My Health - Why the wheelchair? Could it be gout?

When Paul Manafort appeared in court for sentencing recently, he was in a wheelchair and pleaded for leniency, in part because “his confinement had taken a toll on his physical and mental health.” He reportedly had symptoms of depression and anxiety — but what was the health problem that put him in a wheelchair? According to multiple news reports, the answer is gout. Yes, that ancient disease you may have thought didn’t exist anymore has stricken Mr. Manafort. He joins the rising number of people in the country diagnosed with this common disease.

What is gout?

Gout is a cause of severe joint pain and inflammation. This form of arthritis develops when crystals of uric acid (a normal byproduct of our body’s metabolism) deposit near joints and other parts of the body. Gout develops because the body makes too much uric acid, the kidneys don’t get rid of enough of it, or a combination of both.

For some, dietary factors — consuming foods and beverages that produce a lot of uric acid — seem to play an important role. For others, the problem may be one or more medications that cause the level of uric acid to rise. Genetic factors are also important; the way the body handles uric acid may vary based on the genes you inherit. The observation that gout sometimes runs in families supports a genetic contribution.

Some facts about gout

Gout is on the rise. According to the most recent estimates, nearly 4% of the adult population in US now has gout, while less than 3% had it 25 years ago. The increase is thought to be due to rising rates of obesity, use of certain medications, and the rising popularity of high-fructose corn syrup (as found in carbonated beverages and many other foods and drinks).

Men are more likely to get gout and can develop gout at any age, but women rarely get it before menopause.

Gout used to be called “The disease of kings.” This was supposedly because in ancient times, only those who were wealthy enough to consume a lot of alcohol, red meat, and organ meats (such as liver) tended to get gout. While Henry VIII reportedly had gout, it can no longer be considered the disease of kings. People of any socioeconomic status can have gout.

Diet may matter less than we thought. A new study analyzed dietary surveys, genetic analyses, and uric acid levels among more than 16,000 people in the US. They found that dietary choices accounted for less than 0.5% of the variation in uric acid, while genetic factors accounted for about 24%. Since gout is caused by high uric acid, this study suggests that genetics matter much more than diet when it comes to the risk of gout.

The good news

Among all forms of arthritis, gout is among the most preventable and treatable. Some of the best ways to avoid gout include maintaining a healthy weight, moderating alcohol consumption, and maintaining a healthy blood pressure.

And there are highly effective treatments. These include several medications (including corticosteroids, anti-inflammatory medications, and colchicine) to treat a sudden gout attack, and others (including allopurinol and febuxostat) that can prevent future attacks by lowering uric acid. In fact, treatments for gout are so good, it’s quite unusual that a person would be confined to a wheelchair despite proper treatment.

There may be more to gout than arthritis

While the sudden and severe arthritis of gout gets most of the attention, high blood uric acid may cause other problems. A kidney stone is another common (and terribly painful) complication. In addition, there is mounting evidence that high uric acid may contribute to high blood pressure, kidney disease, and cardiovascular disease, and that medications to lower uric acid may reduce the risk of these problems (although more research is needed to prove this).

The bottom line

Although gout can be temporarily debilitating, excellent treatments are available. So, while most of the news hasn’t been good for Paul Manafort lately, his gout should be just a temporary setback.

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My Health - Safer Surgery: Steps you can take

Chances are high that most of us will have a surgical procedure at some point during our lives. Estimates based on 2002 data in three states suggest Americans have a lifetime average of nine surgical procedures. In 2010 in the United States, there were an estimated 1.4 million inpatient procedures, ranging from childhood tonsillectomies, breast lumpectomies, and gallbladder removal to cataract surgeries, hernia repairs, and hip or knee replacements. And the rate of surgical procedures continues to rise. So it’s valuable to know what you can do to make safer surgery and a successful outcome more likely.

How do I choose my surgeon?

If you are having elective (non-emergency) surgery, such as a knee or hip replacement, you have a choice of surgeons. Your primary care physician, best friend, or physician acquaintance may recommend a surgeon. Even with a strong referral, though, it’s essential to ask questions. What do they like about that surgeon? Do they have any concerns you should be aware of?

When you meet with a surgeon, find out if he or she is board-certified. Board certification tells you that a doctor has gone beyond minimum licensing requirements to demonstrate expertise in their specialty. Ask how often the surgeon has done your procedure. Studies show that outcomes improve when a surgeon has more experience –– for example, in performing hip surgery.

Less obvious is whether you’ll have your procedure at a hospital that does a high or low volume of surgeries. Research suggests it’s safest to avoid having surgery at a hospital that does less than 10 per year of a given procedure. Outcomes are better for certain surgeries –– including orthopedic and cardiovascular procedures –– when performed in a hospital that does a high volume versus a low volume of surgeries. That’s because high-volume hospitals have processes, resources, and an experienced team that can lower complication rates and respond quickly if a complication does occur.

How do I choose my procedure?

Most often, your surgery will seem straightforward –– for example, you are having your gallbladder out. However, increasingly people are faced with several choices for a given surgery. For example:

• Traditional “open” surgeries are one option.
• Noninvasive approaches using laparoscopy are increasingly common. Laparoscopy is done using a small scope and tools that require a few small incisions, instead of the larger incision needed for open surgery.
• Sometimes there is a choice between laparoscopic robotic surgery — that means a robotic device helps the surgeon control the tools –– and standard laparoscopic surgery.
• Also, surgery like a hip replacement can be done with an anterior (front), lateral (side), or posterior (rear) approach. The newer anterior approach for hip replacement may not be how your surgeon was originally trained.

Ask which approach your surgeon plans to take, why, and what the risks and benefits are for this approach versus alternative options. Also ask about his or her experience with the chosen approach. Think about whether you prefer an older surgeon with deep experience using a traditional procedure or a more recently trained surgeon using new advances.

Prior to your surgery, you will be asked to sign an informed consent: one for your surgery, and another for your anesthesia. This is your time to ask questions about risks and alternatives, if you haven’t already done so.

If you feel inclined or your insurance requires this, get a second opinion. This is quite common. In fact, having a doctor discourage you from getting a second opinion is a red flag.

Are there steps I can take to help ensure safer surgery?

You can compare rates of surgical complications and infections at different hospitals on the Medicare website. You may also wish to check out your hospital’s patient satisfaction scores. These scores are also associated with higher surgical quality.

Although an infection after surgery is a common complication, you can take steps to protect yourself.

• You will likely be asked to bathe or shower before surgery with plain or antimicrobial soap. This reduces the likelihood of skin bacteria entering the incision.
• Not only do you want your surgical team to be clean and sterile, it’s also important that you, your visitors, and family members all wash hands rigorously. Be sure people do this when entering your room, after coughing, or before touching your skin following surgery.
• If you are having surgery after a long hospitalization or nursing home stay, you may be tested for colonization of a certain type of bacteria known as methicillin-resistant Staphylococcus aureus, or MRSA. If present, these bacteria can be eradicated prior to surgery.

Most importantly, always speak up if something doesn’t look or feel right. Ask your family members to do the same. You and your family members are valuable members of your safety team.

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My Health - A silver lining for migraine sufferers?

Could there be any benefit associated with having migraine headaches? Most migraine patients would agree this is an odd question. Migraine is a common, inherited, lifelong, and often debilitating illness that impacts people most during their productive working and parenting years. It has been associated with a higher risk of vascular disorders such as stroke and heart attack, and psychiatric disorders like depression and anxiety. What could possibly be good about migraine?

Migraines may protect against type 2 diabetes

But maybe there is some good news. A recent study suggests that, at least in women, having a diagnosis of active migraine is somewhat protective against the development of type 2 diabetes. In this study, which followed nearly 75,000 women for 10 years, women with active migraine were 20% to 30% less likely to develop type 2 diabetes over the course of the study than women with no history of migraine. In addition, if the migraine condition improved and the headaches lessened, the chances of developing diabetes went up. This supports the notion that migraine is protective against developing diabetes, and this is not simply a chance association.

Headache specialists had long observed that their migraine patient populations did not develop diabetes as frequently as the general population, so this finding was not entirely unexpected. The reason for this relationship, though, remains unclear; after all, what could it be about having a headache that could make your blood sugar and insulin function improve? Looked at the other way around, one consideration could be that elevated blood sugar levels are somehow protective against developing a headache. Yet another explanation may have to do with CGRP, a protein molecule in the body that is active in both conditions and may be the factor that links them.

This was a large, well-conducted study. Two limitations were that it only studied women and that the population studied was a rather homogenous group of mostly white professionals. Nonetheless, experts feel that the findings can likely be generalized to other populations.

Migraines may protect against alcoholism

There is another beneficial effect of migraine: research has suggested that migraine sufferers are relatively protected against the development of alcoholism. This may be a more intuitive relationship than with diabetes, since many people with migraine report that they avoid alcohol because it can trigger headache.

Migraines may have offered an evolutionary advantage

The possible evolutionary advantages of migraine have also been studied. As a rule, conditions that impair the function of an individual should lead to poorer survival in the long run and eventual dying out of the trait. And yet, after millions of years, migraine survives and thrives.

Several evolutionary explanations have been cited. One is that migraine may have originally evolved as a protective alarm system against toxins entering the body. Avoiding the ingestion of toxic substances because they produce headache could result in improved health and evolutionary advantage, compared to individuals without headache who might overuse such substances and thus suffer undesirable consequences. The migraine that we know today may have developed as a result of overactivity or oversensitization of that evolutionarily important early warning system.

However small the practical and daily consequence to those who suffer its effects, migraine may in fact have one or more silver linings after all.

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My Health - African American men respond better to treatments for advanced prostate cancer in clinical trials

Racial differences have long been evident in prostate cancer statistics. In particular, African American men are diagnosed with prostate cancer more often than white men, and they’re also nearly twice as likely to die of the disease.

But new research also shows that African American men who receive the most advanced treatments for late-stage prostate cancer can live at least as long — or even longer — than their Caucasian counterparts.

Why is this the case? Scientists are searching for an explanation. “The fact that African American men have better survival is of huge research interest,” said Dr. Stephen Freedland, a urologist at Cedars-Sinai Medical Center in Los Angeles. “If we can figure this out, we’ll obtain key insights into the factors driving survival in late-stage prostate cancer. And that in turn will help spur better treatments for all men — regardless of race.”

Each year, about 160 per 100,000 African American men receive a prostate cancer diagnosis. That’s three times higher than the comparable figure for white American men, and it’s also higher than the number of black men diagnosed annually with prostate cancer in Africa. It’s possible that dietary or environmental factors — perhaps in combination with genetic susceptibilities — put African American men at greater risk in the United States. But African American men also tend to have less access to health care than white Americans, and many of them are diagnosed after their tumors have already begun to metastasize, or spread.

A surprising survival advantage

What the new research shows, however, is that survival advantages can favor African Americans who undergo treatment for advanced prostate cancer in clinical trials. One study  pooled data from nine clinical trials, enrolling a combined 88,200 men with metastatic prostate cancer who were treated with a chemotherapy drug called docetaxel. The African American and white men had similar survival rates — 21 months and 21.2 months respectively. But after adjusting for factors such as age and prostate-specific antigen levels, the researchers found that African Americans were 20% less likely to have died during the course of those trials than their white counterparts.

Freedland co-authored another recent study showing that African Americans respond better to newer drugs that target testosterone, which is a hormone that drives prostate cancer to grow faster. Using data gathered by the Veterans Health Administration between 2013 and 2018, the researchers looked at how long African American and white men with metastatic prostate cancer lived after treatment with one of two drugs: abiraterone acetate or enzalutamide. They had access to records from nearly 3,000 men. The unpublished results, presented at a medical conference in February, showed that median survival among the African Americans lasted 30 months, compared to 26 months among their white counterparts. “So, the key takeaway is that if they get to advanced prostate cancer, and are treated equally in an equal access medical center, black men can have similar or even better outcomes,” Freedland said.

The data still need to be confirmed in additional research, Freedland emphasized. But in the meantime, the studies add to a growing body of evidence that’s changing how scientists look at racial differences in prostate cancer. Ideally, the research will reveal new biological insights into prostate cancer, and allow doctors to tailor treatments more effectively.

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My Health - Preventing depression in pregnancy: New guidelines

While pregnancy and a child’s birth are often depicted in pastel tones, many women struggle with depression during this time. Up to 14% of women are diagnosed with depression during pregnancy. Far more report having symptoms of depression during pregnancy and the first year after birth. Now new guidelines published by the US Preventive Services Task Force in the Journal of the American Medical Association provide the first-ever recommendations for preventing perinatal depression.

How can the new guidelines help?

Depression can be difficult during any period of life. Its main symptoms — a depressed or hopeless mood, a loss of interest and joy — can be accompanied by trouble sleeping, eating, and managing daily life. When depression occurs during pregnancy (perinatal) or up to 12 months after childbirth (postpartum), it can have a negative impact on the health of both the mother and the infant. For example, women with postpartum depression engage in fewer positive maternal behaviors, such as playing or praising, and more negative maternal behaviors, such as hurtful comments or harsh discipline. Children whose mothers had perinatal or postpartum depression are more likely to develop behavior problems and other psychiatric disorders.

The new guidelines recommend that health care providers discuss mental health with women during pregnancy and after birth, and screen women for depression. They can then refer women who report such symptoms, or have risk factors, to an appropriate mental health clinician. Simply raising the topic with a woman might help her feel more comfortable asking questions about depression and sharing her concerns.

Are there ways to prevent depression during pregnancy?

The Task Force reviewed a number of studies aimed at preventing depression in pregnant women. It identified two counseling interventions as recommended practices: cognitive behavioral therapy and interpersonal therapy. Both can effectively prevent perinatal depression.

Cognitive behavioral therapy, or CBT, helps people identify and change negative and incorrect thoughts. It helps people develop alternate, and more accurate, ways of viewing themselves and life events. For example, you might have broad, global, negative views of your ability to parent (“I am a terrible parent.”). Therapy focuses on identifying these thoughts, challenging the errors in them, and developing more balanced thoughts. The behavioral component of CBT includes increasing positive activities, such as social interactions and pleasant events.

Interpersonal therapy focuses on helping people resolve interpersonal conflicts and navigate role transitions, such as becoming a mother for the first time. It also teaches people how to increase effective communication with others.

The Task Force found limited or mixed evidence for other approaches to preventing depression in pregnant women, including taking dietary supplements and engaging in physical activity.

What else is important for preventing depression during pregnancy?

Further, the Task Force identified a number of risk factors that make women more vulnerable to perinatal depression. These factors include having a history of depression, experiencing abuse, having an unplanned or unwanted pregnancy, or complications during pregnancy. Other possible risk factors are stressful life events, diabetes, low socioeconomic status, lack of financial or social support, and teen parenthood. Women who have these risk factors may wish to consider counseling during pregnancy and after childbirth. Counseling can be a source of support and a way to prevent, or cope with, depression.

The Task Force recommended further efforts to develop new ways to screen women for depression and prevent depression.

What if you’re experiencing depression?

If you are experiencing symptoms of depression, it is important to talk to your health care provider about treatment options. Your provider can refer you to mental health professionals who have experience working with women during pregnancy or after a birth. Encourage friends and family who are experiencing depression to seek help.

In addition to seeking help for symptoms of depression, if you or a friend of yours is thinking about harming themselves, please call the Suicide Prevention Hotline at 800-273-8255 (TALK), or go to the closest emergency room for help.

Editor’s note

In March 2019, the FDA approved the first treatment for moderate to severe postpartum depression. Brexanolone (Zulresso) is given intravenously over a 60-hour period. During this time, women must be monitored at a certified health care facility. While the medicine can work quickly to ease depression (within 48 hours), it is not effective for everyone.

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My Health - 6 Simple Steps To Lose Thigh Fat Without Exercise

6 Simple Steps To Lose Thigh Fat Without Exercise

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 - Cleaner living: Plant-friendly is planet-friendly

Climate change is in the news more and more, and the projections from virtually all of the world’s climate scientists are becoming increasingly dire. Almost daily, we are confronted with images of extreme weather patterns, disease outbreaks, and the loss of certain species. It is almost biblical in proportion. Most poignant, to me, are the distressing images of starving, displaced polar bears whose icy habitats are melting away.

Many of the things that we can do to prevent or slow climate change are intuitive, difficult as they may be to put into practice: conserve energy, drive less, elect politicians that are dedicated to working on this problem, and recycle, to name the basics. However, many people may be unaware that some simple changes to our daily diet can have a tremendous impact on the emission of greenhouse gasses.

How does food production affect the climate?

About 30% of global greenhouse gas emissions come from food production. About half of this is from the livestock sector alone. And it’s not just the greenhouse gasses that are the problem. Food production occupies about 40% of the global land, uses about 70% of our fresh water (which is increasingly in short supply in many places in the world, leading to strife), causes many species to become extinct, and is responsible for large areas of deforestation (cutting down the rain forest so cattle can graze) and desertification (the process by which fertile land becomes desert, typically as a result of inappropriate agriculture).

Make a difference with a planet-friendly diet

The good news is that simply by making some changes to your diet, by adopting what is known as a “planet-friendly” diet, it is possible to contribute to the solution to climate change. It’s merely a question of knowing which foods are the worst climate offenders, and then either transitioning away from these foods or replacing them altogether with climate-friendlier alternatives.

According to the World Resources Institute, far and away the most destructive food is beef. In terms of all three markers — greenhouse gas emissions, freshwater consumption, and land use — beef is an environmental disaster. Just behind beef is dairy, followed by poultry, pork, eggs, and fish.

The United Nations Intergovernmental Panel on Climate Change (IPCC) proposes that people reduce their consumption of animal products by 30% as an urgent component of their recommendations to combat climate change.

About a year ago, I gave up red meat for exactly this reason, with less than perfect success. Old habits are hard to break, and change comes slowly and requires patience.

Healthier for you and the environment

Fortunately, the foods that are healthy for the climate almost completely overlap with the foods that are healthy for your physical well-being. Cutting down on beef in favor of plant-based protein, even once a week, can lower the risk factors for diabetes, heart attack, and stroke. So, the next time you start reaching for that burger, or think about ordering that prime rib, consider choosing the veggie option instead. You’ll be doing your part to take better care of the planet and yourself in the process.

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My Health - Cancer treatment: Is a clinical trial right for you?

Clinical trials are research studies that test a new drug or therapy in patients who have a disease. These studies are classified as phase I, II, or III depending on their purpose.

• Phase I: These initial, small studies test promising new drugs that effectively kill cancer cells in laboratory experiments. The goal is to understand the safe dose and capture early evidence of benefit. Phase I trials may be open to patients with any type of cancer, or only certain types of cancers more likely to respond to specific drugs. Generally, fewer than 50 patients are enrolled.
• Phase II: Once a phase I trial identifies a safe dose, a phase II trial is done to better understand the potential benefit and side effects of the drug. Generally, these studies enroll fewer than 100 patients.
• Phase III: If the new treatment has promising activity in the phase II trial, the next step is usually a phase III trial comparing it with an existing standard treatment. If there is no standard treatment, patients may be randomly assigned to receive either the new treatment or a placebo (such as a sugar pill). Generally, phase III trials are large. The researchers may enroll many hundreds of patients, or even more than 1,000, to establish whether the new treatment is an advance over standard treatment and warrants US FDA approval. Many immunotherapy drugs have been approved in recent years to treat different cancers based on phase III trials showing improved survival compared with previous standards of treatment. A few examples are pembrolizumab (Keytruda) for metastatic bladder cancer, and ipilimumab (Yervoy) combined with nivolumab (Opdivo) for kidney cancer and melanoma.

Why are clinical trials so important?

Often, compounds that work against cancer cells in a laboratory fail in clinical trials. Sometimes, even promising benefits that a new drug exhibits during phase II trials are misleading. A phase III trial is necessary to confirm the benefits. It’s also possible that patients who come to major academic medical centers where phase I and II clinical trials are often conducted might have better outcomes than a broader population of patients.

Why join a clinical trial?

The drugs that help many people living with cancer today became available only after confirmation of their efficacy and safety in patients who chose to enroll in clinical trials. Unfortunately, most commercially available treatments cannot cure metastatic cancer. Clinical trials offer hope and the possibility of improving outcomes for individual cancer patients, and perhaps many others. Information from studies with diverse populations is important when developing new treatments. Yet only one in 10 people participating in clinical trials is black, Hispanic or Latino, Asian, or from another underrepresented group, according to the National Institute of Minority Health and Health Disparities, which is working to improve access to trials.

If you do choose to join a clinical trial, you retain the right to revoke your consent for any reason.

Are there possible disadvantages to joining a trial?

One troubling issue is the prospect of receiving a placebo, which may be an oral tablet or an intravenous infusion. Some, but not all, phase III trials compare a new treatment to placebo. Depending on the number of groups being compared, the chance of receiving a placebo may be I in 2, 1 in 3, or even less. Patients randomized to placebo are monitored with the same standard of care and may receive another drug if their cancer grows.

The new drug being tested may have unforeseen side effects. Clinical trials, especially phase I and II trials, can also have more intensive clinic visit schedules and require extra blood draws and biopsy procedures.

If the type of cancer you have might be curable, or can be controlled for a prolonged period using an existing, effective standard treatment, it may make sense to try the standard treatment before enrolling in a clinical trial.

How can you find appropriate clinical trials?

Start by talking to your cancer care team. Given recent advances in immunotherapy and targeted therapy, the number of these trials is particularly large, though often confusing to navigate.

Different cancer centers may offer different menus of clinical trials. Eligibility criteria also may affect your options. Some trials require patients with “measurable” tumors because shrinkage of cancer is difficult to measure without a minimum size. Other trials are not open to people taking certain medicines for other health conditions due to the risk for interactions.

You can also learn about appropriate trials by contacting National Cancer Institute-designated cancer centers, or by searching the National Cancer Institute clinical trials website (or calling 800-422-6237 for help).

Who pays for a clinical trial?

It’s wise to ask about costs. Generally, a pharmaceutical company or another funding agency covers the costs of the research drug, and procedures such as biopsies, lab tests, and genetic testing. Health insurance usually covers standard care, such as commercially approved treatments, monthly clinic visits, routine laboratory tests, periodic radiographic imaging, and hospital admissions for urgent problems.

Follow me on Twitter @sonpavde

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My Health - 7 Awesome Benefits Of Drinking Apple Cider Vinegar Before Bedtime

7 Awesome Benefits Of Drinking Apple Cider Vinegar Before Bedtime

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

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My Health - A practical guide to the Mediterranean diet

The Mediterranean diet has received much attention as a healthy way to eat, and with good reason. The Mediterranean diet has been shown to reduce risk of heart disease, metabolic syndrome, diabetes, certain cancers, depression, and in older adults, a decreased risk of frailty, along with better mental and physical function. In January, US News and World Report named it the “best diet overall” for the second year running.

What is the Mediterranean diet?

The traditional Mediterranean diet is based on foods available in countries that border the Mediterranean Sea. The foundation for this healthy diet includes

• an abundance of plant foods, including fruits, vegetables, whole grains, nuts and legumes, which are minimally processed, seasonally fresh, and grown locally
• olive oil as the principal source of fat
• cheese and yogurt, consumed daily in low to moderate amounts
• fish and poultry, consumed in low to moderate amounts a few times a week
• red meat, consumed infrequently and in small amounts
• fresh fruit for dessert, with sweets containing added sugars or honey eaten only a few times each week
• wine consumed in low to moderate amounts, usually with meals.

How to bring the Mediterranean diet to your plate

How can you incorporate these healthy foods into your everyday life? Here are some small changes you can make. Pick one change every week and incorporate it gradually. Start with the changes you think will be the easiest.

• Switch from whatever fats you use now to extra virgin olive oil. Start by using olive oil in cooking, and then try some new salad dressings with olive oil as the base. Finally, use olive oil in place of butter on your crusty bread.
• Eat nuts and olives. Consume a handful of raw nuts every day as a healthy replacement for processed snacks.
• Add whole-grain bread or other whole grains to the meal. Select dense, chewy, country-style loaves without added sugar or butter. Experiment with bulgur, barley, farro, couscous, and whole-grain pasta.
• Begin or end each meal with a salad. Choose crisp, dark greens and whatever vegetables are in season.
• Add more and different vegetables to the menu. Add an extra serving of vegetables to both lunch and dinner, aiming for three to four servings a day. Try a new vegetable every week.
• Eat at least three servings a week of legumes. Options include lentils, chickpeas, beans, and peas.
• Eat less meat. Choose lean poultry in moderate, 3- to 4-ounce portions. Save red meat for occasional consumption or use meat as a condiment, accompanied by lots of vegetables, as in stews, stir-fries, and soups. Eat more fish, aiming for two to three servings a week. Both canned and fresh fish are fine.
• Substitute wine in moderation for other alcoholic beverages. Replace beer or liquors with wine — no more than two 5-ounce glasses per day for men, and one glass per day for women.
• Cut out sugary beverages. Replace soda and juices with water.
• Eat less high-fat, high-sugar desserts. Poached or fresh fruit is best. Aim for three servings of fresh fruit a day. Save cakes and pastries for special occasions.
• Seek out the best quality food available. Farmer’s markets are an excellent source of locally grown, seasonal foods.

Finally, try to have dinner as a family as often as possible. Food as a communal, shared experience is a big part of the Mediterranean approach.

Mediterranean all day

There are many ways to incorporate the delicious foods of the Mediterranean diet into your daily menu. Here are a few ideas to get you started.

Breakfast:

• whole-grain bread topped with a small amount of low-fat cheese and slices of fresh tomato, drizzled with a little extra virgin olive oil
• vegetable omelet made with mushrooms, spinach, and onions cooked in olive oil with crusty whole-grain bread
• plain Greek yogurt topped with nuts and fresh berries.

Lunch:

• Greek salad made with chopped mixed greens, kalamata olives, tomatoes, fresh parsley, feta cheese. Dress with extra virgin olive oil and freshly squeezed lemon
• chickpea and farro salad with red peppers, spring onions, and fresh oregano, dressed with extra virgin olive oil and lemon juice
• vegetarian pizza topped with part-skim mozzarella cheese, roasted broccoli, onions, green peppers, and carrots.

Dinner:

• grilled vegetable kabobs with shrimp, toasted quinoa salad, and mixed green salad with pine nuts
• chicken stir-fried in olive oil with broccoli, cauliflower, asparagus, and yellow peppers, served over brown rice
• steamed mussels with spinach-orzo salad and minestrone soup.

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My Health - Over-the-counter cold and flu medicines can affect your heart

As the cold and flu season continues this year, it is important to be aware that many of the most commonly used over-the-counter (OTC) remedies for congestion, aches, pains, and low-grade fevers contain medicines that can have harmful effects on the cardiovascular system. Chief among these medications are nonsteroidal anti-inflammatory drugs (NSAIDs) and decongestants.

NSAIDs and your heart

Certain NSAIDs are associated with a small increase in the relative risk for developing a heart attack, stroke, heart failure, atrial fibrillation, increased blood pressure, and blood clots. NSAIDs relieve pain and inflammation by inhibiting an enzyme called COX that produces molecules called prostaglandins. However, this enzyme also has additional important effects throughout the body, which may impact cardiovascular risk. For example, the inhibition of a form of COX called COX-2 in the lining of blood vessels may influence blood vessel injury repair, relaxation, and clotting. The inhibition of COX-2 in the kidney may influence fluid retention, which may in turn affect blood pressure and heart failure symptoms.

Large population studies have demonstrated that the use of NSAIDs similar to those in OTC cold and flu remedies is associated with about two additional cardiovascular events (such as a heart attack or stroke) per 1,000 people per year among individuals without a history of cardiovascular disease (CVD). Among individuals with a history of CVD, this association increases to an additional seven or eight cardiovascular events per 1,000 people per year.

Importantly, these studies were primarily conducted in individuals who were using NSAIDs for long periods of time (more than a month) due to chronic pain or inflammatory conditions. Cardiovascular risk associated with NSAIDs decreases by using these medicines for the shortest duration and lowest dose and frequency as possible — as is often the case during short bouts of a cold or the flu.

Thus, among individuals who do not have CVD, the use of NSAIDs such as ibuprofen (Advil, Motrin) or naproxen (Aleve, Naprosyn) is usually a reasonable option for short-term symptom relief. For individuals who do have CVD, it is worth discussing use of NSAIDs with a doctor.

For individuals with CVD, it is often fine to use NSAIDs for a short duration if a different medication, such as acetaminophen (Tylenol), is not an option. In this case, however, the choice of NSAID may be important. Some data suggest naproxen and the COX-2 selective NSAID celecoxib (Celebrex) may have slightly lower associations with CVD in high-risk patients.

Certain individuals should definitely speak with a doctor before considering NSAIDs, even for just a few days. These include individuals who have heart failure; who are on blood thinners such as warfarin, rivaroxaban (Xarelto), apixaban (Eliquis), or dabigatran (Pradaxa); who take antiplatelet medications such as aspirin (Bayer, Bufferin), clopidogrel (Plavix), prasugrel (Effient), or ticagrelor (Brilinta); or who have had a recent heart attack, stroke, angina (chest pain), or coronary artery bypass surgery.

Decongestants and your heart

Decongestants such as phenylephrine (Sudafed PE Congestion, Suphedrin PE) and pseudoephedrine (Sudafed Congestion, Suphedrin) also affect the cardiovascular system. These agents act on the “fight or flight” response to constrict, or narrow, blood vessels. This dries up runny noses and congestion, but may also lead to increases in blood pressure and changes in heart rate. The long-term effects of these drugs on outcomes such as heart attack and stroke have not been as well studied as they have for NSAIDs. However, clinical experience has demonstrated that in certain individuals who are especially sensitive to sudden changes in blood pressure or heart rate, these drugs can sometimes have harmful effects.

People without CVD can almost always safely tolerate the effects of these decongestants when used for short periods of time. As with NSAIDs, it is always best to use the lowest dose and frequency possible for the shortest amount of time.

For individuals with established CVD, however, it is likely best to avoid these medications. This is especially true in individuals with heart failure, difficult-to-control blood pressure, or coronary artery disease. In these cases, blood vessel constriction and abrupt changes in blood pressure and heart rate may not be as safely tolerated by the body.

Many OTC medicines for the cold and flu such as NSAIDs and decongestants can have negative effects on the cardiovascular system. These effects can have significant consequences — even during short-term use — for some people with established CVD. If you fall into this category, discuss your risk and alternative treatment options with your cardiologist.

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My Health - Aspirin for primary prevention of cardiovascular disease, part 2

Update

In March 2019, the American College of Cardiology (ACC) and the American Heart Association (AHA) released new guidelines that suggest that most adults without a history of heart disease should not take low-dose daily aspirin to prevent a first heart attack or stroke. Based on the ASPREE, ARRIVE, and ASCEND trials, the ACC/AHA guidelines concluded that the risk of side effects from aspirin, particularly bleeding, outweighed the potential benefit.

The new guidelines do not pertain to people with established cardiovascular disease, in whom the benefits of daily aspirin have been found to outweigh the risks.

___________________________________________________________________________

Well, it seems as though not even a week can go by without more data on aspirin! I recently reviewed the ARRIVE trial and the implications for primary prevention — that is, trying to prevent heart attacks and strokes in otherwise healthy people. Since then, yet another large clinical trial — the ASPREE study — has come out questioning the use of aspirin in primary prevention. Three articles pertaining to this trial were published in the prestigious New England Journal of Medicine, which is an unusual degree of coverage for one trial and highlights its immediate relevance to clinical practice.

Aspirin still strongly indicated for secondary prevention

Nothing about any of the new aspirin data, including ASPREE, pertains to secondary prevention, which refers to use of aspirin in patients with established cardiovascular disease. Examples include a prior heart attack or certain types of stroke, previous stents or bypass surgery, and symptomatic angina or peripheral artery disease. In general, in patients with a history of these conditions, the benefits of aspirin in reducing cardiovascular problems outweigh the risks. Chief among these is a very small risk of bleeding in the brain, and a small risk of life-threatening bleeding from the stomach.

ASPREE study suggests no benefit from aspirin in primary prevention

ASPREE randomized 19,114 healthy people 70 or over (65 or over for African Americans and Hispanics) to receive either 100 milligrams of enteric-coated aspirin or placebo. After an average of almost five years, there was no significant difference in the rate of fatal coronary heart disease, heart attack, stroke, or hospitalization for heart failure. There was a significant 38% increase in major bleeding with aspirin, though the actual rates were low. The serious bleeding included bleeding into the head, which can lead to death or disability. Again, the actual rates were very low, but they are still a concern when thinking of the millions of patients to whom the ASPREE results apply.

Rates of dementia were also examined, and again, there was no benefit of aspirin. Quite unexpectedly, there was a significantly higher rate of death in the patients taking aspirin. This had not been seen in prior primary prevention trials of aspirin, so this isolated finding needs to be viewed cautiously. Still, with no benefits, increased bleeding, and higher mortality, at least in this population of older healthy people, aspirin should no longer be routinely recommended.

Another unexpected finding in ASPREE was a significantly higher rate of cancer-related death in the people randomized to aspirin. The prior thinking had been that aspirin might actually prevent colon cancer, though generally after many more years of being on aspirin. The ASPREE trial was terminated early due to lack of any apparent benefits. And even though five years is a relatively long period of follow-up, it may not have been long enough to find a benefit on cancer. Thus, the increase in cancer deaths may be a false finding. Nevertheless, the overall picture from this trial is not a compelling one for aspirin use for prevention of either cardiac or cancer deaths.

Should healthy people take a daily aspirin?

In general, the answer seems to be no — at least not without first consulting your physician. Despite being available over the counter and very inexpensive, aspirin can cause serious side effects, including bleeding. This risk goes up with age. So, even though it seems like a trivial decision, if you are healthy with no history of cardiovascular problems, don’t just start taking aspirin on your own.

However, there are likely select healthy patients who have a very high risk of heart attack based on current smoking, family history of premature heart attacks, or very elevated cholesterol with intolerance to statins, for example, who might benefit. Therefore, the decision to start aspirin should involve a detailed discussion with your physician as part of an overall strategy to reduce cardiovascular risk. If you are already taking aspirin for primary prevention, it would be a good idea to meet with your physician and see if you might be better off stopping.

Follow me on Twitter @DLBHATTMD

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My Health - How to prevent poisonings in children — and what to do if they happen

March 17–March 23, 2019 is National Poison Prevention Week

Every day in the United States, over 300 children under the age of 20 are seen in an emergency room because of poisoning, and two of them die. What is most heartbreaking is that poisonings are preventable — and quick action can save lives when they happen.

Poisoning prevention

Here are some tips from the Centers for Disease Control and Prevention and the American Academy of Pediatrics to prevent poisoning in children:

• Keep medicines, cleaning and laundry products, paints and varnishes, as well as pesticides, out of sight and reach of children. If possible, lock these products away.
• Always keep these products in their original containers, which makes it less likely that they will be ingested by accident.
• While laundry and dishwasher detergent pods can be convenient, stick with the standard liquids and powders if there are young children in the house. The pods just look too much like candy.
• Have safety caps for all medications, but don’t rely on them (meaning keep medications out of reach and sight).
• Make sure you know the correct dose of any medication you give your child, and always use a medication syringe or spoon to measure it (ask your pharmacist for one if you don’t have one).
• Get rid of any old or unused medicines or cleaning products. The less around, the better.
• If you use e-cigarettes, only buy nicotine refills in safety containers and keep them out of sight and reach. Nicotine can be very dangerous.
• If you have a gas, kerosene, coal, or wood-burning stove, make sure it is in good working order.
• Have smoke and carbon monoxide detectors, and check them regularly to be sure they are working.
• Know what devices in your home use button cell batteries, and keep them out of reach of children. Don’t buy children’s books or toys that have these batteries; it’s not worth the risk.
• Make sure you know all the types of plants you have in your house or yard. If any are poisonous, either keep your child away from them, or better yet, get rid of them.

What do to should a poisoning happen, or if you think it might have

• If the child is having any trouble breathing, is unconscious, or has what you think even might be a serious injury, call 911 right away.
• For a swallowed poison, have the child spit out whatever isn’t swallowed. Do not use ipecac or anything else to make them vomit. If your child has any symptoms, call 911 or bring your child to a local emergency room. If your child doesn’t have symptoms, call 1-800-222-1222, the nationwide poison control center number. Have the container with you when you call, and be ready to tell the person you talk to how much your child swallowed (or your best guess).
• For something that gets on the skin, take off any clothing and run water over the affected area for 15 minutes. While you are doing that, call the poison center.
• If anything gets in the eyes, hold the eye open and run room-temperature water on the eyes (aim for the inner corner) for 15 minutes. Call the poison center while you do — or call 911 if a lot got into the eyes or the child is in a lot of pain — but don’t stop flushing the eyes.
• If a child swallows a button cell battery, or puts it in his nose or ear, take him immediately and directly to an emergency room. They can do damage quickly.
• If a child has inhaled a poison, or you think that she might have, get her out into fresh air. Call 911 if she is unconscious or having any trouble breathing.

Keep the Poison Center number in your phone and posted in your house so that it is always handy. You can and should also call the number — or your doctor — if you think your child might have gotten into something, but you aren’t sure. It’s always better to be safe than sorry.

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My Health - How long does a joint replacement last?

Joint replacement surgery represents one of the biggest and most life-changing advances in modern medicine. It has meant the difference between disability from crippling arthritis and nearly normal mobility for millions of people in recent decades. The hip and knee are, by far, the most commonly replaced joints, and they have the most reliable results. In the US each year, more than 300,000 hips and 700,000 knees are replaced, and the results are generally good. But every time a joint is replaced, an important question looms: how long will it last?

It’s a fair question. After all, no one wants to go through the risk, discomfort, and recovery time required for a major operation only to need it again in a short time.

The usual estimate: 10 to 15 years

When I was in medical school, the commonly quoted estimate was that a replaced knee or hip should last about 10 to 15 years, but hopefully much longer. That was an average, of course. Rare complications requiring re-operation can occur soon after surgery; for others, a replaced joint can last two decades or more. And since it takes many years to know whether improved surgical techniques and materials have led to longer joint life, it’s hard to know at any given time how long a replaced joint might last.

Why is this so important? Estimates of joint replacement longevity are helpful to the person who is uncertain about whether joint replacement is worth pursuing. But in addition to whether to have surgery, these numbers can help people decide when to have it done. For example, a person in their 30s might be looking at two or more revisions (the surgeon’s term for replacing a previously replaced joint). Some younger joint replacement surgery candidates have been advised to wait until symptoms are more severe in the hopes of reducing the need for multiple revisions in the future.

A new study provides new estimates

In February 2019, two large analyses were published in the medical journal Lancet regarding the longevity of replaced hips and knees, that included nearly 300,000 total knee replacements and more than 200,000 total hip replacements. They found encouraging results:

• Nearly 60% of hip replacements lasted 25 years, 70% lasted 20 years, and almost 90% lasted 15 years.
• Total knee replacements lasted even longer: 82% lasted 25 years, 90% lasted 20 years, and 93% lasted 15 years.

These estimates are quite a bit higher than prior ones and may reflect improvements in surgical technique and materials, general medical care around the time of surgery, or more aggressive mobilization and physical therapy that starts right after surgery. The study authors also suggest that these numbers reflect “real life” patients (including all patients in multiple medical centers who were having their knees or hips replaced), rather than a small number from a single medical center.

Some caveats are worth noting:

• These surgeries were performed in New Zealand, Australia, Denmark, Finland, Norway, and Sweden. The results might be different in the US or other countries.
• Detailed information was not available regarding which patients were considered eligible for total joint replacement and which were denied surgery because they were considered at high risk for failure or complications. These factors can affect the success of joint replacement surgery.

Surgery is usually the last (and sometimes best) option

When a hip or knee has worn out and no longer functions as it should, medications, physical therapy, various injections, and other nonsurgical treatments can only do so much — often they can’t do much at all. For those who are healthy enough to have major surgery (and willing to go through with it), total joint replacement is often the only option that offers a good chance at significant pain relief and improved function. Joint replacement surgery for arthritis is considered a treatment of last resort. But even though replaced joints may not last forever, they may last longer than we’d thought.

Follow me on Twitter @RobShmerling

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My Health - Something else to avoid in pregnancy: Phthalates

Most pregnant women know that they should avoid things like alcohol and tobacco while they are pregnant, as well as certain foods like sushi and soft cheeses. But not many pregnant women think about avoiding lipstick, perfume, or lotions — and it turns out that they probably should.

The problem is a type of chemical called phthalates. It’s nearly impossible to avoid phthalates entirely, as they are quite literally everywhere. They are in plastic products including packaging, in toys and garden hoses, as well as in cosmetics and other personal care products. They can act like hormones and interfere with male genital development, as well as increase the risk of cardiovascular disease and diabetes.

The risks of phthalates, though, begin before birth. A study showed that children whose mothers were exposed to phthalates during pregnancy were more likely to have problems with motor skills, the skills that we use not just in sports but also in everyday activities, and another showed that the children of mothers exposed during pregnancy had problems with language development.

Even if it’s impossible to avoid phthalates entirely, there are ways women can decrease their exposure:

• Limit exposure to plastics, especially anything with the number 3 or 7 on them. Use glass, ceramic, or metal containers for food and drink.
• Try to buy foods that don’t come in plastic packaging.
• If you have to use plastic, don’t microwave it, and wash it by hand rather than in the dishwasher to limit the leaching out of chemicals.
• Avoid anything with fragrance in it, as phthalates are commonly used in making fragrances.
• Look into handmade cosmetic and personal products that don’t use any chemicals (and skip the products entirely when you can). The Environmental Working Group has a database you can use to learn more about commercial products.
• Go DIY. Things like honey, coconut oil, baking soda, vinegar, and salt can be used in place of many commercial beauty products. Do a little research — you may find that it’s easier than you think to make a moisturizer, a shampoo, or a perfume.
• Wash your hands often with soap and water.

Once the baby is born, continue to be mindful about chemicals that can cause harm. Look for fragrance-free products that are as all-natural as possible, keep up with DIY including for cleaning products, and limit plastics in the house, especially baby bottles and toys. We can’t escape all the harmful chemicals around us, but by getting back to basics, we can make things safer for our children.

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My Health - Banishing dry winter skin

Do you have dry, itchy winter skin? You’re not alone. During the winter months, many of my patients come into clinic asking about the right cream to use to cure their dry skin. But dry skin care is about so much more than just moisturizers.

Here are some dermatologist-recommended tips for preventing and relieving dry skin:

• Harsh soaps are not your friend. Many people love the feeling of being “squeaky-clean” after using harsh soaps in the shower. But these soaps strip your skin of essential lipids (fats) that keep the skin moisturized. Instead, try a gentle, fragrance-free cleanser and limit its use to cleaning the underarms and groin, or skin that is visibly soiled.
• Warm showers, not hot. I look forward to a steaming-hot shower at the end of a cold winter day as much as the next person. But hot water and long showers can irritate and dry out the skin. So can saunas, hot tubs, and Jacuzzis. Especially when your skin is dry, try turning the temperature knob down slightly so that the water is warm rather than hot, and limit showering to once a day for no more than 10 minutes.
• When you moisturize matters. The best time to moisturize is when your skin is still damp, such as right after a shower. Pat your skin dry gently, then slather up with a good moisturizer from head to toe. Not only is it more effective, it may also feel less greasy on your skin as the moisturizer traps existing moisture on your skin.
• The thicker the better. Ointments or creams are much more effective at moisturizing than lotions. Ointments are typically petroleum or lanolin based, and creams tend to be thicker than lotions. Additional moisturizing ingredients to look for include shea butter, olive oil, and jojoba oil. If your skin is flaky, look for exfoliating ingredients such as lactic acid or urea, but be careful using these ingredients if you have sensitive skin.
• Go gentle all around. Use skincare products that are gentle and unscented, including deodorants and hypoallergenic laundry detergent. Gentle or hypoallergenic products minimize the chance of skin irritation; avoiding irritation can help maintain the healthy skin barrier needed to retain water from the inside.
• Consider a humidifier. During the dry winter months, using a humidifier to keep the humidity above 30% can make a big difference for your skin.
• Nature versus nurture. Some people have a genetic mutation in the fillagrin gene. This gene is very important in the formation of the outer layer of the skin, which forms a barrier that helps the skin retain moisture. This mutation predisposes the affected individuals to eczema and persistently dry skin. It is especially important for people with this mutation to follow all the tips above to prevent and manage dry skin.

If your skin does not improve after making these changes, you may need to see a dermatologist. Sometimes, severe dry skin can be relieved by a prescription ointment or cream. Dry skin can also indicate a more serious skin condition; a dermatologist can evaluate your skin and decide on the regimen that can help you the most.

Follow me on Twitter @KristinaLiuMD

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My Health - Can exercise extend your life?

Exercise provides a remarkable variety of health benefits, which range from strengthening bones to positive effects on mood and helping to prevent chronic illnesses such as diabetes and heart disease. Research dating back to the late 1980s has consistently shown that aerobic fitness may help extend lives. Yet a few studies on athletes examining whether habitual vigorous exercise might harm the heart made some experts wonder how hard people ought to push when exercising (see here and here).

Do cardiorespiratory fitness levels affect longevity?

A retrospective study in JAMA attempts to answer this question. The study explores the association between long-term mortality and various levels of cardiorespiratory fitness (CRF). CRF is a measure of how well your heart and lungs pump blood and oxygen throughout the body during prolonged bouts of exercise. The more fit you are, the higher your level of CRF. Regular exercise, and vigorous exercise, can both boost CRF.

The researchers looked at over 122,000 patients at a large academic medical center who underwent exercise testing on a treadmill, an objective measure of CRF. While the average age was 53, participants ranged in age from 18 to over 80. Similar to findings of previous studies, being fit was associated with living longer. This held true at any age. The researchers also saw a relationship between CRF and survival rates: the higher the level of fitness, the higher the survival rate. This was especially notable in older people and people with high blood pressure. And the survival benefit continued to climb with no upper limit.

What does this mean for all of us?

Unless there is a clear medical contraindication, we should all strive to achieve and maintain high levels of fitness. Current guidelines recommend 150 to 300 minutes per week of moderate aerobic activity (walking, running, swimming, biking), or 75 minutes of vigorous activity, or a mix of both. Twice-weekly resistance training to strengthen muscles is also recommended. Unfortunately, only about one in five adults and teens gets enough exercise to maintain good health.

Wondering where to start?

There’s a place to start for everyone regardless of age or current fitness level.

• First, think safety.Walking and other low levels of exercise are generally safe for most people. But check with your doctor before starting or making changes to an exercise routine if you have a history of heart disease, or any other medical condition that might impact your exercise tolerance.
• Start small.You’ll be more successful if you set the bar low. For example, start with a simple routine of walking 10 to 20 minutes three times per week. Every week or two, add five minutes per walk until you reach a goal of 30 minutes. Then, every week or two, add a day until you reach at least 150 minutes per week. Over time you can try to increase intensity. Remember, small goals are more achievable, and these little victories will continue to fuel your motivation.
• Don’t be afraid of exercise or the gym. Any movement is good and is a step in the right direction. The gym intimidates many folks — perhaps you’re overweight or inexperienced, and worry that others might stare or judge you. Everyone was new to exercise at one point in time. Focus on your purpose and avoid wasting energy on things that do not matter.
• Plan ahead. To maximize your success in adopting a long-term lifestyle change, plan ahead. Every week, look at your calendar ahead of time and commit to when you will exercise that week. Think of your opportunity to exercise as an appointment, rather than “I’ll get to it if I have time.”
• Expect to lose some battles. Keep in mind that realistically, most people will get derailed at some point as they work on a behavioral change. Do not let this crush your motivation. Instead, identify obstacles that may have interfered, strategize a solution moving forward, and try again.

Trying to get back into physical activity after a hiatus?

Take the first week to ease back into exercising. Avoid building up to your previous level of fitness too quickly to avoid injuring yourself.

Already active and wondering how to reap more benefits?

• Many people fall short on resistance training and are mostly focusing on cardio. Resistance training helps you build strength, thereby improving your overall cardiovascular fitness and performance.
• If you’re short on time, consider a high-intensity interval workout. This will get you more bang for your buck.
• Vary your exercise routine to keep yourself challenged physically.

Too often, our health takes a back seat in the midst of busy careers and the multitude of responsibilities we take on in our lives. Optimizing your health through highly nutritious food choices and by getting enough sleep and exercise takes time and dedicated effort. But it is certainly worth it, and only gets easier over time as these new habits become ingrained.

Follow me on Twitter @MarwaAhmedMD

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My Health - Just do it… yourself: At-home colorectal cancer screening

Colorectal cancer (CRC) is the fourth leading cause of death worldwide. Yet despite the ability of CRC screening to detect colon cancer early, and to find and remove potentially precancerous growths called polyps, screening rates remain low, below 60%. Experts generally agree that people should be screened for CRC at regular intervals beginning by age 50.

Colonoscopy is considered the gold standard for CRC screening. In this procedure, a doctor examines your entire colon through a colonoscope, a flexible tube outfitted with a small video camera and a light.

But concern around pre-colonoscopy bowel cleaning, which can be uncomfortable and unpleasant, may contribute to low screening rates. Your bowel needs to be completely empty during colonoscopy to give your doctor a clear view of your intestinal wall; preparing for the test involves drinking a liquid that triggers bowel-clearing diarrhea.

CRC screening tests: Other options

So, while colonoscopy remains the gold standard, the best test is the one that gets done or gets the process started. A recent meta-analysis found that fecal blood tests, which are available by prescription and can be done at home, are associated with increased screening rates. (Patients still need a colonoscopy if there is an abnormal result, to diagnose cancer or remove polyps to prevent cancer.)

In 2016, the United States Preventive Services Task Force updated its CRC screening recommendations to state that patients and physicians can choose among available screening tests.

Currently, three types of at-home CRC screening tests are approved by the Food and Drug Administration (FDA):

• Guaiac FOBT (gFOBT) uses a chemical to detect a component of hemoglobin, a blood protein in the stool.
• Fecal immunochemical test (FIT or iFOBT) uses antibodies to detect hemoglobin shed by polyps or colorectal cancer.
• Multitarget stool DNA test (FIT-DNA) detects trace amounts of blood and DNA from cancer cells in the stool.

For all of these tests, you collect a stool sample at home using a kit, then mail the sample to a doctor or to a laboratory for testing. None require the bowel-clearing prep required for colonoscopy. Amazon sells screening tests: FOBT for $10 and FIT for $25. These are available without a prescription but are not as well studied or standardized as those available through your physician.

Pros and cons of at-home CRC screening tests

A review published in JAMA concludes that all three home tests may be an efficient first-step for low-risk patients. However, all the kits, as well as colonoscopy, can miss polyps, which can and should be removed at the time of the colonoscopy.

The FIT screening test has been in use for about 10 years. It should be repeated annually in case the cancer or polyp isn’t bleeding at the time of the test. (Colonoscopy is recommended once every 10 years for low-risk patients.) The FIT test detects cancer with 79% accuracy, with about 5% false positive results (suggesting cancer where none exists), which warrant a colonoscopy for further testing.

Studies have shown that the multitarget stool DNA test (Cologuard is currently the only FDA-approved brand) detects cancer with 92% accuracy. However, 14% of tests deliver a false positive result, which is higher than the FIT test. Health experts recommend repeating the test every one or three years.

For years we have used the gFOBT to detect microscopic amounts of blood in the stool that is not visible to the naked eye. It is less accurate than either the FIT or the DNA stool test, identifying only 20% to 50% of cancers. This test has a limited role today.

Cost considerations

An additional barrier to CRC screening is the out-of-pocket cost to patients. The Affordable Care Act mandated that insurance plans cover CRC screening tests, including colonoscopy, in full, with no out-of-pocket cost to patients. However, coverage does not apply to colonoscopies that convert from screening to diagnostic when a polyp is detected and removed during the procedure. And coverage does not apply to diagnostic colonoscopies after a positive CRC FIT or DNA screening test result.

This coverage failure means that patients may have to pay thousands of dollars to complete recommended CRC testing.

How can you decide which CRC screening test is right for you?

Ask your doctor and have a frank discussion about your risks and concerns. Most people find colonoscopy less miserable than they anticipate, and it is still the best option overall. Higher-risk people really do need a colonoscopy, usually until age 80. For others, get tested or get the screening process started, and the only wrong answer is ignoring the possibility of colon cancer.

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My Health - Aging and sleep: Making changes for brain health

As a neuropsychologist, my research interests have focused on the link between sleep and cognitive health. As I have gotten older, I have personally come to appreciate the restorative power of a good night’s sleep for thinking, memory, and functioning at my best.

Sleep affects our overall health, including our hormones and immune system. Neurobiological processes that occur during sleep have a profound impact on brain health, and as a result, they influence mood, energy level, and cognitive fitness. Numerous studies have shown that structural and physiological changes that occur in the brain during sleep affect capacity for new learning, as well as the strength of memories formed during the day. Sleep promotes the consolidation of experiences and ideas; it plays a pivotal role in memory, and has been shown to enhance attention, problem solving, and creativity.

Specific sleep stages are associated with different types of learning

Over the course of each night sleep unfolds in five different cycles which alternate throughout the night. These include Rapid Eye Movement (REM) and Non-REM stages. REM is the stage when dreaming occurs. This stage of sleep is associated with active eye movements and body paralysis, which assures that a sleeping person is protected from acting out the dream. During REM there is increased activity in limbic structures involved in memory and emotional regulation, whereas there is less activity in frontal brain systems involved in analytic thinking. Fragments of events and memories experienced during the day may be combined in novel and often bizarre ways during REM-based dreaming. REM plays a pivotal role in memory and other cognitive functions. Other sleep stages are also associated with memory.  For instance, stage 2 (slow wave) sleep promotes motor skill learning needed for activities such as playing an instrument or keyboarding.

Changing circadian rhythms and sleep disturbances are common

When we get older, we tend to feel sleepy earlier in the evening. This may result in waking up early in the morning as our sleeping hours shift. Older people have less REM and less slow wave sleep. Less slow wave sleep may impede memory consolidation in older adults. In addition to changes in sleep cycles, older people are increasingly vulnerable to sleep disturbances that cause poor sleep and low brain oxygen such as sleep apnea, a medical condition characterized by loud snoring, breathing pauses during sleep, and daytime fatigue. Research has shown that sleep apnea increases amyloid, a protein associated with Alzheimer’s disease. Poor sleep increases amyloid deposition and in turn, amyloid deposition compromises the quality of sleep.  In fact, people with Alzheimer’s disease are prone to sleep problems, including insomnia at night and excessive sleeping during the day.

Aging well means prioritizing sleep

We know that a good night’s sleep is good for our brain, especially as we get older. But how do we do this? As a first step you should use a sleep diary to keep track of your sleep schedule for at least two weeks. This will provide objective information regarding the consistency of your sleep routine as well as the association between sleep and your level of alertness during the day.

Recommendations from sleep experts such as Dr. Suzanne Bertisch provide a road map for improving sleep hygiene. The following tips are highlighted:

Consistency matters. Train your body to sleep well by going to bed and getting up around the same time each day (even on weekends).

Only sleep when you are sleepy. Do not spend too much time awake in bed.

Pay attention to your sleep environment. Your bed should be comfortable. The room should be sufficiently dark and quiet. Some people use eye masks to block light. Some use white noise filters or ear plugs when there is noise in or near the bedroom. The temperature of your bedroom should be cool. A cool room with warm blankets is optimal for a good night’s sleep.

Reserve your bed for sleep (and sex). Avoid television, reading, or work activities while in bed.

Avoid (or limit) naps. You need to be tired at bedtime. If you need a daytime nap, do this before 3 PM and for less than one hour.

Avoid stimulants (coffee, cola, chocolate, and cigarettes) for four to six hours before going to bed.

Limit alcohol intake for four to six hours before going to bed. Alcohol disrupts REM and slow wave sleep, which are important for memory.

Avoid electronic devices with LED screens for at least an hour prior to bedtime. The blue light that comes from these screens interferes with the brain’s natural sleep rhythms, and may trick your brain into thinking that it is daytime.

Use rituals. Some people enjoy a hot bath one to two hours before sleep. Others use stretching or mindfulness practices in preparation for sleep.

If you do wake during the night, don’t remain in bed struggling to fall back to sleep. Get up and do something that may increase sleepiness (like reading) for about 20 minutes, and then return to bed and try to initiate sleep.

Sleep is an important aspect of cognitive health, but it is not whole story. Further information regarding brain fitness can be obtained by reading our Special Health Report A Guide to Cognitive Fitness.

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My Health - Stretching: Less pain, other gains

As you get older, your toes may seem farther away. Stretching to reach them can take a lot more effort than it once did. But while it may be tempting to shrug and assume that losing flexibility is just a cost of aging, it’s nothing to take in stride. It can affect your balance and your posture. It can even make you more prone to chronic pain.

For example, tight hamstrings behind your knees can cause a pelvic misalignment that makes your lower back hurt. A lack of flexibility might also make you more prone to injury.

“In general, a lot of us have bad posture and poor range of motion,” says Dr. Lauren Elson, an instructor in physical medicine and rehabilitation at Harvard Medical School.

How can you improve flexibility?

The solution? Whether you’re an avid exerciser or spend most of your time sitting in front of a computer, stretching should be part of your weekly routine. While this may conjure images of complicated twists and contortions, the type of stretching you need may be as simple as taking periodic work breaks to lift your arms above your head and to perform some other easy movements.

“Stretching doesn’t have to be a particular program. It’s just getting out of the posture you spend a lot of time in, taking some deep breaths, and moving your joints through their full range,” says Dr. Elson.

Try the three main types of stretches described below to help improve flexibility. All are easy to incorporate into your day or week.

Stretches to combat a lack of movement

If you sit at a desk all day, you may be doing your posture a disservice. Many sedentary days can lead to neck and shoulder problems and tight muscles in the hips.

“Get out of your chair and move around for a few minutes every hour,” says Dr. Elson. Focus on stretches that move the neck, shoulders, and hips, in particular. Even simple movements — such as putting your arms above your head or squeezing your shoulders back while sitting at your desk — are helpful.

Also, pay attention to other potential trouble spots. For example, many women wear high heels every day, which can reduce the flexibility of their calves. Stretching the calves daily can help ensure that this does not become a problem.

Dynamic stretches before you exercise

In the past, experts recommended that people stretch thoroughly before exercise to limber up their joints. But this is no longer the case. Research has found that holding stretches for 30 seconds or more can actually reduce the power in your muscles, hindering your performance in the workout that follows.

Instead, try what experts refer to as dynamic stretches. These are movements that will warm you up without sapping your muscle strength. Dynamic stretches are simple movements that put your muscles and joints through a normal range of motion. Examples include rolling your shoulders, circling your arms up and around, or doing lunges from side to side. If you’re going to be running or playing tennis, you might want to focus on dynamic stretches that use movements similar to those you will be performing during your workout.

Static stretches after you exercise

“The best time to stretch for lengthening, for example if you’re trying to increase hamstring flexibility, is after a workout,” says Dr. Elson. This is the time to try your static stretches — those that hold your body in various stretching positions for a few seconds or more. Stretches should be held without bouncing, because bouncing can lead to injuries.

Choose the right level of challenge

How you stretch depends a lot on your basic level of mobility. Stretches can be done at varying degrees of intensity based on your fitness level. There are easier and more challenging versions of various stretches. Select the one that is appropriate for you.

Take cues from your body to determine the right level of challenge. When you stretch, you should feel the sensation in your muscle and not at the joint. “You shouldn’t feel joint pain when stretching. Rather, it should feel like lengthening of the muscle,” says Dr. Elson.

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My Health - Fear of cancer recurrence: Mind-body tools offer hope

Every year, there are more adults who have been diagnosed with cancer at some point in their lives. All of them face the uncertainty and fear that follow cancer treatments. Research shows that fear of cancer recurrence interferes with emotional and physical well-being. And it also suggests that mind-body tools can help people who have been treated for cancer regain control.

A growing number of cancer survivors

Over the past 50 years, the number of adults who have completed primary treatment for cancer has grown steadily. By 2024, an estimated 19 million will be living in the United States, a tribute to rapidly evolving options for diagnosis and treatment. There is a critical need to support survivors as they navigate the uncertainty of post-cancer life. Indeed, if you ask patients, health care providers, and researchers, you’ll find that even the often used term “cancer survivor” has different definitions and connotations.

When treatment is over, this doesn’t mean worries are over — not even among people in remission with no evidence of disease. After active treatment concludes, cancer survivors find themselves facing a new, unforeseen challenge: persistent fear and distress regarding their health and future. Survivors may continue to worry about disease recurrence for years after treatment ends. What’s more, their worries often persist at levels equal to that experienced at the time of diagnosis. In fact, 30% to 70% of cancer survivors report moderate to high levels of fear of cancer recurrence, or FCR.

Which worries crop up most often?

After cancer treatment, people confront prognostic uncertainty about their survival. They may struggle with long-term symptoms from their cancer. They must undergo ongoing medical tests and surveillance. Their treatments may have lasting consequences, such as infertility or cognitive difficulties. Uncertainty, the fear of consequences for loved ones that stem from their illness, and social role changes further contribute to the complexity of FCR.

What triggers fear of cancer recurrence?

If you’ve experienced FCR, you know cues in your social environment can be a trigger: follow-up appointments, public health campaigns, and new diagnoses among family and friends. Physical symptoms, such as pain and fatigue due to cancer treatments, aging, or other factors may also prompt you to worry that cancer has recurred.

How do people respond to these fears?

Unfortunately, distinct patterns of maladaptive behavior can emerge. On one end of the spectrum is reassurance-seeking behavior. People seek extra visits with their oncologists, request additional screenings, engage in overtreatment, or excessively examine their bodies for signs of recurrence. Cancer survivors may also cope with FCR through avoidance. They may skip or delay follow-up visits, engage in substance use, or hide out through patterns of sedentary behavior and social isolation.

How can mind-body tools help?

Mind-body techniques, such as cognitive behavioral skills, mindfulness meditation, and yoga help cancer survivors take control of persistent FCR. A systematic review and meta-analysis of 19 randomized control trials showed that mind-body techniques had small-to-medium effects in easing FCR. The most rigorously tested tools are:

• Cognitive behavioral skills, such as setting aside “worry time,” and learning to recognize and reframe fears
• Meditation techniques, such as seated meditation and meditative movement like yoga or tai chi
• Relaxation techniques, such as deep breathing and guided imagery
• Expressive art therapies, such as dance therapy.

Follow-up assessments showed that the benefits lasted as long as two years after the baseline assessment.

Certain common themes were emphasized in many of the trials included in the review. For example, participants were asked to recognize the harm of appraising ambiguous or unpredictable changes in their bodies as threatening. Indeed, research suggests that physical symptoms such as pain, fatigue, and gastrointestinal symptoms trigger fear in cancer survivors. This heightens stress, which can then aggravate physical symptoms.

Another common theme highlights the benefits of focusing on the present moment, which can help survivors reframe their relationship to uncertainty. Using mindfulness meditation and cognitive behavioral skills, people can curb both reassurance-seeking and avoidance behaviors. They learn ways to let go of thoughts and judgements, tolerate waves of uncertainty, and develop an appreciation for impermanence, particularly regarding physical symptoms.

The bottom line

Mind-body interventions offer a promising solution to managing FCR if you struggle with fear and worry after cancer treatment. If you are struggling with these worries, ask your cancer care team, primary care provider, or therapist if there are mind-body training options available to you. Taming the fear of cancer recurrence through such techniques can help you take control of your emotional and physical well-being.

Follow me on Twitter @DanielHallPhD

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My Health - 5 Things You Should Never Do After Eating! (Habits No.5 must be stopped immediately)

5 Things You Should Never Do After Eating! (Habits No.5 must be stopped immediately)

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 - Thinking about rhinoplasty?

A rhinoplasty, or nose job, is surgery performed to alter the way your nose functions and looks. According to the American Society of Plastic Surgeons, nearly 220,000 rhinoplasties are performed yearly, making this the most common facial plastic surgery procedure. Rhinoplasty can simultaneously help you improve breathing and achieve a more balanced appearance.

Is rhinoplasty right for me?

A common medical reason for rhinoplasty is difficulty breathing through the nose. Nasal obstruction can cause problems with exercise, disturb sleep, contribute to snoring and sleep apnea, or interfere with other activities. If medical treatments (such as nasal spray or sleep apnea treatment) fail, surgery may be the next step. Rhinoplasty done for medical reasons such as these is often covered by health insurance.

Nasal surgery is tailored to the underlying problem. If the septum –– the midline wall of cartilage that divides the right and left sides of the nose –– is deviated, then a septoplasty alone may fix the problem. However, when a septal deviation is more severe, or occurs nears certain critical areas of nasal support, a rhinoplasty is required to ensure proper breathing and nasal shape. Rhinoplasty (also called septorhinoplasty) addresses the septal deformity and strengthens key breathing areas of the nose with strategically placed cartilage grafts.

What about cosmetic rhinoplasty?

Patients often ask, “While you’re in there, could you make other changes to my nose?” The answer is yes. The most common requests are reducing a nasal hump, refining the tip, or correcting asymmetries. These cosmetic changes, which are not covered by insurance, are frequently combined with functional rhinoplasty so there is only one recovery.

What should I know about this surgery?

Rhinoplasty is performed under general anesthesia. A very small incision is made along the base of the nose, which is not noticeable after the skin heals. This incision is connected to incisions inside the nose, which are never seen. Those incisions permit access to the cartilage and bones of the nose. Next, the nasal passageways are improved and nasal reshaping (if desired) is performed through careful, meticulous adjustments to the bone and cartilage.

Frequently patients ask, “Will you need to break my nose?” Usually not. Most rhinoplasties leave the bones intact. If patients have had significant trauma to the nose in the past, the nasal bones are sometimes shifted into a more favorable position during surgery. For cosmetic reasons, a bony nasal hump may be smoothed down to a straight profile or gentler curve. Patients awaken from anesthesia and go home the same day.

What should I expect for recovery?

You should expect to take one week off from work or school. During that time rest, ice, and a regimen of nasal cleaning is recommended. While pain medications are provided, most people only require them for a few days.

During recovery, it is difficult to easily breathe through the nose because splints (bendable, thin plastic sheets) are placed inside the nose to keep the septum straight. Swelling peaks on the third day, and then decreases. Bruising under the eyes can sometimes occur. During the week after surgery, you’ll wear a small cast on your nose to protect it and reduce swelling.

One week after surgery the splints and cast are removed in the office. You may then return to work and resume cardio exercise, such as walking or running. You’ll need to avoid contact sports for six weeks. Otherwise, within two weeks after surgery, you should be back to your normal activities and routines.

While you are likely to heal quickly during the first month, full healing may take up to one year. The majority of swelling disappears in the first month, and all swelling should be gone within a year or less.

To learn more about rhinoplasty

If you are interested in rhinoplasty for functional and/or cosmetic reasons, set up a consultation with a board-certified surgeon who routinely performs nasal surgery. You can ask your primary care doctor or health insurance plan for a referral to a surgeon in your network. Your surgeon and you can then create an individualized plan tailored to your goals.

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