My Health - Why keep a food diary?

Many people begin the new year with a resolve to improve their health. This improvement often starts with changing what they eat.

A food diary can be a useful tool in this process. It can help you understand your eating habits and patterns, and help you identify the foods — good and not-so-good — you eat on a regular basis. Research shows that for people interested in losing weight, keeping a journal can be a very effective tool to help change behavior. In one weight loss study of nearly 1,700 participants, those who kept daily food records lost twice as much weight as those who kept no records.

What should you include in a food diary?

Most experts agree that the secret to successful food journaling is accuracy and consistency. So, what should you record? A basic food diary should include the following:

• What are you eating? Write down the specific food and beverage consumed and how it is prepared (baked, broiled, fried, etc.). Include any sauces, condiments, dressings, or toppings.
• How much are you eating? List the amount in household measures (cups, teaspoons, tablespoons) or in ounces. If possible, it is best to weigh and measure your food. If you are away from home, do your best to estimate the portion.
• When are you eating? Noting the time that you’re eating can be very helpful in identifying potentially problematic times, such as late-night snacking.

Jotting down where you’re eating, what else you’re doing while you’re eating, and how you’re feeling while eating can help you understand some of your habits and offer additional insight.

• Where are you eating? Record the specific place you are consuming food, whether it’s at the kitchen table, in your bedroom, in the car, walking down the street, at a restaurant, or at a friend’s home.
• What else are you doing while eating? Are you on the computer, watching TV, or talking with a family member or a friend?
• Who are you eating with? Are you eating with your spouse, children, friend, or a colleague, or are you alone?
• How are you feeling as you’re eating? Are you happy, sad, stressed, anxious, lonely, bored, tired?

Tips for successful food journaling

Here are more tips for keeping a successful food diary:

• Write down the food or beverage as soon as you consume it. Don’t wait until the end of the day because your recollection is likely to be less accurate.
• Be as specific as you can with the food or beverage. For example, if you are drinking a latte, note the type and size.
• Be sure to include any alcoholic beverages you consume.
• A smartphone app like Lose It! or MyFitnessPal can support your efforts. These apps also offer information on calories and other nutrients.

You’ve kept a food diary. Now what?

After completing a week’s worth of food journaling, step back and look at what you’ve recorded. Search for any trends, patterns, or habits. For example, you might consider:

• How healthy is my diet?
• Am I eating vegetables and fruit every day? If so, how many servings?
• Am I eating whole grains each day?
• Am I eating foods or beverages with added sugar? If so, how frequently?
• Do my moods affect my eating habits? Do I reach for unhealthy snacks when I’m tired or stressed?
• How often do I eat on the run?

Set SMART healthy eating goals

Once you’ve identified areas for improvement, set one or two healthy eating goals for yourself. In doing so, use the SMART goal format. That means your goals should be Specific, Measurable, Achievable, Relevant and Time-based. Here are a few examples of SMART goals.

Food diary observation: You average two servings of vegetables per day.
Goal: Eat more vegetables.
SMART goal: Eat three servings of vegetables per day.

Food diary observation: You order takeout three or four nights per week.
Goal: Cook more at home.
SMART goal: Order take out no more than one or two nights per week.

Food diary observation: You eat healthy meals and snacks until about 3 pm, when you hit the office vending machine.
Goal: Eat healthier snacks.
SMART goal: Bring a healthy snack (a piece of fruit and a small handful of nuts) to work every day.

Keeping a food journal can be very informative and move you toward improving your health. Using the data from your food diary to make SMART changes, and continuing to track your progress, is a great place to start your journey for a healthier 2019.

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My Health - What to do if you think your child has the flu

We are in the thick of influenza season now, and so it’s natural that if you hear your child start coughing, you wonder: could this be the flu?

The flu is different from the common cold, but it’s not always easy to tell them apart, especially at the beginning. The flu usually comes on suddenly, and its symptoms can include fever, runny nose, cough, sore throat, headache, muscle aches, feeling tired, and generally just feeling rotten. Some people have vomiting and/or diarrhea, too. Not everyone has all these symptoms, and the illness can range from mild to severe. So what do you do if you think your child might have the flu?

Call your doctor

You don’t necessarily need an appointment, but you should call for advice. Describe your child’s symptoms. Based on the symptoms, and your child’s particular situation (such as any medical problems they might have, or vulnerable people like infants or elderly living with you), your doctor may want you to bring your child in, and may want to prescribe antiviral medication. Because every child and every situation is different, you should call and get advice that is tailored to your child and family. Once you’ve done that, or once you’re back home with a diagnosis of flu…

Stock up on supplies

There are a few things that make getting through the flu easier, including:

• acetaminophen and ibuprofen for fever and aches
• a reliable thermometer, if you don’t have one
• hand sanitizer (buy a few to keep all over the house)
• tissues
• fluids to keep your child hydrated, such as clear juices, broth, oral rehydration solution (for infants), and popsicles (which are great for sore throats, and eating them is the same as drinking). If you don’t have a refillable water bottle (one with a straw is great if kids are lying down), get one of those too.
• honey (if your child is older than a year) and cough drops (if your child is at least preschool age)
• saline nose drops
• a humidifier, if you don’t have one
• simple foods like noodle soups, rice, crackers, bread for toast.

Make sure your child rests

Turn off or at least limit the screens, as they can keep children awake when their body needs them to sleep. Keep rooms darkened, and limit activity. If they aren’t sleeping, quiet things like reading (or reading to them), drawing, card games, etc. are best.

Push fluids, don’t worry about food

When children are fighting the flu, the most important thing is that they stay hydrated. They need a bit of sugar and salt too, which is why juices and broths are good choices. If they only want water, give them some crackers to get the sugar and salt — but don’t worry too much if they don’t want to eat more than that. They will eat more when they feel better.

Watch for warning signs

Most children weather the flu fine, but some children get very sick, and there can be complications. Call your doctor or go to an emergency room if your child has:

• a high fever (102° F or higher) that won’t come down with acetaminophen or ibuprofen, or a new fever after your child seemed to be getting better
• any trouble breathing
• severe pain of any kind
• severe sleepiness, so that it’s hard to wake them or keep them awake
• trouble drinking or keeping fluids down
• anything that seems strange or worries you (I always respect a parent’s “Spidey sense”).

Keep your child home until they are well

That doesn’t necessarily mean they can’t go to school or daycare until they are cough- or runny nose-free, but it does mean that they have to be fever-free for at least 24 hours, not coughing constantly, able to eat and drink, and have enough energy to do whatever school or daycare entails. Not only is this important for your child’s recovery, but it’s important for preventing the spread of influenza. Which leads me to the last point…

Do your best to keep others from getting sick

Besides keeping your child home (and staying home yourself if you catch it), there are other things you can do, such as:

• make sure everyone in the house washes their hands frequently (that’s where the hand sanitizer all over the house comes in handy)
• teach everyone to cover coughs and sneezes (they should do it into their elbow, not their hands)
• don’t share cups, utensils, towels, or throw blankets
• wipe down surfaces and toys regularly
• discourage visitors (use technology for virtual visits instead)
• be thoughtful about physical contact. Some degree of contact and snuggling is part of parenthood, but siblings may want to keep a bit of distance, and you can always blow kisses and do pretend hugs instead of the real thing.

Remember, too, that it’s never too late to get a flu shot if you haven’t already.

To learn more about the flu and what to do, visit flu.gov.

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My Health - When a pelvic exam is traumatic

If you’re a survivor of sexual assault or trauma, medical visits may heighten anxiety, particularly if you’re concerned that a pelvic exam will be performed. As an obstetrician-gynecologist, I have had patients who experienced sexual assault confess that they have avoided or delayed seeking medical care due to their anxiety surrounding pelvic exams. Even for women without a history of sexual trauma, pelvic exams and a visit to the gynecologist may be embarrassing or painful; for women with a history of sexual trauma, it can be unbearable.

Statistics tell us that one of out of every three women has experienced sexual violence. The #MeToo movement empowered women to speak out about their experiences. Discussions engendered by the movement connected us to people rather than just to a number, subtly shifting  how we as a society think about and process sexual violence. On social media, the hashtag #triggerwarning alerts viewers to potentially disturbing information. However, little discussion has focused on the intersection of trauma and health care.

What does research tell us?

Studies have found that survivors of sexual assault have higher rates of anxiety compared to the general population. They may also be affected by post-traumatic stress disorder (PTSD), which can make them feel as though they are being re-traumatized by a pelvic exam. While taking the initial step to proceed with a gynecologic visit or pelvic exam may feel insurmountable, there are ways that health care providers and patients can approach this visit to make it feel safe for survivors.

A study published in Obstetrics & Gynecology focused on survivors of sexual assault who were pregnant and analyzed what helped them throughout the pregnancy and during the time of delivery. These women wanted their health care providers to know about their history of sexual trauma. At the time of delivery, they wanted to know who would be present in the labor and delivery room. And they wanted to be able to control how much or how little of their bodies they exposed.

How can you talk to your doctor about trauma?

Communication is key to the physician-patient relationship, especially when a patient has a history of trauma. In my practice, I want my patients to feel empowered to inform me of their history, without ever feeling the need to delve into specifics or details. They can choose to establish rapport prior to undergoing a pelvic exam, even if that necessitates multiple visits. They can dictate the pace of the pelvic exam and tell me if they need a break or feel overwhelmed.

As the patient, it can feel difficult to ask this much, but as a women’s health physician, one way in which I can address a woman’s anxiety about a pelvic exam is by giving her control over the exam and over her body. I appreciate it when patients voice their concerns. I always tell my patients, particularly those with a history of sexual trauma, that they have control over their bodies and the exam, and that my office is a safe space for them.

Wondering what to say?

Maybe you’re wondering what to say. People may start the conversation in different ways. Here are some ideas that may help:

• You might start by saying, “I feel anxious when I come to the doctor.”
• You could say a few words about what worries you: being touched, needing to undress, having a pelvic exam.
• You can choose how much to explain. “I’ve experienced sexual assault. I’d rather not talk about the details, though.”
• You can even keep it vague: “Pelvic exams are difficult for me because of my history.”
• You can share any ideas you have about how to make you comfortable during a pelvic exam or any medical exam. Please also share anything that you’ve found helpful. “It might help if you explain steps before doing them. I hope you’re willing to go slowly, stop for a break, or even stop the exam if I start feeling overwhelmed.”

If you’re a survivor of sexual violence, I encourage you to openly communicate with your health care providers. If you’re a provider, listen carefully and do all you can to create a safe space that allows women to obtain the care that they need without compromise.

Resources

Boston Area Rape Crisis Center has a phone (800-841-8371) or web chat hotline and offers a range of resources to people in the greater Boston area.

The National Sexual Violence Resource Center has a list of groups that offer online support for sexual violence survivors.

RAINN offers information on recovering from sexual violence, a national hotline (800-656-4673), and access to local resources.

The Voices and Faces Project hosts writing workshops for people who have experienced gender-based violence called The Stories We Tell.

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My Health - Hormonal therapy for aggressive prostate cancer: How long is enough?

Men weighing treatment options for intermediate- or high-risk cancer that is still localized to the prostate can face a tricky question. A standard approach in these cases is to give radiation to the prostate along with drugs that block testosterone, a hormone that makes the cancer cells grow faster. For how long should this hormone therapy last? That’s not entirely clear. The drugs have side effects, such as fatigue, impotence, and a loss of muscle mass. But radiation doesn’t control prostate cancer effectively without them. Doctors therefore aim to give hormone therapy only for as long as it takes to help their patients, without causing any undue harm.

Now, newly published results from a phase 3 clinical trial are providing some needed guidance.

How the study was performed

During the study, scientists randomized 1,071 men with intermediate- or high-risk localized prostate cancer into four groups. One group received radiation and six months of an anti-testosterone drug called leuporelin, and the second group received radiation plus 18 months of leuporelin therapy. Two other groups were treated with the same regimens of either radiation plus six or 18 months of leuporelin therapy, along with another drug called zoledronic acid, which helps to limit skeletal pain and related complications should cancer spread to the bones. Study enrollment occurred between 2003 and 2007 at 23 treatment centers across New Zealand and Australia.

Here’s what the results showed

After a median follow-up of just over 10 years, 9.7% of men who were treated with radiation and leuporelin for 18 months had died from prostate cancer, compared to 13.3% of the men treated with radiation and leuporelin for six months. Adding zoledronic acid made no difference in either case.

The authors concluded that hormonal therapy is more effective at preventing prostate cancer death when it’s given for 18 months rather than six. And similar benefits were noted for other endpoints as well. For instance, prostate tumors were less likely to metastasize, or spread, among men in the longer duration treatment group, and it took longer for their cancers to become resistant to hormone therapy if it was reinitiated later.

In earlier clinical research, scientists discovered that hormonal therapy given for three years protects against prostate cancer death more effectively than a six-month treatment regimen. But three years of hormone therapy isn’t easily tolerated, and evidence so far shows that 10-year survival rates after either 18 months or three years of hormonal therapy are similar, the authors of the new study claim.

“This study reaffirms what many clinicians have put into practice: longer duration hormonal therapy in appropriately selected patient populations provides a greater benefit,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org. “Prior studies using three years of hormonal therapy have also shown this, but it is important to recognize that some men may have significantly delayed return of the body’s testosterone upon completion of the therapy — a fact that needs to be discussed when contemplating longer-term treatment programs.”

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My Health - Your genes and addiction

Over the last decade, the prevalence of opioid addiction has increased to epidemic levels, but unfortunately therapeutic interventions for the treatment of addiction remain limited. We need to better understand the triggers for the development of addiction in order to develop more targeted prevention and treatments. One of the key questions that researchers in the field of neuropsychiatry are trying to answer is why some people are more vulnerable to addiction. As in most cases of psychiatric disorders, genetic and environmental factors interact to determine how vulnerable, or likely, you are to developing a substance use disorder.

Drugs of abuse, including opioids, act on the brain’s reward system, a system that transfers signals primarily via a molecule (neurotransmitter) called dopamine. The function of this system is affected by genetic and environmental factors. For example, a recent study published in the scientific journal PNAS revealed one of those genetic factors. Researchers demonstrated that a type of small infectious agent (a type of RNA virus called human endogenous retrovirus-K HML-2, or HK2) integrates within a gene that regulates activity of dopamine. This integration is more frequently found in people with substance use disorders, and is associated with drug addiction.

How does stress induce epigenetic changes?

Accumulating evidence suggests that environmental factors, such as stress, induce epigenetic changes that can trigger the development of psychiatric disorders and drug addiction. Epigenetic changes refer to regulations of gene expression that do not involve alterations in the sequence of the genetic material (DNA) itself. Practically, epigenetic changes are information that is added on to already existing genetic material, but can affect the expression of genes.

A stressful situation, such as the death of a significant other or the loss of a job, triggers the release of steroid hormones called glucocorticoids. Those stress hormones trigger alterations in many systems throughout the body, induce epigenetic changes, and regulate the expression of other genes in the brain. One of the systems that is affected by stress hormones is the brain’s reward circuitry. The interaction between stress hormones and the reward system can trigger the development of addiction, as well as a stress-induced relapse in drug or alcohol recovery.

Stress reduction can help reduce the risk of developing an addiction and prevent relapse

Fortunately, the negative effects of stress can be alleviated by other factors, such as physical activity or social support. These behaviors produce epigenetic changes that prevent the development of addiction and can have a beneficial role in treatment when used in combination with other interventions, such as cognitive behavioral therapy and, for some people, medications. One of the ways that physical activity could be effective is by reducing negative feelings, including stress and the accompanied stress-induced epigenetic changes. In the example of a stressful situation such as the death of a significant other or loss of a job, if a person engages in physical activity this can reduce their stress-induced epigenetic changes, which will decrease the risk of developing addiction or stress-induced relapse.

Hope for targeted addiction treatments

We now know that the function and dysfunction of the brain’s reward system is complicated, plastic (undergoes changes based on negative and positive factors), and involves complex interactions of genetic and environmental factors. Alterations in gene expression can lead to changes in the function of the brain’s reward system, so a person is more or less likely to self-administer drugs. Together this knowledge can ultimately lead to the development of multilevel and more efficient prevention and therapeutic approaches to address the ongoing opioid epidemic.

Resources

Human Endogenous Retrovirus-K HML-2 integration within RASGRF2 is associated with intravenous drug abuse and modulates transcription in a cell-line model. Proceedings of the National Academy of Sciences, September 24, 2018.

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My Health - Dairy: Health food or health risk?

When I was a growing teenager, I drank as much milk as possible (often straight from the carton while standing in front of the open fridge, much to my mother’s chagrin). I’d seen the TV ads — milk and other dairy foods were the express ticket to stronger bones and bigger muscles.

But today dairy’s nutritional reputation is as clear as, well, a glass of milk. Dairy is either good or bad for you depending on the latest diet trend or recent study. So what is the truth — is dairy healthy, or a health risk? “Dairy isn’t necessary in the diet for optimal health, but for many people, it is the easiest way to get the calcium, vitamin D, and protein they need to keep their heart, muscles, and bones healthy and functioning properly,” says Vasanti Malik, nutrition research scientist with the Harvard T.H. Chan School of Public Health.

Dairy products as a source of calcium and protein

Dairy products like milk, yogurt, cheese, and cottage cheese, are good sources of calcium, which helps maintain bone density and reduces the risk of fractures. Adults up to age 50 need 1,000 milligrams (mg) of calcium per day. Women older than 50 and men older than 70 need 1,200 mg. (For comparison, a cup of milk has 250 mg to 350 mg of calcium, depending on the brand and whether it’s whole, low-fat, or nonfat. A typical serving of yogurt has about 187 mg of calcium.) Milk is also fortified with vitamin D, which bones need to maintain bone mass.

Older adults also need protein to protect against sarcopenia, the natural age-related loss of muscle mass and strength, and dairy can be a decent source. The recommended amount for older adults is 0.8 grams per kilogram of body weight. A 180-pound man would need about 65 grams of protein per day, and a 140-pound woman would need about 50 grams.

Still, when it comes to the direct health impact of dairy, the existing science is mixed. Some research warns against consuming too much dairy, while other studies show some benefits from regular dairy consumption.

Is one form of dairy better than another?

The American Heart Association still recommends adults stick to fat-free or low-fat dairy products. But new research suggests full-fat dairy might not be much of a threat to heart health. A report presented at the 2018 Congress of the European Society of Cardiology looked at 20 studies involving almost 25,000 people, and found no association between the consumption of most dairy products and cardiovascular disease. The exception was milk, but the results showed that only very high milk consumption — an average of almost a liter a day — was linked with a higher risk of cardiovascular disease.

Some science has even suggested that the right kind of dairy may prevent heart disease. A study involving 2,000 men published by the British Journal of Nutrition found that those who ate plenty of fermented dairy products like yogurt and cheese had a smaller risk of coronary artery disease than men who ate less of these products. This supports earlier studies that showed that fermented dairy products have more healthful effects on blood lipid profiles and the risk of heart disease than other dairy products.

Another proposed benefit, however, has not panned out. “Despite the push by the US dairy industry to promote dairy products, especially milk, as a weight-loss tool, research hasn’t supported that except when also restricting calories,” says Malik.

The bottom line

When it comes to overall health benefits, it seems that dairy is neither a hero nor a villain. Adding some dairy to your daily diet — a splash of milk in your coffee or a cup poured over your breakfast cereal, or a slice of cheese on a sandwich — can help you get some of the vital nutrients you need. “But keep in mind that eating a well-balanced diet that includes plenty of green leafy vegetables and nuts can better help you get the calcium and protein you need rather than relying too much on dairy,” says Malik.

Malik still prefers most people stick with low-fat dairy, as this helps reduce your intake of saturated fat but still offers good amounts of nutrients. Alternatively, you can choose almond and soy milk substitutes — but be aware that they have lower amounts of protein than regular milk. For a single go-to dairy source, Malik recommends plain Greek yogurt. (Avoid flavored versions, which are high in sugar). “It has more protein than regular yogurt and contains probiotics that help with gut health. And it’s quite versatile, as you can eat it alone or add it to other dishes like smoothies and use it as a substitute for cream in recipes.”

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My Health - Couch potatoes start early: How to get kids moving

We know that American adults are couch potatoes. According to the Department of Health and Human Services, only 5% of US adults are physically active for 30 minutes every day, and only one in three gets the recommended 150 minutes of physical activity every week. It’s understood that people get less active as they get older, but we generally think of children as being physically active. However, according to a study in the journal Pediatrics, these days being a couch potato starts in childhood.

As part of the Childhood Obesity Project in Europe, researchers followed 600 children between the ages of 6 and 11, and measured how physically active they were using a wristband designed for that purpose. They found that physical activity was lower than expected even starting at age 6, with only 80% being active for the recommended 60 minutes a day. It wasn’t just a matter of starting school, either. Researchers found that they weren’t particularly active on weekends, school holidays — or even at lunchtime, when they generally have recess.

Activity declined steeply after age 8. By age 11 only 20% were active for an hour a day. Boys were more likely to engage in more vigorous activity than girls. Interestingly, they also found that overweight children were less likely to be active than children who were at a healthy weight, which raises an interesting question: is obesity not just a result of a lack of physical activity, but also a cause of it?

For anyone who has or interacts with children, this information is probably not a surprise. As the study notes, there has been a massive increase in sitting activities in children over the last decades. Much of this is screen-related — initially with video games, and now including social media and other activities that children do on their phones. Just going outside and playing has become less common. There is less free time for children, who are far more scheduled than they used to be. Physical activity tends to take place in the setting of organized sports — which, unless a child is at or working toward an elite level, rarely take place every day. For many low-income children, there are few safe spaces to play outside, and not only can their families not afford the cost of organized activity, but because of work and other life realities they are not able to supervise them in safe play or exercise with them.

All of this matters — because physical activity habits start early. Children who are sedentary turn into sedentary adolescents who turn into sedentary adults. And being sedentary not only puts people at risk of obesity, but is a risk factor in and of itself for a whole host of health problems. If we want our children to live healthy lives, we need to get them moving.

How to get children moving more

Here are some ideas:

• Look for sports teams and other physical activity opportunities in your community. Many communities offer low-cost activities, and scholarships are often available if you ask.
• Look for and support school-based exercise opportunities. (This is yet another reason why children need recess!)
• For elementary school children, instead of scooping your child up at school pickup and heading home right away, stay and let your child play on the playground for a while if you can.
• Limit screen time (of all kinds). Children should be engaged in entertainment media for no more than two hours a day. If your child is spending a lot of time on his or her phone, consider taking it away as soon as they come home.
• If it’s hard to get out to exercise for whatever reason, get creative about exercising at home. Use exercise equipment like a stationary bike. Exercise videos are widely available on cable and the Internet; move the furniture back, make some space, and have your own Zumba class. Or just turn on some music and dance.
• Go for walks and do other exercise together. Not only will your child get moving, but you will too — which sets a good example and helps you get healthier.

This study also points out that it’s important to start early. As a pediatrician, I see sedentary habits start very early, with families that put their children in seats and playpens rather than putting them on the floor to learn to crawl and stand. As soon as a child can move, we need to give them lots of opportunities to do so — and we need to keep it up throughout childhood. Their future health depends on it.

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My Health - Post-hospital syndrome: Tips to keep yourself or a loved one healthy after hospitalization

If you or a loved one have ever been hospitalized, you know that the primary focus of the hospital team is on diagnosing and treating the condition that put you in the hospital in the first place. The medical team works to treat a patient’s condition until the patient has improved enough to continue treatment and recovery out of the hospital.

But recent findings have brought attention to an important issue that doesn’t strike until after you’ve left the hospital — post-hospital syndrome.

What is post-hospital syndrome?

Post-hospital syndrome can be defined as a period of vulnerability lasting up to seven weeks after a patient is discharged from the hospital. This period of vulnerability leaves people at increased risk for rehospitalization from a diverse range of conditions, which are often separate from the original cause of hospital admission. Some patients even face an increased risk of death during this period.

Post-hospital syndrome is caused, in part, by ongoing effects of the original illness. For example, someone who has been hospitalized for pneumonia may experience lingering fatigue, reduced strength, foggy thinking, or constipation after leaving the hospital.

But while providing needed treatment, hospitalization also wreaks havoc on a patient’s physical and emotional stability, and these disruptions also contribute to post-hospital syndrome. During hospitalization, for example, a patient is likely to encounter changes to their diet, routine, sleep patterns, and activity level, and experience stress and medication-induced side effects.

Minimizing the effects of post-hospital syndrome

Fortunately, there are things that patients and their loved ones can do, both during hospitalization and after discharge, to prevent or at least minimize the effects of post-hospital syndrome:

• All hands on deck. Think of hospitalization as an emergency. Whenever possible, enlist a family member, friend, or colleague as an advocate to help with care and support while you are hospitalized.
• Get names. After admission, request a list of doctors, nurses, therapists, and social workers caring for you. This will allow you and your advocate to communicate more effectively with those in charge of your care.
• Plan meeting times. Ask when your doctors, physical therapists, and social workers will be discussing your case and working with you so that your advocate can be included in discussions about care. If it is important that certain family members or friends are present for such meetings, communicate this to your team ahead of time.
• Keep a medication list. Have a current list of your medications available and bring it to the hospital when admitted. After admission, regularly review your current and hospital medication lists with your doctors. This will help to eliminate medication errors and prevent potentially harmful side effects.
• Bring your equipment. If you regularly use hearing aids, dentures, eyeglasses, or mobility aids, such as a cane or walker, take them with you to the hospital, or have them delivered once hospitalized. Make certain they are labeled and kept in a safe, accessible location during your hospital stay.
• Stick to your routine. Whenever possible, maintain a daily routine that closely mirrors your life outside the hospital. For example, if you always have a caffeinated beverage every morning, followed by a bowel movement, make sure you order caffeine for breakfast and make time to move your bowels. Informing the clinical staff of your daily routine is important.
• Keep moving. After being cleared by your medical team, spend as little time in your hospital bed as possible. Lying in bed all day leads to reduced blood flow, muscle loss and weakness. Walk around the unit with a nurse, friend, or aide, as much as you are able, multiple times during the day. Spend time out of bed, sitting upright in a chair while eating meals, watching TV, and reading.
• Rest at the right Avoid extended sleep during the day when possible. Try to stay awake until close to your normal bedtime, in order to promote and maintain your body’s natural circadian rhythm.
• Request quiet nights. Request that all medications be given before bed, and ask your nurse or doctor not to wake you for nighttime vitals checks or blood draws. If there is a disruption, do not hesitate to ask nurses to reduce noise, or request earplugs.
• Seek out natural light. Request a room with a bed next to the window when available. Exposure to natural light helps maintain a normal sleep/wake cycle.
• Maintain your normal diet. If you require special dietary accommodations, such as low salt, lactose free, gluten free, or vegetarian, inform your doctors and nurses, and reconfirm these requirements when you order meals.
• Plan ahead for hospitalization. If you have a chronic health condition (heart failure, cancer, dementia, Parkinson’s disease, or difficulty walking, for example), create an “in case of hospitalization plan” with your doctor. This will essentially be a personalized version of the issues discussed here. It is important to think ahead to optimize ways for your hospitalization to go smoothly and reduce the risk and severity of post-hospital syndrome.
• Health care proxy. Assign a trusted advocate (relative or friend) as your health care proxy. This person has the legal standing to communicate your health care preferences to your medical team, in the event that you are unable to do so yourself. Discuss your medical care preferences with your health care proxy in advance.
• Ensure continuity. Before leaving the hospital, confirm you have timely follow-up appointments scheduled with your primary care doctor and appropriate specialists.

It may not be possible to eliminate all of the causes of post-hospital syndrome. But attention to the risk factors during hospitalization may significantly reduce the likelihood of difficulties after hospitalization.

Follow me on Twitter  @jwhymanMD

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My Health - Immunotherapy: What you need to know

Not all that long ago, chemotherapy was the only option to treat most advanced (metastatic) cancers. Because these drugs work by destroying rapidly dividing cells, they harm some healthy cells — such as hair follicles — as well as cancer cells. In the past two decades, cancer treatment has been transformed by targeted drugs and the emergence of chemotherapy. Targeted drugs are designed to home in on specific genes or proteins that are altered or overexpressed on cancer cells. Immunotherapy has been very successful for certain types of advanced cancers, such as lung, bladder, and skin cancers.

One form of immunotherapy is called an immune checkpoint inhibitor. It takes the brakes off immune cells, unlocking their ability to detect altered proteins on cancer cells in order to attack and kill these cells. These drugs include programmed death (PD-1)-inhibitors and PD-L1-inhibitors (such as pembrolizumab, atezolizumab, nivolumab), and cytotoxic T-lymphocyte antigen (CTLA)-4 inhibitors (ipilimumab).

The speed of FDA approvals for these drugs has outstripped the general understanding of their effects, and side effects, raising many questions for people who have cancer — and even for many physicians. If you’re receiving immune checkpoint inhibitors, or wondering about them as part of cancer therapy, here are some facts you should know.

Does immunotherapy benefit all patients?

Immunotherapy benefits some, but not all, cancer patients. It seems to work better for certain cancers — for example, cancers with higher levels of PD-L1 protein or a massive number of gene mutations due to DNA repair defects. However, there are many exceptions, and we do not fully understand how best to select patients who will benefit.

How long does immunotherapy last?

Cancer cells adapt, building resistance to targeted therapies. When a tumor responds to immunotherapy, the remission tends to last a long time (a year or more), unlike a response to chemotherapy (weeks or months). Also, with immunotherapy, tumors initially may swell as immune cells engage with the cancer cells, then later shrink as cancer cells die. The early swelling is called psuedoprogression.

What about side effects?

All drugs have side effects, including the immunotherapy drugs discussed here. Understanding the information below can help if you or a loved one does experience side effects.

Does immunotherapy have serious side effects?

Immunotherapy with PD1/PD-L1 inhibitors is generally well tolerated, but serious side effects may occur. This happens in about 20% of people given PD1/PD-L1-inhibitors. It occurs in 40% to 60% of people given a combination of PD1-inhibitor and CTLA4-inhibitor immunotherapies.

Most side effects appear around two to three months after therapy starts. However, close monitoring, early recognition, and prompt therapy can help control side effects. Because immunotherapy drugs unleash immune cells, inflammation may occur in organs such as the colon (causing diarrhea), lungs (causing coughing or shortness of breath), skin (causing rash), liver (causing an elevation of liver enzymes in blood), thyroid gland (causing generally low, but sometimes high, thyroid hormone levels), and other areas of the body.

How are side effects of immunotherapy managed?

Severe side effects are controlled by stopping the immunotherapy and starting corticosteroids (such as prednisone), which are tapered slowly over a period of weeks. If you’ve had immunotherapy at any time in the past, report any new symptom to your treating oncologist before self-medicating with drugs purchased over the counter. For example, if you have diarrhea, taking loperamide (Imodium) may arrest the symptom. But it won’t address the root cause, which is inflammation of the large intestine. Uncontrolled inflammation of the intestine may lead to rupture of the intestinal wall, which can be life-threatening. Similarly, if you have a cough, consuming cough suppressants allows lung inflammation to continue and become potentially life-threatening.

Do antibiotics affect how well immunotherapy works?

As we are beginning to better understand the immune system, an important nugget of emerging information is that antibiotics may reduce the ability of immunotherapy to kill cancer by killing harmless bacteria that live in the gut. People taking immune checkpoint inhibitors who receive antibiotics are less likely to benefit from immunotherapy than those who do not. Hence, it appears important to avoid unnecessary antibiotics for minor infections, which may be prescribed for patients visiting the ER for fever, cough, or other symptoms suggestive of infections. Check with your cancer team about this.

What do healthcare professionals need to know when I’m sick?

If you go to urgent care or the emergency room, tell health professionals about your cancer treatment. What type of cancer was diagnosed? When and where were you treated? What type of immunotherapy and other therapies did you receive? Also, ask your primary care doctor to include important information like this in your medical records. Remind health care providers about it if you’re sick. You can use health apps to log the information, so you’ll always have it handy if you need it.

To learn more about immunotherapy or join a clinical trial, talk to your cancer care team. You can also search for clinical trials on the National Cancer Institute web site, or call 1-800-422-6237.

Follow me on Twitter @sonpavde

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My Health - Bad breath: What causes it and what to do about it

Almost everyone experiences bad breath once in a while. But for some people, bad breath is a daily problem, and they struggle to find a solution. Approximately 30% of the population complains of some sort of bad breath. Halitosis (Latin for “bad breath”) often occurs after a garlicky meal or in the morning after waking. Other causes of temporary halitosis include some beverages (including alcoholic drinks or coffee) and tobacco smoking.

Some people may not be aware of their own halitosis and learn about it from a relative, friend, or coworker, causing some degree of discomfort and distress. In severe cases, bad breath may negatively impact personal relationships and a person’s quality of life.

What causes bad breath? And what can you do about it?

Bad breath can originate both inside and outside of the mouth. Bad breath is typically caused by bacteria present on the teeth and debris on the tongue. So it’s no surprise that most cases of halitosis are associated with poor oral hygiene, gum diseases such as gingivitis and periodontitis, and dry mouth, a condition in which the salivary glands cannot make enough saliva to keep your mouth moist. A visit with a dentist may help rule out periodontal disease and identify any mouth problem that could be contributing to bad breath.

Tonsillitis, respiratory infections such as sinusitis or bronchitis, and some gastrointestinal diseases may be responsible for a small number of cases of bad breath. Advanced liver or kidney disease and uncontrolled diabetes can also lead to unpleasant breath. In these cases, a person is likely to experience significant symptoms beyond bad breath, and should seek medical attention.

Sometimes people think they have bad breath, even when their breath is objectively fine. This is called “pseudo-halitosis.” Halitophobia, or fear of bad breath, is real and may persist despite reassurance from a doctor. People with pseudo-halitosis respond well to reassurance, and may benefit from speaking with a therapist or psychiatrist who has expertise in the field.

A person complaining of bad breath can be initially evaluated by a primary care physician (PCP). The doctor will begin with a thorough medical and dental history and an oral exam. Tests may be done to confirm the presence of halitosis by measuring the strength of bad breath on a predefined scale, and by using instruments to detect specific compounds related to halitosis. The intensity of malodor is usually assessed by the doctor smelling the air that the person breathes out through the nose or mouth, or from judging the odor of a tongue scraping, a length of dental floss, or a dental appliance such as a night guard.

Your PCP may refer you to a dentist if there is evidence of dental or gum problems, which is the cause in the majority of people with bad breath. Visits with other medical specialists are warranted when an underlying medical problem requires attention.

Tips to improve bad breath

Here are some helpful tips to improve bad breath:

• Brush your teeth at least twice a day, after meals, with a fluoridated toothpaste.
• Avoid tobacco smoking and chewing tobacco-based products.
• Rinse and gargle with an alcohol-free mouthwash before bed.
• If you have dry mouth, make sure to drink enough fluids throughout the day and use over-the-counter moisturizing agents, such as a dry mouth spray, rinses, or dry mouth moisturizing gel. If you don’t see any improvement, you may want to schedule a visit with an oral medicine specialist. Oral medicine doctors provide comprehensive care for mucosal diseases, salivary gland disorders, orofacial pain conditions, and oral complications of cancer therapies, among other things.
• Visit your dentist regularly. Remember, oral causes are responsible for most cases of bad breath!

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My Health - Bleeding after menopause: Get it checked out

Bleeding after menopause can be disconcerting, but the good news is, more than 90% of the time it’s not caused by a serious condition, according to a study in JAMA Internal Medicine. That said, the study also reinforces the idea that postmenopausal bleeding should always be checked out by your doctor to rule out endometrial cancer, a cancer of the uterine lining, says Dr. Ross Berkowitz, William H. Baker Professor of Gynecology at Harvard Medical School. This is because the study also found more than 90% of women who did have endometrial cancer had experienced postmenopausal bleeding. And screening all women who experience bleeding after menopause for endometrial cancer could potentially find as many as 90% of these cancers, which are highly curable if found early.

The reassuring news on postmenopausal bleeding

The analysis found that most post-menopausal bleeding is caused by a noncancerous condition, such as vaginal atrophy, uterine fibroids, or polyps. That information doesn’t really differ from what doctors have historically thought about the incidence of endometrial cancer and bleeding, says Dr. Berkowitz. But it does finally put solid data behind those figures, which was missing in the past, he says. The researchers who conducted this study were looking for clues about postmenopausal bleeding and how it relates to endometrial cancer.

But here is why you really need to see your doctor

Endometrial cancer, which affects 2% to 3% of American women, is the most common type of gynecological cancer. According to the American Cancer Society, it most often affects postmenopausal women — 60 is the average age at diagnosis. There is currently no way to screen for endometrial cancer. Identifying it early has become a pressing issue, because the incidence of this cancer has risen gradually but steadily over the past 10 years, according to the National Cancer Institute.

“Endometrial cancer is a fairly common disease, and it’s unfortunately becoming more common due to the growing rates of obesity,” says Dr. Berkowitz. A woman’s risk of endometrial cancer can increase substantially if she is obese. Generally, risk rises among women who are 50 pounds or more above their ideal body weight, he says.

This is because of the role estrogen plays in endometrial cancer. The most common type of endometrial cancer, known as type 1 cancer, is fueled by estrogen. Estrogen is produced by body fat, so women with a larger amount of fatty tissue generally have higher levels of estrogen. They also typically have more free estrogen, an active form that produces stronger effects. This may lead to cancerous changes in the uterine lining.

How your doctor will investigate postmenopausal bleeding

If you do experience unusual or postmenopausal bleeding, make an appointment with your doctor to have the problem investigated, says Dr. Berkowitz. Your doctor will likely recommend an ultrasound, a biopsy, or both. Ultrasound can measure the thickness of the lining inside the uterus. In some women with endometrial cancer, this lining becomes thicker than usual, which alerts doctors to the possibility that it is cancerous. Not all thickened linings mean cancer, though. The ultrasound should be followed by a biopsy, even if the ultrasound doesn’t show any thickening of the uterine lining, says Dr. Berkowitz. A biopsy can often be done as an in-office procedure, in which the doctor uses a thin tube with a collection device on the end to gather some uterine cells. The sample is then examined under a microscope to check for cancer or precancerous changes.

Dr. Berkowitz stressed the importance of doing both tests, because not all endometrial cancers thicken the uterine lining. Some cases are caused by type 2 endometrial cancer, which may not produce the thickening typically seen in the more common type 1. If only ultrasound is used for screening, up to 20% of endometrial cancer cases may be missed. Many of these are type 2, which tend to be the more aggressive, invasive, and deadly. Keep in mind, a Pap test cannot detect endometrial cancer. “Assuming the patient does not have any health issues, such as serious heart disease, and is otherwise healthy, doing a biopsy would be the safest, most assured way to rule out endometrial cancer,” says Dr. Berkowitz.

Then what?

If your tests suggest that you don’t have endometrial cancer, but the bleeding comes back or continues, it’s reasonable to have it re-evaluated, says Dr. Berkowitz. If you do have bleeding again after your first evaluation and normal biopsy, most likely it’s not because cancer was missed. However, it’s worth getting checked again. “I don’t recommend waiting much more than six months,” he says. Investigate unusual bleeding early, because endometrial cancer is highly curable. “The vast majority of patients with endometrial cancer can be cured with surgery alone,” says Dr. Berkowitz.

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My Health - Does weather affect arthritis pain?

Medical myths die hard. Maybe that’s because there’s no agreement on whether a common belief is indeed a myth.

For example, there’s the longstanding belief that weather affects arthritis pain. Many of my patients notice a clear connection; some are so convinced of the link, they believe they can predict the weather better than the TV meteorologists. And maybe that’s true.

But that’s not what the science says. A recent study finds no connection between rainy weather and symptoms of back or joint pain. This conclusion was based on a staggering amount of data: more than 11 million medical visits occurring on more than two million rainy days and nine million dry days. Not only was there no clear pattern linking rainy days and more aches and pains, but there were slightly more visits on dry days.

Still not convinced? That’s understandable. Maybe it’s not rain or shine that matters — maybe it’s barometric pressure, changes in weather, or humidity that matters most. Or maybe the study missed some key information, such as when symptoms began or got worse — after all, it can take days or even weeks after symptoms begin to see a doctor.

What does past research say about weather and arthritis pain?

The question of whether there’s a link between weather and aches and pains has been studied extensively. While a definitive answer is nearly impossible to provide — because it’s hard to “prove a negative” (prove that something doesn’t exist) — researchers have been unable to make a strong case for a strong connection.

For example, a 2014 study in Australia found no link between back pain and rain, temperature, humidity, or air pressure. This study collected data regarding features of the weather at the time of first symptoms, and compared it to the weather a week and a month before. But, an earlier study found that among 200 patients followed for three months, knee pain increased modestly when temperature fell or barometric pressure rose.

Does research matter when you have personal experience?

That’s a fair question. And it’s something I’ve even heard in TV commercials about headache medicines: “I don’t care about the research. I just know what works for me.” But it’s worth remembering that humans have a remarkable tendency to remember when two things occur or change together (such as wet, gloomy weather and joint pain), but remember less when things do not occur together. That rainy day when you felt no better or worse is unlikely to be so notable that you remember it. If you rely solely on memory rather than on more rigorous, data-based evidence, it’s easy to conclude a link exists where, in fact, none does.

In conclusion…

It’s true: medical myths die hard. In fact, some seem immortal. One could argue that’s as it should be. After all, yesterday’s medical myth is only one discovery away from becoming tomorrow’s medical fact.

Still, when the evidence is compelling, I think we’d be better off letting go of what’s been disproven, give more credence to evidence than folklore, and keep an open mind — just in case the evidence changes.

When my patients tell me they can predict the weather by how their joints feel, I believe them. It’s hard to discount it when so many people notice a connection. They could represent an exception to what the studies show. But I also believe the science. Until I see evidence that’s even more compelling, I remain a skeptic about the weather/arthritis connection.

Follow me on Twitter @RobShmerling

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My Health - Going Mediterranean to prevent heart disease

There is a mountain of high-quality research supporting a Mediterranean-style diet as the best diet for our cardiovascular health. But what does this diet actually look like, why does it work, and how can we adopt it into our real lives?

What is a Mediterranean diet?

The Mediterranean diet is not a fad. It is a centuries-old approach to meals, traditional to the countries bordering on the Mediterranean Sea. The bulk of the diet consists of colorful fruits and vegetables, plus whole grains, legumes, nuts and seeds, fish and seafood, with olive oil and perhaps a glass of red wine. There is no butter, no refined grains (like white bread, pasta, and rice), and very little red or processed meat (like bacon). There is also an emphasis on sitting down and enjoying a meal among family and friends, as well as avoiding snacking, and getting plenty of activity. It’s not just about the food: it’s a way of being.

What’s a Mediterranean-style diet?

The food part is similar to most other healthful diet approaches in that it’s plant-based. And the recipes do not have to be Italian or Greek, which is why I refer to it as a Mediterranean-style diet. Every meal should have vegetables and fruits as the base. Any grains should be whole grain, like quinoa, brown rice, corn, farro, or whole wheat. Legumes are an excellent source of plant protein, things like lentils, garbanzo, kidney, cannellini, or black beans. Nuts and seeds have protein and healthy fats, and olive oil provides even more healthy fat. Including fish and seafood is traditional, but not required. I advise people not to stress about dairy, poultry, and eggs; these are okay in small amounts. A glass of wine a day may be beneficial, but not for everyone, and there is no reason for non-drinkers to take it up.

Why does this way of eating produce such impressive health benefits?

In a recent study published in JAMA Network Open, researchers looked at data from over 25,000 women over 45 (with an average age of 55) and with no history of heart disease.

Using the baseline dietary questionnaire, a Mediterranean diet “score” was calculated. Basically, there was one point given for each of these nine main components: higher than average intake of fruits, vegetables, whole grains, legumes, nuts, fish, and healthy fats; healthy level of alcohol intake; and lower than average intake of red and processed meats. Participants were divided into groups based on low, medium, and high Mediterranean diet consumption (scores of 0–3, 4–5, and 6–9).

After 12 years average follow-up time, 1,030 participants had some kind of serious cardiovascular issue (including heart attack, angina with stent placement, peripheral vascular disease requiring intervention, or stroke). The women in the medium and high Mediterranean diet groups had significantly lower risk (23% and 28% lower, respectively).

Higher Mediterranean diet scores were also associated with lower body mass index and blood pressure, as well as more optimal lab data like lower inflammatory markers (high-sensitivity CRP), lower diabetes risk (insulin resistance), and a better lipid profile (higher HDL). These findings suggest the pathways through which the diet benefits the body: by decreasing inflammation and promoting healthy blood cholesterol and sugar levels.

How to “go Mediterranean”

Adopting the Mediterranean diet in our busy, high-tech world may seem daunting. But there are tips and tricks to change your eating habits and reduce your risk of heart disease.

My book, Healthy Habits for Your Heart, teaches you the basics of behavior change, as well as step-by-step methods to make these changes happen in your real life. Chapter 5, “Eat For Your Life: Nutrition Habits” takes you through the science-backed recommendations for adopting a heart-healthy, plant-based Mediterranean-style diet. One suggestion is:

Aim for eight servings of fruits and vegetables per day (4 to 5 cups)

Eight servings of fruits and vegetables could look like:

Breakfast: 1 cup of berries

Lunch: 2 cups of lettuce + 1/2 cup tomatoes + 1/2 cup cucumbers + an orange for dessert

If you wanted to get to 10 servings, then add:

Dinner: 1 cup broccoli + 1/2 cup diced peppers + 1/2 cup snow peas (in a stir fry)

Tips to make the habit stick

• Start with at least one serving of fruits and/or vegetables with every meal and snack, and increase over time to two or three. You’ll be up to 10 in a matter of weeks!
• It’s fine to use frozen fruits and vegetables. High-quality berries, tropical fruits, and mixed vegetables are cheaper than fresh, and can be bought in bulk from the grocery store and stored in the freezer for long periods.
• Make breakfast with two (or more) servings of fruits and/or veggies. This gets the good stuff in early in the day. Try my Filling Fruit and Nut Bowl with Greek Yogurt.
• Free meal tracker apps like MyFitnessPal or Dr. Michael Greger’s Daily Dozen app can help you get your 10 servings of fruits and veggies daily.

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My Health - Infertility and regret: If only…

I can often hear it coming. One need spend only a few minutes with someone coping with infertility before encountering a cascade of regret. “If only we hadn’t waited so long.” “If only I had frozen my eggs.” “If only we had changed doctors sooner.” “If only I hadn’t believed my OB/GYN when she told me not to worry.” “If only I’d realized earlier that I could do it on my own.” “If only I’d met my husband when I was younger.”

And so it goes.

Sure, other thoughts and feelings may torment infertile women and men. Sadness, anger, helplessness, and envy are all part of the deal. However, unlike regret, which seems to keep people in a stranglehold, I’ve found that most of those struggling with infertility can grapple with and move on from these other emotions. In fact, for many, the experience of enduring the sadness or accepting the anger can bring added strength and new resolve. Not so with regret.

When people talk with me about their sadness, or their anger, or their envy, I listen and respond with compassion. I know they are suffering, but I have faith that they will get through it.

When they talk with me about their regret, I simply want to make the pain go away. Often I imagine assembling a group of infertility patients at water’s edge and giving each a small wooden boat.

“Please take these,” I would say. “Pile your regrets on them and make them sail away.”

Why do I react this way? Why, when it comes to regret and infertility, do I feel the urge to do rather than listen? I believe the reason is that I haven’t found that talking about regret helps people move away from it. Once someone gets into the groove of self-blame, a circular motion takes hold.

The entangling circle of regret

A patient of mine, a woman of 44, wanted to have a baby on her own. She regretted not having frozen her eggs when she was 32 or 33.

I told her that egg freezing wasn’t really effective and widely available until a few years ago. So really, you couldn’t have frozen your eggs when you were younger, I said, adding that I hoped this would make her feel better and free her from regret.

Not really, she answered. She’d spent her 30s in dead-end relationships. By her late 30s, she’d begun to think about single motherhood. She should have moved on it then, she said regretfully.

I regrouped. She hadn’t come to the decision to become a single mother easily — she’d given it a lot of thought, I said. She couldn’t have rushed such a big decision. She needed the time.

Well, yes, she allowed. Then regret surfaced again. But I could have researched doctors sooner, she said. I could have found sperm donors and gotten myself ready to go at least a year or two earlier.

And on it goes — a glimpse of the ways that people become entangled in a circle of regret.

Casting away regret

Why do I wish people could cast their regrets away? Among the many reasons is that regret can have a negative impact on their decisions moving forward. Thankfully, there are some who come to accept that we all make the best decisions we can at any given time. Inevitably some of these decisions will not go as we hoped, but that does not mean we did something wrong when we decided.

However, when regret continues to overshadow infertility treatment, decisions are so often made with an eye on anticipatory regret. Sometimes, this prompts people to continue seeking IVF treatment when it is unlikely to work. Or to spend more money than they can afford on treatment. Or to see yet another doctor in another city when the first, second, and third opinions were all from skilled and caring physicians.

What, then, can be done about regret? Sadness and anger, helplessness and envy are already a lot to deal with, to say nothing of all the other insults and injuries of infertility. Where I land regarding regret is with the belief that there is something to my fantasy of the little wooden boats piled high with regrets. There are times during infertility — a “failed cycle,” a miscarriage, an embryo that is being donated or discarded — when a ritual or ceremony can help. People may not choose to join me at water’s edge, but I hope they can create their own meaningful and effective ways of casting their regrets away.

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My Health - Is there a place for coconut oil in a healthy diet?

Coconut oil has seen a surge in popularity in recent years due to many touted health benefits, ranging from reducing belly fat to strengthening the immune system, preventing heart disease, and staving off dementia. These claims are often backed by celebrity endorsements and bolstered by proponents of popular diets such as ketogenic and Paleo, with little support from scientific evidence. On the flip side, and further adding to the confusion, you also may have seen headlines calling out coconut oil as “pure poison,” implying that it shouldn’t be consumed at all. Given these contradictory claims, a question of much public and scientific interest is whether there is room for coconut oil in a healthy diet.

Bad fats, good fats

Coconut oil largely consists of saturated fat (80% to 90% of fat in coconut oil is saturated), making it solid at room temperature. Other sources of saturated fat include animal products such as meat and dairy, and other plant-based tropical oils such as palm oil. Consumption of saturated fat has long been associated with increased risk of cardiovascular disease due to its ability to raise harmful LDL cholesterol levels.

Unlike saturated fats, unsaturated fats are liquid at room temperature. They can improve blood cholesterol levels and reduce inflammation, among other cardiovascular benefits. Unsaturated fats are predominantly found in vegetable oils, nuts, seeds, and fish.

Guidelines advise limiting the type of fat found in coconut oil

The current Dietary Guidelines for Americans recommend consuming no more than 10% of total calories from saturated fat. And last year the American Heart Association (AHA) released a scientific advisory statement recommending the replacement of saturated fats in the diet, including coconut oil, with unsaturated fats. In their statement, the AHA cited and discussed a review of seven randomized controlled trials, in which coconut oil was found to raise LDL cholesterol levels.

The rationale behind the AHA recommendation is that consuming unsaturated fats in place of saturated fat will lower “bad” LDL cholesterol, and improve the ratio of total cholesterol to “good” HDL cholesterol, lowering the risk of heart disease. For those at risk of or who already have heart disease, the AHA advises no more than 6% of total calories from saturated fat, or about 13 grams based on a 2,000-calorie diet. One tablespoon of coconut oil comes close to that limit, with about 12 grams of saturated fat.

Health benefits of coconut oil may be exaggerated

With such salient evidence supporting the replacement of saturated fat, including coconut oil, with unsaturated fat for optimal cardiovascular health, where do the myriad health claims for coconut oil come from?

Many of the health claims for coconut oil are based on studies that used a special formulation of coconut oil made of 100% medium-chain triglycerides (MCTs). This is not the coconut oil available on supermarket shelves. MCTs have a shorter chemical structure than other fats, and are quickly absorbed and metabolized by the body, which is thought to promote a feeling of fullness and prevent fat storage.

However, the coconut oil found on most supermarket shelves contains mostly lauric acid, which is absorbed and metabolized more slowly than MCT. As a result, the health benefits reported from specially constructed MCT coconut oil cannot be applied to regular coconut oil.

Interestingly, lauric acid itself has also been purported to have health benefits. While lauric acid has been shown to increase LDL cholesterol levels, it also raises HDL cholesterol levels, suggesting a potential heart-protective role of coconut oil. However, large epidemiological studies have failed to report protective associations between lauric acid and cardiovascular disease.

Findings from epidemiological studies that report low rates of cardiovascular disease among populations who consume coconut oil as part of their traditional diets (in India, the Philippines, and Polynesia, for example) have also been cited as support for the health benefits of coconut oil. However, in these studies many other characteristics of the participants, including background, dietary habits, and lifestyle, could explain the findings.

Coconut oil: neither superfood nor poison

Based on the current evidence, coconut oil is neither a superfood nor a poison. Rather, its role in the diet falls somewhere in between. Coconut oil has a unique flavor and is best consumed in small amounts, as a periodic alternative to other vegetable oils like olive or canola that are rich in unsaturated fat. This dietary choice should be made in the context of an overall healthy dietary pattern, and within the recommended limits for saturated fat intake.

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My Health - Younger kindergarteners more likely to be diagnosed with ADHD

In a class of kindergarteners, a child born in August is about 30% more likely to be diagnosed with attention deficit hyperactivity disorder (ADHD), and 25% more likely to be treated for it, than a child born in September — if you have to be 5 years old by September 1st to start kindergarten.

These were the findings of a study published in the New England Journal of Medicine. They didn’t find such a difference between any two other months — and in schools that didn’t have a September 1 cutoff for entry, the difference between August and September disappeared.

It’s not a Leo versus Virgo thing: it’s age. In schools with a September 1 cutoff, children born in August are a full year younger than children born in September. For children who are only 5, a year is a lot, especially when it comes to maturity, and the ability to stay focused and engaged on academic subjects. While some children might be naturally more mature than others, a child who is turning 6 is likely going to be able to sit still and focus more than a child who just turned 5.

But that doesn’t mean that the 5-year-old has ADHD; it means that the 5-year-old is acting normally for his or her age. And that’s what is worrisome about the study: it suggests that at least in some cases, teachers and doctors are mistaking normal behavior for a problem. Even worse, some children are getting medications that they really don’t need — or they wouldn’t need, if they were just a little bit older or the classroom demands were a little bit different.

Some families may see this study as proof that they should “red-shirt” their child. (The term is borrowed from school sports when a high school or college student is kept out of varsity sports for a year to gain skills while still keeping their eligibility to play; apparently they wear red shirts to set them apart from other new players.) When parents red-shirt their child, they wait an extra year before starting kindergarten. Parents are more likely to do this when their child has a spring or summer birthday, especially if their child is a boy. It’s thought that the extra year gives them more time to mature and be ready for school.

There are certainly some children who benefit from a bit more time before starting kindergarten, which has become increasingly focused more on academics than on socialization and play. But I would argue that parents shouldn’t have to do it — and many families simply can’t afford to pay for another year of preschool or childcare.

As a pediatrician, I see two big take-homes from this study. First, teachers and doctors need to do a better job of factoring in a child’s age and maturity level when assessing their behavior; just because they are different from their classroom peers doesn’t always mean that they have a psychiatric diagnosis, let alone need medication. Some do, of course, but many just need time.

Second, we need to do a better job of accommodating the relative differences in ages and maturity levels that exist in a perfectly normal kindergarten classroom. We need to be able to meet children where they are, and help each child get where they need to be — with patience and support, not labels or medications. That definitely means more support for teachers, but it also may mean that we need to rethink kindergarten curricula. Maybe we had it more right when we focused more on socialization and play. If a child needs to be 6 to do what we are asking a 5-year-old to do, maybe the problem isn’t with the child. Maybe it’s with us.

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My Health - Can watching sports be bad for your health?

As the new year begins, sports fans rejoice! You’ve had the excitement of the college football bowl games and the national championship, the NFL playoff games are winnowing teams down to the Super Bowl contestants, and basketball and hockey seasons are in full swing. There’s even some early talk of spring training for the upcoming Major League Baseball season.

While I hate to rain on anyone’s parade, the truth is that there can be health risks associated with watching sports. I’ve seen it firsthand while working in a walk-in clinic near Fenway Park, where people would show up bleeding from cuts that needed stitches (from trips and falls at the stadium), broken bones (from trying to catch a foul ball or after an altercation with another fan), dehydration, or other minor problems.

The problems can be more serious. In fact, studies have shown that watching sports — whether live at the stadium or on television — can have dire health consequences.

The big game may come with a big cost

Doctors and nurses often describe how quiet things get in the emergency room during a World Series game or the Super Bowl. But once the game ends, things get busy. It seems that many people with chest pain, trouble breathing, or other symptoms of a potentially serious problem delay seeking care until after the game.

Of course, there’s another possibility: the game itself — especially if a game is close and particularly exciting — might cause enough stress on the body that heart attacks, strokes, or other dangerous conditions develop.

A number of studies support the idea that watching sports can lead to health problems. For example, a 2017 study found that spectators of Montreal Canadiens hockey games experienced a doubling of their heart rate during games. The effect was more pronounced for live games than televised games, but even the latter experience led to faster heart rates similar to that during moderate exercise.

A similar observation had been made in the 1990s by researchers studying spectators of live Scottish football matches: blood pressure and heart rate rose dramatically compared to baseline measures while at home. The maximal heart rates were recorded just after a goal had been scored by the favored team.

Perhaps these observations explain why other studies have linked hospital admission for heart failure and even cardiac arrest with watching sporting events. The former study (in New Zealand) only found higher rates of heart failure admissions among women, and the latter study (in Japan) only found higher rates of cardiac arrest among older men. The gender differences remain unexplained.

Keeping it in perspective

It’s worth emphasizing that most people who choose to watch sports enjoy it and do not experience any health problems during or afterwards. My sense is that people with no health problems are at little risk even if they get worked up while watching sports, but there may be some small risk (similar to what might accompany moderate or vigorous exercise) for people who have cardiovascular disease.

What’s a sports fan to do?

The obvious recommendation is to remember, it’s only a game. But, ask anyone who cares about sports, sporting events, or a particular team — it’s much more than that.

It’s also easy to suggest being careful about how much you drink, to avoid overeating (especially salty junk food), and to be aware of your surroundings. For example, if you’re at a baseball game, pay attention to the game so you’ll at least have a chance of getting out of the way of a line-drive foul ball. Notice where the railings are and avoid leaning over dangerous ledges. And, of course, avoid altercations with hostile fans. Stay well-hydrated if you’re out in the heat for hours — remember that although beer is a liquid, it can actually make you more dehydrated.

For people who have cardiovascular disease, don’t forget to take your medications, even when there’s a big game on. Ask your doctor about how much exercise your heart can take, and whether you have any conditions that restrict your ability to exercise. If you do, improving your cardiac fitness might help improve your ability to exercise — and it might also make it safer to enjoy watching the sports you love.

Follow me on Twitter @RobShmerling

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My Health - Fatty liver disease: What it is and what to do about it

Non-alcoholic fatty liver disease (NAFLD), a condition of extra fat buildup in the liver, is on the rise — it now affects roughly 20% to 40% of the US population. It usually doesn’t cause any symptoms, and is often first detected by accident when an imaging study (such as an abdominal ultrasound, CT scan, or MRI) is requested for another reason. A fatty liver may also be identified on an imaging test as a part of investigating abnormal liver blood tests. NAFLD is intimately related to conditions like diabetes and obesity. It’s also linked to an increased risk of cardiovascular disease. Understanding NAFLD and its causes, consequences, and treatment options is still a work in progress.

The many faces of fatty liver disease

There are lots of medical terms related to fatty liver disease, and it can get confusing. The main medical umbrella term NAFLD refers to a fatty liver that is not related to alcohol use. NAFLD is further divided into two groups:

• Non-alcoholic fatty liver (NAFL), otherwise known as simple fatty liver, or
• Non-alcoholic steatohepatitis (NASH)

Why the type of fatty liver disease matters

Distinguishing between simple fatty liver and NASH is important. Why? Because for most people, having simple fatty liver doesn’t cause sickness related to the liver, whereas those with NASH have inflammation and injury to their liver cells. This increases the risk of progression to more serious conditions like fibrosis (scarring) of the liver, cirrhosis, and liver cancer. NASH cirrhosis is expected to be the number one reason for liver transplant within the next year. Luckily, most people with NAFLD have simple fatty liver and not NASH; it is estimated that 3% to 7% of the US population has NASH.

It takes a liver biopsy to know if a person has simple fatty liver or NASH. But the possible (though infrequent) complications and cost of a liver biopsy make this impractical to do for everyone with NAFLD.

Scientists are trying to find noninvasive ways to identify who is at the greatest risk for fibrosis, and thus who should go on to have a liver biopsy. Possible approaches include biomarkers and scoring systems based on blood tests (such as the NAFLD fibrosis score and Fibrosis-4 index), as well as elastography (a technology which uses soundwaves to estimate fibrosis based on the stiffness of the liver).

Keeping your liver healthy

If you have been diagnosed with fatty liver disease, it is important to keep your liver as healthy as possible and avoid anything that can damage your liver. Here are some important things you should do.

• Don’t drink too much alcohol. How much is too much remains controversial, but it’s probably best to avoid alcohol completely.
• Make sure that none of your medications, herbs, and supplements are toxic to the liver; you can crosscheck your list with this LiverTox Even acetaminophen (the generic ingredient in Tylenol and some cold medicines) may be harmful if you take too much for too long, especially if you have liver disease or drink alcohol heavily.
• Get vaccinated to protect against liver viruses hepatitis A and B.
• Control other health conditions that might also affect your liver, and check with your doctor if you might have other underlying, treatable diseases contributing to your fatty liver.
• Get regular screening tests for liver cancer if you already have cirrhosis.

What about drug therapy?

Unfortunately, there are no FDA-approved medications for fatty liver disease. So far, the two best drug options affirmed by the American Association for the Study of Liver Diseases for biopsy-proven NASH are vitamin E (an antioxidant) and pioglitazone (used to treat diabetes). However, not everyone will benefit from these treatments, and there has been some concern about safety and side effects. If you have NASH, it’s best to speak to your doctor about whether these treatments are appropriate for you, as they are not for everyone. There are more drugs in the pipeline, some with promising initial study results.

The most effective treatment: lifestyle changes

The good news is that the most effective treatment so far for fatty liver disease does not involve medications, but rather lifestyle changes. The bad news is that these are typically hard to achieve and maintain for many people. Here’s what we know helps:

• Lose weight. Weight loss of roughly 5% of your body weight might be enough to improve abnormal liver tests and decrease the fat in the liver. Losing between 7% and 10% of body weight seems to decrease the amount of inflammation and injury to liver cells, and it may even reverse some of the damage of fibrosis. Target a gradual weight loss of 1 to 2 pounds per week, as very rapid weight loss may worsen inflammation and fibrosis. You may want to explore the option of weight loss surgery with your doctor, if you aren’t making any headway with weight loss and your health is suffering.
• It appears that aerobic exercise also leads to decreased fat in the liver, and with vigorous intensity, possibly also decreased inflammation independent of weight loss.
• Eat well. Some studies suggest that the Mediterranean diet may also decrease the fat in the liver. This nutrition plan emphasizes fruits, vegetables, whole grains, legumes, nuts, replacing butter with olive or canola oil, limiting red meat, and eating more fish and lean poultry.
• Drink coffee, maybe? Some studies showed that patients with NAFLD who drank coffee (about two cups every day) had a decreased risk in fibrosis. However, take into consideration the downsides of regular caffeine intake.

Even though it can be difficult to make these lifestyle changes and lose the weight, the benefit is immense if you have fatty liver, so give it your best effort! And remember, the greatest risk for people with a fatty liver is still cardiovascular disease. Not only can some of these lifestyle changes improve or resolve your fatty liver, they will also help keep your heart healthy.

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My Health - Surgery for appendicitis? Antibiotics alone may be enough

I remember when my best friend in fifth grade couldn’t make our much-anticipated end-of-the-school-year camping trip because he had just undergone surgery for appendicitis. Now I prevent kids from participating in their school activities for four to six weeks after I remove their appendix. But what is the appendix, why do we have an organ that causes so many problems, and do you need surgery for appendicitis?

Role of the appendix is unclear

The appendix is a fingerlike tube, about three to four inches long, that comes off of the first portion of the colon. It is normally located in the lower right abdomen, just after the small intestine (needed for digestion and absorption) turns into the colon (whose purpose is to reclaim water and remove waste products).

The true function of the appendix remains unknown today, but one debated theory is that the appendix acts as a storehouse for good bacteria, to reboot the digestive system after a diarrheal illness. Other experts believe the appendix is just a useless remnant from our evolutionary past. Surgical removal of the appendix appears to cause no observable health problems.

Today, appendicitis is usually treated with surgery

In the medical community, the suffix “-itis” refers to inflammation (think arthritis, which is inflammation of a joint). Many times, “-itis” is due to an infection — pharyngitis, or strep throat, for example. After much research and debate, the cause of “-itis” of the appendix is still unclear. However, it appears that most causes of appendicitis are infectious agents, such as bacteria, viruses, parasites, or fungi.

Whatever the cause, whenever there is an obstruction of the entrance to the appendix — either from swelling or inflammation, or from mechanical blockage, like a hard piece of stool or a tumor — appendicitis may ensue. The real danger from appendicitis comes from the potential of the appendix to perforate, or burst, which can spread infection throughout the abdomen.

Even before 1886, when Dr. Reginald Fitz, a Harvard pathologist, first described appendicitis as a surgical disease, physicians had dealt with the pain and complications stemming from this tiny, menacing organ. Today, the standard of care for the treatment of appendicitis remains surgical removal of the appendix (appendectomy), along with intravenous fluids and antibiotics. In fact, appendectomy is one of the most common abdominal operations in the world. It is also the most common emergency general surgical operation performed in the United States. Most appendectomies are performed by the laparoscopic technique, also known as “keyhole” or minimally invasive surgery. Patients usually remain at the hospital for less than 24 hours post-operatively.

Emerging evidence suggests antibiotics alone may be enough to treat appendicitis

Many studies have demonstrated that surgery may not be necessary for all cases of appendicitis. A paper published in June 2015 received international visibility and challenged the status quo when antibiotic therapy was compared with surgery for the treatment of appendicitis. The conclusion of the APPAC trial (APPendicitis ACuta), which ran in Finland from November 2009 to June 2012, was that most patients who were treated with antibiotics for uncomplicated acute appendicitis did not require surgery during the one-year follow-up period. (Uncomplicated appendicitis refers to those cases in which there is no evidence of perforation or abscess formation, and in which the inflammation is mostly confined to the appendix.) Those who eventually did require appendectomy after failure of the antibiotic regimen did not experience significant complications.

In 2018, the APPAC authors published a follow-up in which they concluded that six out every 10 patients who were initially treated with antibiotics for uncomplicated acute appendicitis remained disease-free at five years. They again concluded that antibiotic treatment alone appears feasible as an alternative to surgery for uncomplicated acute appendicitis. Many additional studies also support a nonoperative approach to appendicitis. (And having spent almost 15 years in the navy, I know that for sailors suffering from appendicitis at sea, the use of powerful antibiotics has been the standard of care for decades when access to a surgeon is not readily available.)

As is always the case in scientific research, these studies have many limitations, including basic study design, multiple confounding variables, misinterpretation of results, and intrinsic flaws known to anyone using statistics. You can also find many articles and rebuttals describing the problems with using medication for a “surgical disease.” So as of now, while we eagerly await more data on the integrity of antibiotics for the safe use and definitive treatment of uncomplicated appendicitis, surgery remains the gold standard.

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