic exercise successfully reduced anxiety in people who had been diagnosed with anxiety disorders and people with raised scores when tested for anxiety.  Those who engaged in high-intensity exercise (such as jogging) gained more relief than those who did low intensity exercise (such as walking), although both approaches had positive effects.

Can’t find the energy or time to exercise regularly? Even so, the distraction factor and chance to burn off anxiety through bursts of activity can help you feel calmer. Run in place, sprint up and down stairs, do jumping jacks, or take yourself out of the mix for a while and go for a walk outside.

Change the conversation

Defuse charged conversations: Let’s say you have family members whose conversations or actions reliably raise your blood pressure. Are polar-opposite politics are the root of the problem? Angry Uncle Bot, an interactive chat program published in the New York Times, offers ideas on ways to change the script this year. Or maybe it’s more than just politics that you and your family wrestle over. If so, try these simple tips to help promote peace among relatives from Melissa Brodrick, ombudsperson at Harvard Medical School.

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My Health - Gut feelings: How food affects your mood

The human microbiome, or gut environment, is a community of different bacteria that has co-evolved with humans to be beneficial to both a person and the bacteria. Researchers agree that a person’s unique microbiome is created within the first 1,000 days of life, but there are things you can do to alter your gut environment throughout your life.

Ultra-processed foods and gut health

What we eat, especially foods that contain chemical additives and ultra-processed foods, affects our gut environment and increases our risk of diseases. Ultra-processed foods contain substances extracted from food (such as sugar and starch), added from food constituents (hydrogenated fats), or made in a laboratory (flavor enhancers, food colorings). It’s important to know that ultra-processed foods such as fast foods are manufactured to be extra tasty by the use of such ingredients or additives, and are cost effective to the consumer. These foods are very common in the typical Western diet. Some examples of processed foods are canned foods, sugar-coated dried fruits, and salted meat products. Some examples of ultra-processed foods are soda, sugary or savory packaged snack foods, packaged breads, buns and pastries, fish or chicken nuggets, and instant noodle soups.

Researchers recommend “fixing the food first” (in other words, what we eat) before trying gut modifying-therapies (probiotics, prebiotics) to improve how we feel. They suggest eating whole foods and avoiding processed and ultra-processed foods that we know cause inflammation and disease.

But what does my gut have to do with my mood?

When we consider the connection between the brain and the gut, it’s important to know that 90% of serotonin receptors are located in the gut. In the relatively new field of nutritional psychiatry we help patients understand how gut health and diet can positively or negatively affect their mood. When someone is prescribed an antidepressant such as a selective serotonin reuptake inhibitor (SSRI), the most common side effects are gut-related, and many people temporarily experience nausea, diarrhea, or gastrointestinal problems. There is anatomical and physiologic two-way communication between the gut and brain via the vagus nerve. The gut-brain axis offers us a greater understanding of the connection between diet and disease, including depression and anxiety.

When the balance between the good and bad bacteria is disrupted, diseases may occur. Examples of such diseases include: irritable bowel disease (IBD), asthma, obesity, metabolic syndrome, diabetes, and cognitive and mood problems. For example, IBD is caused by dysfunction in the interactions between microbes (bacteria), the gut lining, and the immune system.

Diet and depression

A recent study suggests that eating a healthy, balanced diet such as the Mediterranean diet and avoiding inflammation-producing foods may be protective against depression. Another study outlines an Antidepressant Food Scale, which lists 12 antidepressant nutrients related to the prevention and treatment of depression. Some of the foods containing these nutrients are oysters, mussels, salmon, watercress, spinach, romaine lettuce, cauliflower, and strawberries.

A better diet can help, but it’s only one part of treatment. It’s important to note that just like you cannot exercise out of a bad diet, you also cannot eat your way out of feeling depressed or anxious.

We should be careful about using food as the only treatment for mood, and when we talk about mood problems we are referring to mild and moderate forms of depression and anxiety. In other words, food is not going to impact serious forms of depression and thoughts of suicide, and it is important to seek treatment in an emergency room or contact your doctor if you are experiencing thoughts about harming yourself.

Suggestions for a healthier gut and improved mood

• Eat whole foods and avoid packaged or processed foods, which are high in unwanted food additives and preservatives that disrupt the healthy bacteria in the gut
• Instead of vegetable or fruit juice, consider increasing your intake of fresh fruits and vegetables. Frozen fruits without added sugars/additives are a good choice too.
• Eat enough fiber and include whole grains and legumes in your diet.
• Include probiotic-rich foods such as plain yogurt without added sugars.
• To reduce sugar intake at breakfast, add cinnamon to plain yogurt with berries, or to oatmeal or chia pudding.
• Adding fermented foods such as kefir (unsweetened), sauerkraut, or kimchi can be helpful to maintain a healthy gut.
• Eat a balance of seafoods and lean poultry, and less red meat each week.
• Add a range of colorful fresh fruits and vegetables to your diet, and consider choosing certain organic produce.

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My Health - Creating recovery-friendly workplaces

People who work in manual labor have higher rates of injury and overdose

Our country’s ongoing opioid crisis has many faces, from teenagers on Cape Cod to middle-aged parents in West Virginia. A recent report from the Massachusetts Department of Public Health provides another demographic affected by opioids: people who work in the trade industries, namely construction. The report broke down overdose deaths by industry, and construction workers were involved in almost a quarter of overdose deaths recorded in the state over five years. Farming, forestry, and hunting, along with fishing, are the next most dangerous industries. And there are relatively high overdose death rates for women working within health care support and food services.

This research supports what we have seen in our own work treating patients for substance use disorders who work in manual labor jobs. On-the-job hazards and related injuries are common, and pain medications of all kinds tend to be readily available as workers informally share and sell them on worksites.

The need for recovery-friendly workplaces

A recent National Safety Council report found that 70% of surveyed employers have been impacted by prescription drug misuse, but fewer than 20% feel extremely prepared to deal with it. The financial cost to employers in lost productivity is significant: in Massachusetts alone, opioid addiction cost businesses $2.5 billion annually from employees who aren’t functioning at full capacity, and $5.9 billion in lost productivity from people who can’t join the workforce due to addiction. Opioid use disorder has kept nearly 33,000 people in Massachusetts from participating in the labor force each year, on average, over the past five years.

But what could a recovery-friendly workplace look like? Drawing inspiration from models like Supported Employment, an evidence-based intervention for individuals with serious mental illness, and recovery high schools, we describe five key features of a recovery-friendly workplace:

Available counseling for scheduled and on-demand recovery support. Manual labor workers with varying schedules often have trouble making appointments in traditional healthcare settings, which tend to be offered only during normal business hours. Missed work equals lost income, which is harmful to workers and employers alike. An onsite counselor for large worksites or availability of remote telehealth counseling on-demand during work breaks could encourage participation in these programs.

Peer support groups built into the daily schedule. Like individual appointments, therapy groups often occur during the business day. Open and safe discussions with crewmates who are also in recovery can help build a culture of mutual support. Onsite peer support by recovery coaches in the industry might be particularly impactful.

A supervisor who understands the challenges and needs of people in recovery. Slip-ups are part of the recovery process, and a positive drug test should signal the need for more counseling support and closer monitoring, not automatic termination of employment.

Support for medication-assisted treatment. We’ve heard anecdotally about certain union health insurance plans that deny coverage of buprenorphine (Suboxone), a medication for opioid use disorder that calms cravings and halves the risk of overdose death. This kind of discrimination is a federal crime, and for good reason — imagine employer-based health insurance refusing to pay for insulin for workers who have diabetes. Unfortunately, stigma and fear of retribution may keep union workers from speaking out to claim their rights.

Onsite drug testing (where appropriate) and telepsychiatry. Regular drug testing could help make construction sites safer and indicate when people need more support. Crews often share transportation to and from worksites, making it hard for an individual to leave in the middle of the day for a medication appointment or to provide required toxicology testing for their program. Telepsychiatry visits in a secure room on a worksite could allow people to get assessed more regularly and prevent missed doses of recovery medications like buprenorphine.

Recovery-friendly workplaces may lower healthcare costs

Employers in all kinds of industries should consider how establishing recovery-friendly workplaces may help them access an underutilized workforce while addressing a vital social need. People in recovery from opioid use disorder commonly describe their core recovery goals as needing to keep busy, to achieve financial self-sufficiency, and to recapture the dignity of being a working member of society. Our clinical work can go only so far in supporting our patients’ recovery, but with the right kinds of partnership across sectors, we can make great strides together.

Given the high prevalence of substance use disorders in certain sectors, investing in supported employment with recovery support and medication-assisted treatment might reduce costs associated with missed work as well as employee hiring and retraining, improving overall work quality while also lowering overall healthcare costs. Finally, substance use is rampant on construction and manual labor worksites, so investing in recovery support and treatment might improve the relationship of workers with management and unions and reduce risk for accidental injuries in the future.

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My Health - Coping with infertility during the holidays: Darkness and light

In my experience, most people dealing with infertility would say that their longing for a child brings sadness year-round. Still, there are times and seasons when the pain intensifies.

This may be in spring or early summer when the world is in bloom, winter coats are off and pregnant bellies are out, when greeting card companies and florists ambush airwaves to promote Mother’s Day and Father’s Day.

Similarly, the winter holidays present an ever-lengthening stretch during which many women and men who are struggling with infertility feel pummeled. Bookended by Thanksgiving and New Year’s, this has become a season of holiday cards spotlighting happy children, and loud messages of merriment in stores and public places. Short days, dark nights, cold, snow, and clouds further conspire to tell those who are struggling with infertility that ‘tis hardly the season to be jolly.

Approaches to coping with infertility

So, how best to get through the holidays when you are enduring infertility? You might wish to set sail for an island paradise and remain there until the January blizzards take everyone’s focus off babies and young children. An escape could be sweet, but for many, the desire to share holidays with loved ones coexists with the pain of being infertile.

Rather than isolating yourself or disconnecting from those you love, you may simply want to hurt less. One way to do so is to find ways to claim some modicum of control during the winter holidays. Here are some ideas that have worked for people I’ve counseled over the years.

• Develop a strategy for opening holiday cards. For anyone going through infertility, the contents of each envelope may bring pain. While you have endured a year — or yet another year — of longing and disappointment, other people’s children have grown. Some cards hurt more: announcements of a new baby entering the world. One coping strategy is collecting the cards and opening a batch with a partner or a close friend who “gets it.” It can help a lot to feel that you are doing this as a team, letting fly with dark humor or sarcasm to fortify you in the process. Celebrate when the last envelope has been opened. For some, a bottle of wine or a nice dinner to enjoy afterwards eases sadness.
• Host a holiday gathering? Or just make a cameo? No one going through infertility wants to feel trapped in a holiday gathering with no way to escape. But how to avoid this? Surprisingly, one way is to host the party. Yes, it’s a lot of work, but you set the timing and format, and can shape content for the occasion to focus guests on something other than family chatter. A Yankee swap? A wine, cheese, or olive oil tasting?

Alternatively, leave the heavy lifting to others and participate in their events on your terms. Agree on an escape clause — a reason to depart from a gathering early. That way, you know you can leave if someone announces a new pregnancy or is gushing about his children — or worse, grumbling about them and seemingly oblivious to her good fortune in having children. If you like, you can share your strategy with your host. The key, as with opening holiday cards, is to find pathways to control.

• Decide what to share. One way to claim some control at family holiday gatherings — and in general during infertility — is to manage information and communication. What do you want people to know? What is too much information? For example, you may feel it’s important that people you care about know you want to have a baby and are seeking medical help. Yet they need not know exact treatments, timing and outcomes of treatments, or the doctors you are seeing. Providing basic information protects you from being misunderstood, or the subject of queries. Offering detailed information invites commentary and advice.
• Consider how it might feel to acknowledge pain without showing it. Acknowledging pain might sound like this: “This has been a hard year. We’ve had some disappointing fertility treatments and gone through tough times, but we’re so happy to be here welcoming a new year with all of you.” Showing pain might sound like this: “It’s too hard for me to be here with all the children. I need to leave now.”

Giving back

Infertility draws us inward, prompting us to focus on our bodies, our sadness, our longings, and our helplessness. It blurs time and strains relationships, even when we do our best to stay connected. The holiday season, for all its commercial fanfare, is also a time when we remember those in need and those whose suffering eclipses ours.

Think perhaps of the holiday lights: Hanukah, the festival of lights, Kwanzaa, with seven glowing candles in the kinara, and Christmas, with its illuminated trees and homes, remind us that light in darkness is far more beautiful than light in light. At the risk of sounding preachy — which is not my intent — I think that doing good in dark times alleviates some of the seasonal pain of infertility. It reminds us that we do have some control, that the holidays are not simply a time to escape from, and that in helping others, we help ourselves.

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My Health - Safe and effective use of insulin requires proper storage

Insulin is a naturally occurring, glucose-lowering hormone used by many people with diabetes to control their blood sugar. In people with type 1 diabetes, supplemental insulin makes up for the insulin that is not produced by the body. People with type 2 diabetes may need to take insulin if they cannot maintain adequate blood sugar control with other medications.

Insulin is manufactured to be identical to the insulin produced by the human pancreas. These synthetic insulins can work from a few hours (rapid-acting insulin) to a whole day (long-acting insulin). They are typically injected via a needle or pen.

Guidelines for proper insulin storage

All insulins must be stored with care to ensure that they remain safe and effective. Improper storage could result in the breakdown of insulin, affecting its ability to effectively and predictably control your blood sugar level.

Depending on the type of insulin you are prescribed, there may be some subtle differences in how best to store it and how long it will last once open. Ask your doctor or diabetes educator for specifics on how to store your own insulin prescription.

Here are some general rules that reflect best practices for properly storing insulin:

• All insulins are sensitive to temperatures that are too high or too low. Once you receive your insulin prescription, you should store all the supplies you’ve received in the refrigerator.
• Once you open a new vial (meaning once you stick a needle in the vial) or pen, use a Sharpie to note the date you opened it right on the packaging. This will help you remember when to stop using it. Throw the insulin away 28 days after opening it.
• Once you open a vial, keep it stored in the fridge or at room temperature. Be aware that injecting refrigerated insulin may be painful.
• Keep an insulin pen refrigerated until you open it; after that, you can store it at room temperature.
• Ask your doctor if your particular insulin has a shorter or longer lifespan. Some insulins must be used in as little as 10 days.
• If you suspect your insulin was ever frozen, you should not use it. Insulin could freeze if it was left outside in extreme cold temperature, for example if it was delivered on a cold day and stayed outside for a while, or if it was left in your car. But insulin could also freeze in your refrigerator. Research presented at the European Association for the Study of Diabetes meeting in Berlin showed that domestic refrigerators may have unexpected temperature fluctuations. To ensure that your refrigerator keeps a constant temperature and does not go below the freezing point at any time, keep a thermometer in the fridge to check for a stable temperature of 39° F (or 4° C).
• Insulin is also sensitive to hot temperatures, so do not leave it outside in extreme heat. This could happen in the summer, especially if you leave your insulin in the car for several hours, or you leave a “spare” insulin sample in the glove compartment of the car as backup.
• Exposure to sunlight can also degrade insulin.
• Always check the expiration date and do not use expired insulin.
• Inspect your insulin before each use. Look for changes in color or clarity. Look for clumps, solid white particles, or crystals in the bottle or pen. Insulin that is clear should always be clear and never look cloudy.

Finally, if you have any doubts, start a new vial or pen to avoid unpleasant surprises.

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