My Health - Where people die

Truer words were never spoken: we all have to die sometime. But here’s something you may have thought less about: we all have to die somewhere. And most people don’t want it to be in a hospital. Despite this, about one-third of deaths in this country occur in hospitals. The good news is, that this seems to be changing.

Where people die is changing

Although more than 700,000 people die in hospitals each year in the US, the trend is toward fewer in-hospital deaths. According to the CDC, the number of people dying in the hospital dropped from 776,000 to 715,000 (an 8% drop), even as hospital admissions increased from 31.7 million to 35.1 million (an 11% increase). Some of the most dramatic reductions in hospital deaths were among people with kidney disease and cancer.

A July 2016 study published in the medical journal Health Affairs found that deaths in the emergency room have dropped as well. In fact, the study found that the number of deaths occurring in US emergency rooms dropped by almost half between 1997 and 2011. The actual rates reflect how rare emergency room deaths are: from 1.48 to 0.77 per 1,000 adults. It’s unclear how much lower these numbers can go. Almost two-thirds of the deaths occurred among people who arrived in the ER unconscious, in cardiac arrest, or dead on arrival.

What explains these trends?

Some of the reduction in deaths during hospital stays and emergency room visits could be due to improved treatment. But much of the decrease is probably due to other factors, including:

• Improved availability and acceptability of alternative sites of care, including hospice settings. A 2018 study of older adults found that compared with deaths occurring in 2000, those who died in 2015 were more likely to die at home or in a community-based setting (31% vs. 40%) and less likely to die in an acute care hospital (33% vs. 20%).
• A growing movement to “have the conversation,” to find out what people want in the event of terminal illness. Often it is not heroic, inpatient treatment.
• A growing awareness by patients and their doctors that in many situations, inpatient treatment is futile, and that concerns about quality of life should matter more than length of life. For conditions that are known in advance to be terminal, including many types of cancer, there is ample opportunity to plan ahead regarding what types of treatment to accept and where they should be provided.

Of course, where a person dies isn’t the whole story. It’s possible that patients who used to die in the hospital may be saved by aggressive and intensive medical care, only to be transferred to nursing homes with severe disabilities and a poor quality of life. In addition, the 2018 study found that “late transitions of care” (a change in the site of care within three days of death) occurs about 10% of the time. So more deaths at home may still be preceded by days and weeks in and out of the hospital, with hospice care only at the very end.

Many people still die in hospitals

If most people do not want to die in hospitals, why are so many deaths in this country still occurring there? There are probably a number of reasons, including:

• Death is often unpredictable. Many inpatient deaths occur after long admissions that begin with what seems to be a treatable problem.
• An overestimation of the ability of medical care to cure incurable illness or reverse setbacks.
• A lack of alternatives. In many parts of the country, dying patients are stuck in the hospital because they need more care than they can get at home and have nowhere else to go.
• The “culture” of medicine and availability of medical care. Medical training teaches doctors to diagnose and treat illness, but until recently, trainees learned little about when treatment is futile or how to de-escalate treatment. In addition, studies suggest that more aggressive, inpatient medical care tends to be offered in places where there are more specialists and more hospitals. Doctors may encourage patients to have inpatient treatment with little chance of changing the long-term outcome, perhaps due to an overly optimistic view of the prognosis.
• Medical error or “misadventure.” Critically ill individuals have limited capacity to tolerate the downsides of medical treatment, such as side effects or medical errors.
• A healthcare system focused on the short term. For example, Medicare will cover inpatient care for a person who has had a stroke. But if that patient preferred to stay at home, care at home would not be covered even though it would be much less costly.

What’s next?

The dropping rates of inpatient and emergency room deaths are encouraging trends. But if where you die is important to you, plan ahead. And if you haven’t given much thought to what you would want in the event of terminal illness, or if you’ve never discussed it with your loved ones (or healthcare proxy), don’t put it off. We all need to think about end-of-life care, especially if we want to avoid dying in the hospital.

I think hospital deaths will continue to fall. Increasingly, doctors and patients are recognizing that more care is not always better care. Most hospitals have active error-reduction programs. And medical care continues to improve thanks to cutting-edge research. All of these developments should lower in-hospital deaths further. Although change of this sort tends to be quite slow, these new studies suggest it’s happening faster than I would have expected.

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My Health - What parents need to know — and do — about e-cigarettes

Here’s why parents need to know about e-cigarettes. First, many more teens are using them. In 2017, 3% of middle school students and 12% of high school students reported using them, and while that may not sound like a lot, since 2011 use has gone up about 500% in middle school and 800% among high school students. And, e-cigarettes can be dangerous.

How e-cigarettes work

E-cigarettes are basically delivery devices for nicotine, the addictive chemical in tobacco. The hope of the Food and Drug Administration (FDA) is that they might possibly decrease smoking — which would be great, as smoking is the leading preventable cause of death in the United States. It’s the smoke itself that causes the vast majority of the health risk, so the idea was that perhaps if you gave people a way to inhale nicotine that didn’t involve burning tobacco, you might get them away from tobacco, especially if you were able to gradually decrease the amount of nicotine they inhale.

The problem is that not only did it turn out that these devices don’t really help people quit, they are being marketed to youth, and youth are buying them.

Why e-cigarettes are especially dangerous for young people

This is where the danger comes in. E-cigarettes are dangerous for youth in at least three ways:

• Nicotine can affect developing brains, putting young users at higher risk of addiction and mental health problems.
• Inhaling the vapor itself can cause breathing problems.
• E-cigarette use makes it more likely that youth will start smoking tobacco.

This is a big enough concern that the FDA is launching an effort to curb e-cigarette use in youth. They have targeted the major manufacturers (JUUL, Vuse, blu E-Cig, MarkTen, Logic) and are not only examining their marketing practices, but asking them to come up with “robust” plans to curb youth use of their products. They are also looking at other ways to curb use, including education and regulation. Many states have laws regulating the sale of e-cigarettes to youth, and others are considering them.

Here’s what parents need to do

• Get educated. Learn about e-cigarettes and their health risks.
• Talk to your kids about them. Ask about what they know, ask if they have tried them, ask if their friends have tried them. Ask if they see others using them at school. Make sure they understand the dangers.
• Advocate! Talk to your elected officials about better laws to protect our children. Talk to your school and community about education and outreach.

All of us need to take action, before the danger gets any worse.

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My Health - Investigators unveil metastatic prostate cancer’s genomic landscape

Localized prostate cancer that is diagnosed before it has a chance to spread typically responds well to surgery or radiation. But when a tumor metastasizes and sends malignant cells elsewhere in the body, the prognosis worsens. Better treatments for men with metastatic prostate cancer are urgently needed. In 2018, scientists advanced toward that goal by sequencing the entire metastatic cancer genome.

The newly revealed genomic landscape includes not just the active genes that make proteins, but also the vast stretches of DNA in between them that can also be functionally significant. Most of the genomic alterations were structural, meaning that DNA letters in the cells were mixed up, duplicated, or lost. A major finding was that the androgen receptor, which is a target for hormonal medications used when cancer returns after initial treatment, was often genetically amplified. That could explain why patients often become stubbornly resistant to hormonal therapies: if the androgen receptor is hyperactive, then the treatments can’t fully block its activity.

The research revealed many other sorts of alterations as well. For instance, DNA-repair genes such as BRCA2 and MMR were often defective. Cells rely on these genes to fix the genetic damage that afflicts them routinely every day, but with their functional loss, cancerous changes can follow. Cancer-driving oncogenes such as MYC were common, as were “tumor-suppressor” genes such as TP53 and CDK12, which ordinarily work to keep cancer at bay.

Metastatic prostate cancer differs from one man to another, and likewise, the frequency of these alterations varied among the more than 100 men who provided samples for analysis. By exploring the data, scientists can now develop new hypotheses for testing, and refine personalized treatment strategies to help men with this life-threatening disease.

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My Health - Do I need orthotics? What kind?

Many people come to my office complaining of foot pain from conditions such as bunions, hammertoes, pinched nerve (neuroma), and heel pain (plantar fasciitis). I perform a thorough evaluation and examination, and together we review the origin, mechanics, and treatment plan for the specific problem or issue. The patient usually asks if they need an orthotic and, if so, which type would be best.

I recommend a foot orthotic if muscles, tendons, ligaments, joints, or bones are not in an optimal functional position and are causing pain, discomfort, and fatigue. Foot orthotics can be made from different materials, and may be rigid, semirigid, semiflexible, or accommodative, depending on your diagnosis and specific needs.

Different types of orthotics

Most of my discussions center around three types of foot orthotics: over-the-counter/off-the-shelf orthotics; “kiosk-generated” orthotics; and professional custom orthotics. Over-the-counter (OTC) or off-the-shelf orthotics are widely available and can be chosen based on shoe size and problem (such as achilles tendinitis or arch pain). Kiosk orthotics are based on a scan of your feet. A particular size or style of orthotics is recommended for you based on your foot scan and the type of foot problem you are experiencing. They may help with heel pain, lower back pain, general foot discomfort, or for a specific sport.

For custom prescription orthotics, a health professional performs a thorough health history, including an assessment of your height, weight, level of activity, and any medical conditions. A diagnosis and determination of the best materials and level of rigidity/flexibility of the orthotics is made, followed by an impression mold of your feet. This mold is then used to create an orthotic specifically for you. The difference between OTC/kiosk and custom orthotics may be likened to the difference between over-the-counter and prescription reading glasses.

Which type of orthotic is right for you?

A person of average weight, height, and foot type, and with a generic problem such as heel pain, usually does well with an over-the-counter or kiosk orthotic. They are less expensive, and usually decrease pain and discomfort. However, you may have to replace them more often. Someone with a specific need, or a problem such as a severely flat foot, may benefit from custom prescription orthotics. While more expensive and not usually covered by insurance, they generally last longer than the OTC/kiosk type.

Before investing in orthotics, I recommend spending your hard-earned money on quality, properly fitted shoes specific for your work or athletic activities. You may be surprised to learn that many people have not had their feet professionally measured at a shoe store in years. As we age, our foot length and width changes. And sizing may not be consistent between brands; the same size 9-1/2 narrow shoe may differ significantly from one manufacturer to another.

If your pain or discomfort does not improve with new shoes, try over-the-counter or kiosk orthotics for a period of time. If you see improvement, fine. If not, see a health care professional for an evaluation for custom prescription orthotics.

In my experience, certain groups of people benefit from an examination performed by a health care professional, and a prescription for custom orthotics. These include people with diabetes who have loss of feeling in their feet, people with poor circulation, and people with severe foot deformities caused by arthritis. In fact, Medicare has a program that covers 80% of the cost of diabetic shoes and orthotics, because studies have shown that they decrease the chance of developing an open sore that can lead to amputation.

In summary, if you feel you know what is causing your foot pain, you don’t fall into any of the groups that benefit from professional custom orthotics, and you already wear a properly fitted pair of shoes, go ahead and try the OTC or kiosk orthotics. For most people, these will provide relief. After taking these steps, if you notice no improvement in your condition, then seek out the advice of a health care professional.

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My Health - A new option for immunotherapy in metastatic prostate cancer

Dividing cells face daunting challenges when replicating the billions of letters of DNA in their genomes. For instance, DNA letters in new cells can get mixed up, and then the affected genes don’t function correctly. To fix that problem, healthy cells can deploy so-called mismatch repair (MMR) genes that put scrambled DNA letters back in the correct order. But when those genes are themselves defective, then this repair system breaks down. And as a result, cells develop a progressive condition called microsatellite instability that leaves them vulnerable to cancer.

Those sorts of defects are shared by many different tumor types. The good news is that they are susceptible to the killing effects of an immunotherapy drug called pembrolizumab. The FDA approved that drug last year for all MMR/MSI-positive metastatic cancers, regardless of where they originate in the body. Pembrolizumab works by training the immune system’s T cells to recognize and destroy cancer cells bearing this genetic biomarker.

Earlier this year, scientists reported new findings with pembrolizumab in men with prostate cancer. Of the 839 men they evaluated, 2.5% had MMR defects and high levels of microsatellite instability. In about a quarter of the men, those defects were somatic, meaning they had been acquired after conception and were localized to the cancer. In the rest of the men, the defects were inherited and expressed by all the cells in their bodies.

This was the first study to investigate how the drug performs in men with MMR/MSI-positive prostate cancer, and the results were encouraging: Among half the treated men, PSA levels dropped by 60% to 80%. Since prostate cancer cells release PSA, a decline in the level of that hormone shows the drug is working. Moreover, tumors also shrank in as many as 40% of the men whose PSA levels were responding to treatment.

The authors of this study recommended that all metastatic prostate cancer patients be tested for these defects, since pembrolizumab might also work for them. 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, agrees. “This is an exciting development as it opens up therapeutic possibilities that would have never been considered previously,” he said. “Moreover, our own personal experiences in testing for MMR mutations and treatment with pembrolizumab have been remarkable. Testing will likely become mandatory as more experience is gathered.”

 

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My Health - Alcohol and headaches

Alcohol is embedded in our society, and it is difficult to be in a public space without seeing a reference to alcohol or being offered a drink. Alcohol is broken down in the liver by an enzyme called alcohol dehydrogenase. People with a variant in this enzyme have issues with metabolizing alcohol and can develop total body flushing or reddening of the skin.

Alcohol consumption has been associated with pregnancy defects, liver disease, pancreatitis, high blood pressure, coronary artery disease, stroke, cancer, addiction issues, and physical injury (trauma to self/others with acute intoxication). The health benefits of alcohol may be up for debate. However, moderate alcohol consumption may have some beneficial effects, which was appreciated in 1992 based on the observation that populations in France had high dietary intake of saturated fats, but a relatively low incidence of cardiovascular disease. This phenomenon was labeled as the “French paradox,” and has been thought to be due in part to the consumption of red wine.

Quit your wine-ing?

Alcohol has long been associated with the development of headache, with about one-third of patients with migraine noting alcohol as a trigger. Based on this association, population studies show that patients with migraine tend to drink alcohol less often than people without migraine. Wine in particular is an alcoholic beverage that has been linked to headaches dating back to antiquity, when Celsius (25 B.C.–50 A.D.) described head pain after drinking wine. Despite this commonly held belief, there is very little scientific evidence to support the belief that wine is a more common trigger of headaches than other forms of alcohol.

The studies that have been conducted suggest that red wine, but not white and sparkling wines, trigger headache independent of how much a person drinks in less than 30% of people. Lower quality wines may cause headaches due to the presence of molecules known as phenolic flavonoid radicals, which may interfere with serotonin, a signaling molecule in the brain involved in migraines. In one study, the odds of a person citing red wine as a trigger of headache were over three times greater than the odds of indicating beer as a headache trigger. In some studies, it was observed that spirits and sparkling wines were associated with migraines significantly more frequently than other alcoholic beverages.

Here is the advice of one wine expert

I turned to Barb Gustafson, a sommelier (certified wine professional) for some insight on the qualities of wine that might be associated with headache.

(Barb works at Paul Mathew Vineyards — and yes, there is actually a winemaker in California that bears a name spelled identically to my own, but there is no relation.)

Barb comments:

As far as red wine, often I’m told by consumers they cannot drink red wine or wine with sulfites. This to me is not accurate. I cannot be of absolute certainty but my circle would disagree. It is often the quality of the red wine that seems associated with headaches. Of course, quantity can certainly play a role regardless of quality. As well, highly processed wines should be of concern. “Low input” winemaking relies on native yeasts that live on the vine, adding very low amounts of sulfur dioxide, and allowing the wine to ferment in its own time. This type of wine seems less likely to affect our heads.

With 30 years of paying close attention to consumption and the boundaries, I have evolved to limiting high alcohol, highly tannic, and heavily processed wines. With the huge focus on organic foods and what we all eat, there should be as much attention put on what we drink.

A parting shot: What does this mean for you?

It is clear that quantity can play a role in triggering headaches, and quality probably plays a role, but we do not know for sure how any type of wine or alcohol will affect people with migraine or who are prone to headaches. Like food triggers, the likelihood of a particular type of alcohol triggering a headache is probably different from person to person. If you suffer from migraines, talk with your doctor about how alcohol may affect you.

Sources

Moderate red wine consumption and cardiovascular disease risk: beyond the “French paradox”. Seminars in Thrombosis and Hemostasis, February 2010.

Alcohol and migraine: what should we tell patients? Current Pain and Headache Reports, June 2011.

Wine and Headache. Headache: The Journal of Head and Face Pain, June 2014.

Alcohol Use as a Comorbidity and Precipitant of Primary Headache: Review and Meta-analysis. Current Pain and Headache Reports, August 2017.

Wine and migraine: compatibility or incompatibility? Drugs Under Experimental and Clinical Research, 1999.

Food as trigger and aggravating factor of migraine. Neurological Sciences, May 2012.

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My Health - Q&A with Dr. Daniel Rukstalis on prostatic urethral lift for enlarged prostates

A new procedure that relieves symptoms without causing sexual side effects

As men get older, their prostates often get bigger and block the flow of urine out of the bladder. This condition, which is called benign prostatic hyperplasia, causes bothersome symptoms. Since men can’t fully empty their bladders, they experience sudden and frequent urges to urinate. Treatments can relieve these symptoms, but not without troubling side effects: pharmaceutical BPH treatments cause dizziness, fatigue, and retrograde ejaculation, meaning that semen gets diverted to the bladder during orgasm instead of being ejected from the body. Surgical treatments such as transurethral resection of the prostate, or TURP, can relieve symptoms for many years. But they also take weeks or months to recover from, and men can experience permanent retrograde ejaculation, and in some instances, long-term impotence.

Still, it’s important to treat BPH to avoid even worse problems later. Left untreated, men can develop urinary retention, which is an acute inability to urinate without a catheter, and their bladder health can also deteriorate over time.

An alternative

Now a newer BPH procedure, called prostatic urethral lift, or UroLift, provides another option. And unlike drugs and older BPH surgeries, it spares sexual functioning.

During a UroLift procedure, doctors use tiny implants and sutures to pull the prostate away from the bladder so that urine flows more freely out of the body. The procedure can be performed in a doctor’s office, and most men go home the same day without a catheter. Clinical studies have shown that symptomatic improvements hold up for at least five years, which is comparable to study results with TURP.

The FDA approved UroLift for enlarged prostates in 2013, and the American Urological Association began recommending it as a standard of care option this year. Urologists around the country are getting up to speed on the procedure, which is now becoming increasingly available. Readers should be aware that the AUA gave UroLift a “C” grade, in part because the long-term data in support of the procedure aren’t as plentiful as they are for TURP and other more invasive surgeries, which received a grade of “B.”

For more information, we spoke to Daniel Rukstalis, M.D., a professor of urology at Wake Forest School of Medicine in Winston-Salem, North Carolina. Dr. Rukstalis led the clinical trials behind UroLift’s approval by the FDA, and he’s performed the UroLift procedure on over 350 BPH patients. (For full disclosure, Dr. Rukstalis is a clinical investigator for NeoTract, the company that developed UroLift).

Q: Dr. Rukstalis, thank you for joining us. Why would a man consider UroLift offer over other BPH treatments?

Rukstalis: Well, all the available therapies can lessen obstructive urinary symptoms and minimize long-term risks to the bladder. But UroLift is at this moment the only BPH treatment that completely spares erectile and ejaculatory functioning.

Q: How good is it at improving BPH symptoms overall?

Rukstalis: Our clinical trial led to a 12-point drop on average in International Prostate Symptom Scores (IPSS). [The IPSS is an eight-question screening tool that scores the severity of symptoms such as incomplete bladder emptying, urinary frequency, and weak streams. Men treated for BPH usually have IPSS scores of at least 20.] The trial had 206 participants. And at five years, their IPSS scores were still improved by about a third and their quality of life scores were also about 50% higher than when they had the procedure.

Q: Who is eligible for a UroLift?

Rukstalis: It’s FDA-approved for men 45 and older with prostates up to 80 grams in size (a normal prostate in a man ranges between 7 to 11 grams). But my view is that UroLift works best in prostates ranging from 25 to 60 grams. About a third of men with BPH also have what’s called a “median lobe,” or a bit of prostate tissue that protrudes up into the bladder. We just completed a clinical trial showing that UroLift works well for these men too. On the basis of that study, the FDA approved UroLift for men with median lobes in early 2018. We’ll typically evaluate potential candidates with a pelvic ultrasound, which provides a lot of information about the health of the bladder and the size and shape of the prostate.

Q: What can a man expect going into the procedure?

Rukstalis: We’ll put him to sleep with intravenous propofol, which is the same anesthetic used during a colonoscopy. The UroLift implants get delivered into the prostate with a rigid metal scope that goes directly through the penis. By pulling excess prostate tissue out of the way, the implants create a channel through which urine can flow. (This YouTube video provides a good overview.) We do this as an outpatient procedure.

 Q: What will he experience after the procedure is done?

Rukstalis: He can expect some transient blood in the urine and a burning sensation when he pees, but this all clears up within about three days. About 2% to 4% of the men I treat spend a few days using a catheter.

Q: Why doesn’t UroLift work for larger prostates over 60 grams?

Rukstalis: Because beyond a certain size threshold, the implants don’t open the channel well enough. Also you wind up needing too many implants, and they’re very expensive — anywhere from $700 to $1,000 each. The procedure is optimized for four to six implants and you really don’t want to use more than seven of them.

Q: This is a new procedure. How important is the doctor’s experience?

Rukstalis: UroLift is a judgment-based procedure in terms of the number of implants used and where in the prostate a doctor puts them. What I would say is that you’re looking for a doctor who’s comfortable with a cystoscope [which is a hollow metal rod with a lens used for prostate examinations]. If a doctor is comfortable with cystoscopy equipment, then he or she can adopt quite readily to the technology. And there are excellent UroLift training programs around the country for any urologist who wants to do it.

Q: What about long-term prospects? Do men need repeat treatments?

Rukstalis: We know that most men still benefit from treatment at five years. But we can’t say whether those results predict benefits at 10 years or longer. We haven’t done those studies yet, but they haven’t been for TURP and the other surgical procedures either. My view is that it depends on prostate size. Men with smaller prostates will benefit for longer durations.

Q: Does having had a UroLift complicate things for a man who might need a TURP later?

Rukstalis: Not in my experience. I’ve performed TURPs, prostatectomies, and laser prostate surgeries in people who had a UroLift with no trouble.

Q: Do you have any criticisms of the procedure?

Rukstalis: It’s too expensive. We need to find ways of doing UroLift at lesser cost. And some men find it doesn’t work as well as they had hoped, even though in these men, the procedure goes a long way toward protecting bladder functioning.

Q: Thanks very much! I’m sure our readers will appreciate your insights.

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 also commented on the UroLift: “This is one of many emerging options for non-pharmacologic BPH treatment that can now be offered to the proper patient matched to the appropriately trained urologist. As with many procedures, longer-term outcomes are needed to determine its proper role in treating this very common problem.”

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My Health - Love those legumes!

“Legumes” sounds like such a fancy word.  Let’s clarify that we’re talking about beans, folks. Beans, lentils, peas, chickpeas, it’s all good… and good for you.  Legumes are amazingly nutritious, high in protein and fiber, low in fat, and low in glycemic load.

Legumes for heart health

Scientific studies have definitively linked a diet high in legumes with a lower risk of developing obesity, diabetes, high blood pressure, high cholesterol, heart disease, or strokes. As a matter of fact, eating legumes every day can effectively treat these diseases in people who already have them. In one randomized controlled clinical study of over 100 people with type 2 diabetes, consuming at least one cup of legumes (beans, chickpeas, or lentils) every day for three months was associated with significant decreases in body weight (2.7 kilograms, about 6 pounds); waist circumference (a 1.4 centimeter decrease); blood sugar (a 0.5% decrease in HbA1c); cholesterol (an 8-point decrease in LDL, measured in mg/dl); and blood pressure (a 4.5-point decrease in systolic and a 3.1-point decrease in diastolic blood pressures, measured in mm Hg). All of these improvements are impressive! We’re talking about beans, not medicines with all those side effects, right? Right: you can check out the entire study here.

Similar findings have been reported from other studies. An analysis of eight randomized controlled clinical trials including data from over 550 participants with a wide variety of medical problems found that participants who consumed about a cup of legumes every day for 10 weeks had a significant decrease in systolic blood pressure (average 2.25 points). In another study, researchers combined data from ten randomized controlled trials representing over 250 participants who had been prescribed legumes every day for at least three weeks. The legumes varied: pinto beans, chickpeas, baked beans, lentils, and peas in amounts ranging from 1/2 cup to 2 cups. None of the participants was taking cholesterol-lowering medication, and yet the legume diets resulted in an average 8-point decrease in LDL cholesterol (that’s the low-density lipoprotein, the “bad” cholesterol). This is better than many people can achieve with pills! You can check out this study here.

How can beans have all of these benefits?

Legumes are high in fiber, specifically viscous soluble fiber, which not only slows their absorption in the small intestine, but also binds up certain molecules having to do with cholesterol. This makes legumes very low in glycemic index and load, meaning they result in lower blood sugars and less insulin released after eating them. This fiber also lowers cholesterol levels.

But wait — there’s more: not only are legumes high in fiber, they are also high in protein, making them very filling and satisfying, so people tend to eat less of other things. And they contain plenty of potassium, magnesium, folate, and other plant nutrients that are associated with lower blood pressure and improved cardiovascular health.

Despite all of this good evidence, people in the United States tend not to eat a lot of legumes. Given how healthy and economical beans, lentils, chickpeas, and peas are, we aim to help with some suggestions:

• Chili: this popular dish can be super-healthy, too. Omit any meat and add extra beans (no-salt-added or low-salt canned beans work well).
• Lentil or minestrone soup: hearty and warming soups can easily be made at home or purchased (be sure to purchase low-salt varieties).
• Hummus: you can make this at home! Check out Dr. Rani Polak’s easy recipe below.

Healthy Hummus

Ingredients

1 pound dry chickpeas, soaked overnight and drained (or use three 16-ounce cans chickpeas, which is equal to 4 cups, and omit the water and baking soda below)

3 quarts water

1 teaspoon baking soda

1/2 teaspoon Atlantic sea salt

1/2 teaspoon ground black pepper

1/3 cup tahini

The juice from 1/2 large lemon (about 2 tablespoons of juice)

2 cloves garlic

1/4 teaspoon cumin

Directions

Prepare dried chickpeas: In a large pot, combine chickpeas, water, and baking soda, and bring to a boil over high heat. Reduce heat to medium and cook, uncovered, for about 2 hours, until chickpeas are soft. Drain chickpeas (keep 1/2 cup of the cooking water), season with salt and pepper, and set aside to cool.

(If using canned, no need for the water and baking soda)

Transfer cooked or canned chickpeas, tahini, garlic, lemon juice, cumin and 1/2 cup of the cooking water to a food processor and puree.  Adjust flavors with salt and pepper, and serve with olive oil.

Resources:

Can Pulses [Legumes] Play a Role in Improving Cardiometabolic Health? Evidence from Systematic Reviews and Meta-Analyses. Annals of the New York Academy of Sciences, March 2, 2017.

Prevention and Management of Type 2 Diabetes: Dietary Components and Nutritional Strategies. The Lancet, June 7, 2014.

Effect of Legumes as Part of a Low Glycemic Index Diet on Glycemic Control and Cardiovascular Risk Factors in Type 2 Diabetes Mellitus. JAMA Internal Medicine, November 26, 2012.

Effect of Dietary Pulses [Legumes] on Blood Pressure: A Systematic Review and Meta-Analysis of Controlled Feeding Trials. American Journal of Hypertension, September 7, 2013.

Non-soy Legume Consumption Lowers Cholesterol Levels: A Meta-Analysis of Randomized Controlled Trials. Nutition, Metabolism and Cardiovascular Diseases, February 2011.

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My Health - 10 behaviors for healthy weight loss

Losing weight is challenging, and it seems everyone has an opinion on the best way to do it. The bottom line is “one size does not fit all” when it comes to weight loss. Basic differences such as age, sex, body type, underlying medical issues, physical activity, genetics, past experiences with dieting, and even food preferences can influence a person’s ability to lose weight and keep it off.

About half of American adults surveyed between 2013 and 2016 reported trying to lose weight at some point during the prior 12 months. And yet nearly 70% of adults in the United States are overweight or obese. Excess weight is associated with serious health conditions including type 2 diabetes, cardiovascular disease, and some cancers.

Although there is not one “perfect” diet for weight loss, research does support certain universal behaviors for people who are trying to lose weight. These include cutting out soda and sugary drinks, avoiding a sedentary lifestyle, and focusing on food quality rather than simply on calories.

Here are 10 behaviors that can support efforts for weight loss and healthful eating:

1. Know where you are starting. Keep a food record for three days. Track all the food and beverages you eat along with the portions. Identify how often you are eating away from home, eating takeout, or buying food on the run.
2. Home in on your goal and make a plan. What is your goal? Do you want to lose weight to improve your health? Do you dream of fitting into an old pair of jeans? How will you achieve your goal? Will you cook more meals at home? Will you eat smaller portions? Be specific and start small.
3. Identify barriers to your goals — and ways to overcome them. Could a busy schedule get in the way of going to the gym? Wake up an hour earlier. Has an empty pantry prevented you from cooking at home? Look up some healthy recipes, then head to the grocery store armed with a list of ingredients you’ll need to prepare them.
4. Identify current habits that lead to unhealthful eating. Do you relax and reward yourself by snacking in front of the TV? Do you skip lunch only to feel starved by midafternoon, ready to eat anything in sight? Do you finish everything on your plate even after you start to feel full?
5. Control your portions. Refamiliarize yourself with standard serving sizes. Did you know that one serving of poultry or meat is 4 ounces, or the size of a deck of playing cards? Or that one serving of pasta is only 1/2 cup?
6. Identify hunger and satiety cues. Be aware of physical versus emotional hunger. Do you eat when you feel something physical in your body that responds to food? Or do you eat when you are stressed, bored, tired, sad, or anxious? Try to stop eating BEFORE getting full (it takes about 20 minutes for your brain to register “stop eating” signals from your stomach). Foods that can help you feel fuller include high-fiber foods such as vegetables, whole grains, beans, and legumes; protein (fish, poultry, eggs); and water.
7. Focus on the positive changes. Changing behavior takes time — at least three months. Don’t give up if you slip up along the way. Get support from others and take the time to acknowledge the changes you have made.
8. Go with the 80/20 rule. Stay on track 80% of the time, but leave some room for a few indulgences. You don’t want to feel deprived or guilty.
9. Focus on overall health. Walk, dance, bike, rake leaves, garden — find activities you enjoy and do them every day. Ditch the “diet” aisle and focus on seasonal, whole, high-quality foods.
10. Eat slowly and mindfully. Enjoy the entire experience of eating. Take the time to appreciate the aromas, tastes, and textures of the meal in front of you.

Changing behavior takes time and effort. Taking a few small steps today will make a difference in your health tomorrow.

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My Health - Intensive CBT: How fast can I get better?

A highly effective psychotherapy called cognitive behavioral therapy (CBT) focuses on how our thoughts, beliefs, and attitudes can affect our feelings and behavior. Traditional CBT treatment usually requires weekly 30- to 60-minute sessions over 12 to 20 weeks. A faster option now emerging is intensive CBT (I-CBT), which employs much longer sessions concentrated into a month, week, or weekend — or sometimes a single eight-hour session.

CBT helps people learn tools to reframe different types of thinking, such as black-and-white thinking (I can’t do anything right) and emotional reasoning (I feel you dislike me, so it must be true) and other potentially harmful thought patterns that fuel mental health problems and undermine relationships, work, and daily life. Once learned, the coping strategies taught during CBT or I-CBT sessions can help people deal with a variety of problems throughout life.

Can intensive CBT help people with anxiety, depression, and other issues?

I-CBT has been used to treat many people suffering from mood and anxiety disorders, trauma-related disorders, and other issues. Some programs treat children or teens who have mild autism spectrum disorder (mild ASD), selective mutism, or prenatal alcohol exposure, or who are struggling with school refusal.

There are I-CBT programs that focus in specific areas, such as:

• attention deficit hyperactivity disorder (ADHD)
• anxiety disorders, including agoraphobia, generalized anxiety disorder (GAD), social anxiety, specific phobias, panic attacks and panic disorder, and separation anxiety
• obsessive-compulsive disorder (OCD)
• post-traumatic stress disorder (PTSD), sexual trauma, and traumatic brain injury (TBI).

Is intensive CBT effective?

Research on effectiveness — or whether or not I-CBT works — is relatively new. Studies suggest it is effective for treating OCD. Children and adults who have this condition make similar, long-lasting gains with traditional or intensive CBT. It’s also effective for treating panic disorder in teens, anxiety symptoms in children with mild autism spectrum disorder, and severe mood disorders.

Additionally, fewer people drop out of treatment with I-CBT compared with traditional CBT.

Who might benefit from the short time span?

People with full-time jobs who find it difficult to take time off during the work week for weekly appointments might be able to commit to a weekend of intensive treatment. Teenagers busy with academics and activities during the school year may benefit from intensive sessions for a week during the summer. Families juggling multiple schedules can benefit from I-CBT because it allows them to focus on treatment without feeling their time is split among several other commitments. And people who live in areas without easy access to mental health services or specialists may be able to travel for a weekend for intensive treatment.

I-CBT may also help people who have tried traditional CBT, but have not found it feasible or successful. Alternatively, I-CBT sessions may introduce people to this form of psychotherapy, and its benefits, thus serving as a catalyst for traditional CBT treatment.

What are the drawbacks?

Most importantly, the effectiveness of I-CBT is still being evaluated. Intensive treatment requires specialized therapists who are trained to deliver I-CBT. It may not be possible to find a well-qualified program or therapist nearby, which would add to the cost and time commitment of treatment. Most insurance companies do not cover intensive treatments such as I-CBT, so it can be expensive.

Resources

Programs specializing in I-CBT for children and teens include the following:

• Boston University Child and Adolescent Fear and Anxiety Treatment Program, Boston, MA.
• Boston University Brave Bunch Program, Boston, MA.
• Child Mind Institute Intensive Treatment, New York, NY.
• McLean Anxiety Mastery Program, Belmont, MA.
• UCLA Semel Institute for Neuroscience and Human Behavior Child OCD Intensive Treatment Program, Los Angeles, CA.
• UCLA Resnick Neuropsychiatric Hospital ABC Intensive Outpatient Program, Los Angeles, CA.
• University of South Florida Rothman Center for Pediatric Neuropsychiatry Intensive CBT for OCD, Tampa, FL.
• Weill Cornell Medicine Intensive Treatment Program (ITP) for Children and Adolescents, New York, NY.

Programs specializing in I-CBT for adults include the following:

• Emory Wesley Woods Hospital Adult Intensive Outpatient Counseling Program (IOCP), Atlanta, GA.
• Emory University Veterans Program, Atlanta, GA.
• Home BaseVeteran and Family Care, Boston, MA.

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My Health - How to have a safe Halloween

Halloween is a magical day for children. They get to dress up, there are festivities at school — and, of course, they get candy. Here are some simple tips from the American Academy of Pediatrics to keep Halloween magical by keeping children safe.

Safe Halloween costumes

As you and your child choose a costume, keep this advice in mind:

• Make sure the costume fits. If it’s too big, or too small, it can make it hard to walk and move around safely.
• Make sure that any masks, wigs, hats, or other costume parts don’t block your child’s vision — instead of a mask, you might want to consider face paint.
• Make sure that any accessories — like swords or wands — are safe and carried safely.

Safe pumpkins

What would Halloween be without pumpkins? As you plan whether they will be scary or silly…

• Remember that kids and knives don’t mix. Kids can draw the design and you can carve — or you can have kids decorate with permanent markers instead (which saves you all sorts of scooping out seeds and goop time).
• Consider using flashlights or glow-sticks rather than candles.
• If do you use candles, votive candles are best — and be thoughtful about where you put your pumpkin; make sure it can’t tip over and is away from anything flammable. Don’t leave a lit pumpkin unattended; if you go out, blow out the candle.

Safe house

It’s great to have people come to your house for candy. To keep them safe…

• Get rid of anything that people might trip on.
• Make sure your door and path are well lit.
• If you have a pet that likes to chase, jump, or nip, keep it away from the door for the night.

Safe trick-or-treating

Children are twice as likely to be hit by a car on Halloween than on any other day of the year. Walking around in the dark has its downsides, so…

• Grownups should go along. If children are older (tweens and teens) and want to go alone, the route and ground rules must be decided and agreed upon ahead of time, and they should check in regularly via cell phone.
• Use reflective tape on goody bags.
• Bring a flashlight or glowstick and have it on the whole time, to help people see you.
• Only go to well-lit houses.
• Super important: Stay on the sidewalk, and cross streets carefully and as a group, preferably at a crosswalk.
• If you are driving on Halloween evening, go very slowly, be very watchful for pedestrians, and be extra careful when going in and out of driveways.

Safe treat-eating

Everyone loves Halloween candy. To keep it safe and healthy…

• Wait until you get home to eat the candy. Inspect each piece, throw out anything with a torn wrapper.
• If your child has food allergies:
  • Read all labels.
  • Know that “fun-size” candies may have different ingredients than the regular ones.
  • Don’t eat home-baked goods.
• Ration candy after Halloween. Keep it in somewhere you can watch it (not your child’s bedroom), preferably out of the reach of small children.
• Introduce the idea that not all Halloween candy has to be eaten. Negotiate an exchange of candy for a prize, for example (you can bring candy to work for coworkers). Look into candy exchanges in your community — sometimes schools, dentists, or doctors will sponsor them.

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My Health - 7 Amazing Health Benefits Of Matcha Tea

7 Amazing Health Benefits Of Matcha Tea

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 - Dark patches on the face may be melasma

You may have heard melasma referred to as “the mask of pregnancy,” because it is sometimes triggered by an increase in hormones in pregnant women. But while the condition may be common among pregnant women, you don’t have to be pregnant to experience melasma.

“It’s not only associated with pregnancy, but can affect women at all stages of life,” says Dr. Shadi Kourosh, director of the Pigmentary Disorder and Multi-Ethnic Skin Clinic at Harvard-affiliated Massachusetts General Hospital. And it may last for many years. “Women who develop melasma in their teens or 20s or 30s may see it stay around for decades,” says Dr. Barbara Gilchrest, senior lecturer on dermatology at Harvard Medical School.

Melasma can be hard to treat

While melasma isn’t painful and doesn’t present any health risks, it can cause significant emotional distress. The condition can be difficult to treat, and there’s a lot of misinformation out there about what causes it, says Dr. Kourosh.

You’re more likely to get melasma if you have a darker skin type, probably because your skin naturally has more active pigment-producing cells, according to the American Academy of Dermatology. Melasma appears when these cells become hyperactive and produce too much pigment in certain areas of the skin. Melasma is more common in women, but it can also affect men. It may have a genetic component, as it often runs in families.

Causes of melasma

Melasma has a lot of different causes, says Dr. Kourosh. Two in particular stand out:

• Hormones (including hormonal medications). Fluctuations in certain hormones can cause melasma, which is why it commonly occurs during pregnancy. Melasma may also occur when you either start or stop hormonal contraception, including birth control pills, or when you take hormone replacement therapy, says Dr. Gilchrest.
• Sun exposure. The sun is the big culprit in triggering melasma. “Underlying factors such as hormonal changes may not manifest until a person goes on vacation to a southern location like Florida, or during the summertime when she spends more time in the sun,” says Dr. Kourosh. “The sun is the major exacerbating factor, whatever the underlying cause.” Melasma can be caused or worsened by not only the sun’s rays, but also heat and visible light. This means that even sunscreens that protect against skin cancer aren’t enough to ward off melasma, says Dr. Kourosh. This makes treating melasma a challenge, particularly in the summer months.

Finding the cause of melasma

The first step is to confirm that the darkened skin patches are indeed melasma and try to identify the cause. Treating melasma is unlikely to be effective if the underlying cause isn’t addressed, says Dr. Kourosh. “Even the oral treatments that now exist for severe cases of melasma are really pointless to do if there are still triggers in place,” she says. “We take a thorough medical history to find out what’s causing the melasma,” says Dr. Kourosh. Then adjustments are made. If a hormonal contraceptive is causing the problem, a woman might consider switching to a nonhormonal option, such as a copper intrauterine device.

Medications and topical treatments

Some commonly used options are topical retinols and retinoid treatments, which are applied to the skin to help speed your body’s natural cell turnover process. This may help dark patches clear more quickly than they would on their own. In addition, some doctors may prescribe bleaching agents, such as hydroquinone, which works by blocking melanin production. But while products with hydroquinone can be purchased over the counter, they should only be used under a doctor’s care — and only on the darkened areas of the skin. “Higher concentrations of hydroquinone can cause white spots to develop on the skin,” says Dr. Gilchrest. The medication may even cause a darkening of the skin in some cases. Other topical lightening agents (like kojic acid or azelaic acid) may be recommended. Other treatment options may include chemical peels, laser treatments, and skin microneedling. But at this point they’re not reliably effective, says Dr. Gilchrest.

A critical part of treatment: protect skin from the sun

It is critical to prevent the sun from aggravating the condition. This may require extreme diligence. “The sun is stronger than any medicine I can give you,” says Dr. Kourosh. The most important way to clear up melasma is by using a strict sunscreen regimen. But keep in mind that not all sunscreens are created equal. To prevent against melasma, you need a sunscreen that blocks not only the sun’s rays, but also its light and heat, such as one that includes zinc or titanium dioxide. Chemical sunscreens don’t offer the same protection for melasma, and in some instances, they may even trigger allergic reactions that can make melasma worse, she says.

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My Health - What is keto flu?

Many people have decided to try the ketogenic diet for weight loss. The most recent evidence shows that reducing your carbohydrate intake to a minimum may help you shed a few pounds, at least in the first few weeks to months. However, we don’t really know whether, over the long term, achieving and maintaining ketosis is better for weight loss than other diets. Almost any intervention can cause undesirable consequences, and the ketogenic diet is no different. One of the most well-publicized complications of ketosis is something called “keto flu.”

What is keto flu?

The so-called keto flu is a group of symptoms that may appear two to seven days after starting a ketogenic diet. Headache, foggy brain, fatigue, irritability, nausea, difficulty sleeping, and constipation are just some of the symptoms of this condition, which is not recognized by medicine. A search for this term yields not a single result on PubMed, the library of indexed medical research journals. On the other hand, an internet search will yield thousands of blogs and articles about keto flu.

It is tricky to describe exactly what happens after the diet change, because we are left with only our own observations and experiences. These symptoms may not even be unique to the ketogenic diet; some of my patients describe similar symptoms after they cut back on processed foods, or decide to follow an elimination or an anti-inflammatory diet.

What causes keto flu?

Well, we don’t really know why some people feel so bad after this dietary change. Is it related to a detox factor? Is it due to a carb withdrawal? Is there an immunologic reaction? Or is this a result of a change in the gut microbiome? Whatever the reason is, it appears the symptoms attributed to the keto flu may happen, not to everyone but to some people, after “cleaning up” their diet.

What to do for keto flu?

If you decide for whatever reason to change your diet and feel tired and a little off, do not become exasperated and lose hope. Here are a few tips:

• There is no need to go online and buy any expensive supplements. Many websites are trying to make big bucks selling products to make you feel better without any data to back up those claims.
• Despite its name, this is not like the flu. You will not develop a fever and the symptoms can hardly ever make you incapacitated. If you feel very ill, consider visiting your doctor, as something else may be happening.
• Make sure you drink plenty of water. Some diets can make you dehydrated.
• Eat more often and make sure you have plenty of colorful vegetables. Switching from a standard American diet, rich in simple carbs, trans fats, and saturated fat, is a big change in how your cells use energy. Food is not only calories and energy, it is communication to your cells.
• Do not give up if you are committed to a plan. You may feel exhausted for a few days, but at the end of a week, your energy level will most likely return to normal and you may feel even better.
• If everything else fails, consider easing into the new diet more slowly, instead of “cold turkey.”

Undesirable symptoms may show up in the first few days after changing what you eat. But this should not be the deciding factor when choosing what to put on your plate. Ideally, you should have the most comprehensive and nutritionally dense diet possible, and the Mediterranean and DASH diets have the best evidence to support living a long and healthy life.

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My Health - Self-care for the caregiver

Caregiving can be physically and emotionally exhausting. Whether you are in the profession of caregiving or taking care of a loved one, it is important to remember to recharge your batteries. For family members, caregiving can also lead to additional pressures, such as financial strain, family conflict, and social withdrawal. Over time, caregiver stress can lead to burnout, a condition marked by irritability, fatigue, problems with sleep, weight gain, feelings of helplessness or hopelessness, and social isolation.

Caregiver burnout is an example of how repeated exposure to stress harms mental and physical health. Chronic stress triggers a release of stress hormones in the body, which can lead to exhaustion, irritability, a weakened immune system, digestive distress, headaches, pains, and weight gain, especially in the midsection of the body.

Your body does have a natural way to combat stress. The counter-stress system is called the “relaxation response,” regulated by the parasympathetic nervous system. You can purposefully activate the relaxation response through mind-body practices like yoga, tai chi, meditation, and deep relaxation techniques.

5 ways to care for yourself if you are a caregiver

1.   Self-compassion is essential to self-care.

Being kind to yourself builds the foundation to self-care. Self-compassion means giving yourself credit for the tough, complex work of caregiving, stepping away from the self-critical, harsh inner voice, and allowing yourself time — even if it’s just a few minutes a day — to take care of yourself.

Lack of time or energy can make getting that time away particularly challenging. You may even feel guilty or selfish for paying attention to your own needs. What you need to know is this: in fact, practicing self-care allows the caregiver to remain more balanced, focused, and effective, which helps everyone involved.

2.   Practice simple breath awareness for 10 minutes a day.

One of the simplest deep relaxation techniques is breath awareness. We go over breath awareness, paced breathing, and other breath techniques in the The Harvard Medical School Guide to Yoga. Here is one you can try:

• Find a comfortable seated position on a chair or cushion.
• Close your eyes and begin to notice your breath.
• It is common to have distracting thoughts come and go, but just let them pass, and gently bring your attention back to your breath.
• Breathe in slowly through your nose for five counts, hold and pause for five counts,* and exhale for five counts.
• Continue for 10 minutes. You may substitute phrases for the counts such as:

I breathe in calm and relaxing energy.

I pause to let the quiet energy relax my body.

I breathe out and release any anxious or tense energy.

• For deeper relaxation, gradually extend your exhalation, until you reach an exhalation twice the length of the inhalation (10 counts).

*Breathing exercises should not be painful or uncomfortable; if holding your breath is uncomfortable, just eliminate the pause between the inhalation and exhalation.

3.   Try a mind-body practice like yoga, tai chi, meditation, and deep relaxation techniques.

Mind-body practices not only build physical health, but also deepen the awareness and connection between the mind and body. Yoga has been shown to reduce stress in caregiving groups, like family of those with Alzheimer’s disease and cancer. We describe yoga breathing, poses, and meditation techniques in The Harvard Medical School Guide to Yoga.

Mindfulness meditation and deep relaxation techniques can reduce stress. Guided audio meditations are available online:

• UCLA Mindfulness Awareness Research Center
• smartphone apps like Headspace, Meditation Oasis, or Insight Timer.

4.   Make eating well and getting quality sleep priorities.

It’s easy to forget about your own meals and needs when trying to help others. Maintaining adequate sleep and nutrition are key to preventing caregiver burnout. Build a daily 10-minute nighttime routine to achieve more restful sleep. Your nighttime routine can include your breathing exercises, meditation, or yoga poses. Missing meals can lead to irritability and fatigue, so it is important to eat regularly scheduled meals throughout the day.

Nutrition can also be an important factor to prevent burnout. Chronic stress has been linked to increased inflammation in the body, so it is helpful to avoid foods that are processed or high in refined sugars, which increase inflammation in the body. Avoid or reduce alcohol, since alcohol both increases inflammation in the body and disrupts quality of sleep.

5.   Remain socially connected. Find support through local caregiver support groups.

While it can be difficult to keep social appointments with friends and family in the face of medical caretaking, it is important to maintain social connections to feel less isolated and prevent burnout.

Realizing that you’re not alone and that others are going through similar experiences nurtures your ability to be self-compassionate. Hospitals and local organizations often offer caregiver support groups for family and caregivers.

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Dr. Marlynn Wei is the keynote speaker at South County Hospital’s Women’s Wellness Day at the Newport Marriott on Saturday, October 27, 2018. She will offer self-care tips to relieve caregiver stress and prevent caregiver burnout.

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My Health - Trauma-informed care: What it is, and why it’s important

Update

Writing in the October 10, 2018 New England Journal of Medicine, Eve Rittenberg, MD, assistant professor at Harvard Medical School and practicing physician at Brigham and Women’s Fish Center for Women’s Health, reflects on the impact the Kavanaugh hearing and #MeToo movement have had on patients who have experienced sexual violence. Important principles of trauma-informed care—including ways to ask permission, offer control, and find support—described in her article and in Monique Tello’s post below can make a real difference to many women and health care professionals alike.

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Many years ago, when I was a trainee, I helped take care of patients at a family medicine clinic.* One day, a school-aged brother and sister came in for their annual physicals. They were due for vaccines. Neither wanted any shots, and they were both quite upset. “You’ll do what the doctor tells you, is that clear?” ordered the mother. She and the nurse worked together to hold the sister’s arm down. But just as the nurse was about to deliver the injection, the young girl jerked her arm away and ran to the opposite corner of the room, crying. The brother then ran over and stood in front of her, his arm outstretched, guarding, and yelled “Get away! Leave her alone!” At first, the focus was on forcing them to have their shots, which were required for school. But it only made things worse. The young girl screamed, the boy fought, no one could calm them, and everyone was annoyed.

One of the senior doctors finally conceded: Let them go, we’ll have to work on this. But that family never returned.

Months later, we learned that the children had been removed from the home by the Department of Children and Families, for parental abuse. I could only imagine what had been happening.

*This vignette is based on a composite of several cases I have been involved with over the years. All potentially identifying details have been changed to protect patient privacy.

The prevalence of trauma

The CDC statistics on abuse and violence in the United States are sobering. They report that one in four children experiences some sort of maltreatment (physical, sexual, or emotional abuse). One in four women has experienced domestic violence. In addition, one in five women and one in 71 men have experienced rape at some point in their lives — 12% of these women and 30% of these men were younger than 10 years old when they were raped. This means a very large number of people have experienced serious trauma at some point in their lives.

Medical exams by definition can feel invasive. They often involve asking sensitive questions, examining intimate body parts, and sometimes delivering uncomfortable — even painful — treatments. So, it is important that healthcare providers are mindful of the fact that so many people come to that healthcare interaction with a history of trauma.

Could the case I described have been handled differently?

There have been some recent news articles about a relatively new (and improved) way for health professionals to approach patients. This is called trauma-informed care. Dr L. Elizabeth Lincoln is a primary care physician at MGH who has trained medical professionals and students about approaching patient care with an understanding of trauma. She explains: “Trauma-informed care is defined as practices that promote a culture of safety, empowerment, and healing. A medical office or hospital can be a terrifying experience for someone who has experienced trauma, particularly for childhood sexual abuse survivors. The perceived power differential, being asked to remove clothing, and having invasive testing can remind someone of prior episodes of abuse. This can lead to anxiety about medical visits, flashbacks during the visit, or avoidance of medical care.”

What does trauma-informed care look like?

The first step is to recognize how common trauma is, and to understand that every patient may have experienced serious trauma. We don’t necessarily need to question people about their experiences; rather, we should just assume that they may have this history, and act accordingly.

This can mean many things: We should explain why we’re asking sensitive questions. I might say, “I need to ask you about your sexual history, so I know what tests you may need.” We should explain why we need to perform a physical exam, especially if it involves the breasts or genitals. If someone is nervous, we can let them bring a trusted friend or family member into the room with them. I’ve had many female patients hold someone’s hand during a pelvic exam. We can tell them that if they need us to stop at any time, they can say the word. If someone refuses outright to have a certain exam or test, or if they’re upset about something (like having vaccinations), we can respond with compassion and work with them, rather than attempting to force them or becoming annoyed.

For someone who has experienced trauma, the hospital or doctor’s office can be a scary place. Dr. Lincoln explains: “Patients often do not volunteer such information about prior experiences, because of guilt or shame. Medical professionals often ask about safety in a patient’s present relationships, but few ask about past experiences. A simple question such as, “Is there anything in your history that makes seeing a practitioner or having a physical examination difficult?” or, for those with a known history of sexual abuse, “Is there anything I can do to make your visit and exam easier?” can lead to more sensitive practices geared to developing a trusting relationship. Patients can advocate for themselves by explaining to physicians their anxiety about medical visits, why this is so, and what they have found helpful or harmful in prior healthcare encounters.”

Trauma comes in many forms

It is also important to note that there are many types of trauma. A colleague of mine has a child who survived a life-threatening illness. Prior to his ICU stay, he never flinched at vaccines; since his hospitalization, any needle sticks make him extremely anxious. Another colleague describes how after years of invasive infertility treatments, and despite becoming a mother, she sobbed uncontrollably at her simple routine gynecologic exam, because it touched such a nerve of helplessness and failure. Trauma-informed care is the open-mindedness and compassion that all patients deserve, because anyone can have a history that impacts their encounter with the medical system.

We as providers need to recognize that many, many patients have a history of physical, sexual, and/or emotional abuse, as well as serious illnesses and negative experiences in the medical setting, and we need to learn to respond with empathy and understanding.

Sources

Sexual violence facts at a glance. National Center for Injury Prevention and Control, Division of Violence Prevention.

The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2011.

Child maltreatment facts at a glance. National Center for Injury Prevention and Control, Division of Violence Prevention.

Child maltreatment 2012. US Department of Health & Human Services Administration for Children and Families, Administration on Children, Youth and Families Children’s Bureau.

Violence, Crime, and Abuse Exposure in a National Sample of Children and Youth: An Update. JAMA Pediatrics, July 2013.

The National Intimate Partner and Sexual Violence Survey. Centers for Disease Control and Prevention.

Bringing trauma-informed care to children in need can ease toxic stress. StatNews, December 2017.

Understanding trauma-informed care. Mass General News, January 2014.

Trauma-Informed Care in Behavioral Health Services. Substance Abuse and Mental Health Services Administration, 2014.

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My Health - The real link between breastfeeding and preventing obesity

While we know that breastfeeding has many health benefits for mothers and babies, the studies have been a bit fuzzy when it comes to the link between breastfeeding and preventing obesity in children. Some studies show a clear link, but in others that link is less clear. A new study published in the journal Pediatrics may help explain the fuzziness. It showed that what really helped prevent obesity was getting breast milk directly from the breast.

That’s not to say that drinking expressed breast milk from a bottle isn’t healthy. After all, it’s the food that was explicitly designed for infants — and in the study, babies that got breast milk from a bottle did have lower rates of obesity at 12 months. Some of that benefit is thought to be related to the microbiome that breast milk helps create. Babies who drink breast milk are more likely to have certain bacteria in their digestive tracts that help prevent obesity.

But the babies that had the lowest risk of obesity in the study were those that got only breast milk directly from the breast for the first three months of life. Why would that be?

To be able to breastfeed directly from the breast for three months, you have to be able to be with your baby constantly for three months. Mothers who can do that either have access to paid maternity leave or have enough resources to take an unpaid leave — or to stay at home with their babies and not work outside the home at all. Studies have shown that mothers who breastfeed longer are more likely to have higher incomes, more education, and private insurance.

These, then, are mothers who are also more likely to have access to and be able to afford healthy foods, to live in areas where there are safe places to exercise — and to be able to pay for sports and other forms of exercise as their children grow. It’s not just about how these babies are fed, but also about the context in which they are born and raised.

The way in which they are fed, though, is important. Babies who feed directly from the breast are less likely to be overfed. When they are full, they stop sucking, or switch to a “comfort” kind of sucking that doesn’t produce milk. When babies are fed from bottles, parents and caregivers are more likely to push them to finish the bottle; feeding becomes a bit less about appetite and more about volume and schedule.

Learning to eat only when you are hungry and stop when you are full is a really good skill when it comes to preventing obesity. That’s why the American Academy of Pediatrics has encouraged parents to learn and use “responsive feeding,” that is, responding to the cues of babies and children of both hunger and being full. The motto is, “You provide, your child decides.”

What this study helps us see is that the link between breastfeeding and obesity prevention is part of a bigger picture we need to pay attention to if we want to fight the obesity epidemic. It shows us that we need to:

• Do everything we can to help mothers stay at home with their babies for at least three months, which will require paid maternity leaves. The United States is way behind the rest of the world in this.
• Help all parents, regardless of how they feed their infants, learn about responsive feeding, and thus help their babies learn to eat when they are hungry and stop when they are full.
• Understand obesity risk as part of a bigger societal issue — truly, as a social justice issue. All children need — and deserve — access to healthy foods and exercise, and there is more we can do to make this happen.

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My Health - More water, fewer UTIs?

All too many women recognize the signals of a urinary tract infection, or UTI: pain and burning when urinating, coupled with a frequent urge to do so. A simple change in behavior could help prevent a common UTI known as recurrent cystitis in women, according to a randomized controlled study published in JAMA Internal Medicine in October 2018. The study showed that drinking more water daily led to fewer episodes of recurrent cystitis and less need for antibiotics.

What is cystitis and what causes UTIs?

Cystitis refers to an infection in the bladder, which most women know as a urinary tract infection. Cystitis is extremely common among women, partly because female anatomy increases the risk of infection due to the proximity of the urethra to the anus. Additional risk factors for cystitis include sexual intercourse, diaphragm use, spermicides and spermicide-coated condoms, and a prior history of cystitis. Women with diabetes and those who have abnormalities of the urinary tract are also at increased risk for cystitis.

The vast majority of infections (up to 95%) are caused by one bacteria, E. coli. Signs and symptoms of an infection include pain with urination, increased frequency of urination, and an increased urge to urinate.

What is the treatment?

Cystitis is treated with antibiotics for three to five days, depending on the antibiotic used.

Can UTIs be prevented?

If you’ve ever had cystitis, you may have heard suggestions that are mostly based on anecdotal evidence. To decrease risk for cystitis, women are advised to urinate after intercourse, drink cranberry juice, drink more fluids in general, and keep the perineal area that lies between the urethra and the anus clean. Evidence is mixed on whether these steps may help prevent cystitis. This study sought to provide direct evidence of the benefits of drinking extra fluids.

What did the study tell us?

The study participants were 140 premenopausal women who experienced three or more episodes of cystitis in one year and reported that they drank less than 1.5 liters of fluids daily, which is about 6 1/3 cups. The average amount participants drank daily was a bit over a liter (1.1 liters, or about 4 1/2 cups).

The women were randomized to one of two groups. Every day, one group drank their usual amount of fluids plus an additional 1.5 liters of water. The control group drank just their usual amount of fluids. The women kept journals recording the type and amount of fluids they drank in a day. Their urine was periodically measured for volume and tested for hydration status. The study discovered that women who drank an additional 1.5 liters of water had 50% fewer episodes of recurrent cystitis, and required fewer antibiotics than women who did not drink additional fluid.

Is it safe to drink this much fluid?

While the amount of extra fluids tested in the study may seem like a lot, the Institute of Medicine recommends that women have 2.2 liters daily, which is about 9 cups. Not all of this needs to come just from water — or even fluids. Fruits and vegetables, which are part of a healthy diet, contain a lot of water.

This study used a rigorous scientific method to evaluate the benefits and risks of an inexpensive and safe anecdotal treatment. While it has been suggested that substances in cranberry juice can decrease the risk of urinary tract infection, no studies have conclusively demonstrated its benefits. Water may be the best means to increase hydration because it is inexpensive and has no calories. Although this study focused on women who had recurrent cystitis, its results could be extrapolated for a lower-risk population as well.

If you’re a woman with symptoms of cystitis, such as pain or burning with urination, increased urgency and frequency, try to drink more fluids, but also call your health care team for evaluation. A simple urine test in conjunction with the symptoms you describe may provide enough information for your health care provider to confirm an infection and start you on a brief course of antibiotics.

Better still, going forward, you may be able to decrease the chance that you will develop an infection by drinking more water daily. It’s a simple solution readily available for prevention — and now supported by evidence!

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My Health - Is Coca-Cola really putting pot in its beverages?

A flurry of recent news reports would make you think so — here are a few examples:

Coke plans to brew weed drink
Coca-Cola In Talks To Make Marijuana-Infused Drink
Coca-Cola eyes cannabis market

The truth turns out to be a bit less dramatic. Here’s how the company’s statement put it:

“We have no interest in marijuana or cannabis. Along with many others in the beverage industry, we are closely watching the growth of non-psychoactive CBD as an ingredient in functional wellness beverages around the world…. No decisions have been made at this time.”

A few clarifications are in order here:

“CBD” is short for cannabidiol; it’s found in marijuana but also in hemp, and there are claims that it can provide a number of health benefits (see below).

“Non-psychoactive” means that it does not cause a person to feel intoxicated or “high.” As such, CBD is not considered to be addictive or prone to abuse; that’s why it is legal in all 50 states (though with some restrictions).

“Functional wellness beverages” are those that provide some health benefit above and beyond nutrition or hydration. Gatorade is one example, as it is ‘fortified’ with electrolytes lost during intense exercise. There are many others, such as Pom Wonderful, which describes its products as “the Antioxidant Superpower” and “the perfect fuel to get you to CrazyHealthy;” or Red Bull, which “Vitalizes Body and Mind.” It’s worth emphasizing that in the US, functional beverages do not have to prove that their health claims are true; as with conventional foods, they only have to have ingredients that are “generally recognized as safe.”

There was no mention in this statement of actually putting CBD or other marijuana-related substance in Coca-Cola.

Why would the Coca-Cola Company put CBD in its beverages?

Soda sales are down, while functional wellness beverage consumption and the respectability of CBD are on the rise; industry experts see this as a financial opportunity.

And what is CBD good for? The list of supposed health benefits of CBD is long and includes the treatment of:

• anxiety and depression
• insomnia
• chronic pain
• symptoms related to cancer and its treatment, such as nausea
• symptoms related to neurologic disease, such as multiple sclerosis and Parkinson’s disease.

Most of these claims are considered unproven, based on preliminary evidence such as animal research, or human studies involving a very small number of people. The only approved use of CBD is for certain childhood seizure disorders (called Lennox-Gastaut syndrome and Dravet syndrome); the FDA approved the first-ever medication containing CBD  for these conditions in June of 2018, and then in September the FDA reclassified CBD from Schedule I (“drugs with no currently accepted medical use and a high potential for abuse,” such as heroin) to Schedule V (drugs with a low potential for abuse)

Side effects of CBD are generally minor and include diarrhea, fatigue, and anxiety. It can also interact with medications you take, so it’s important for your doctor to know if you’re taking it.

Is pot going mainstream?

The news about the Coca-Cola Company follows recent announcements by Coors and Constellation Brands (makers of Corona beer) about developing marijuana-containing products. And a few CBD-containing beverages are already on the market.

So, it seems like this is only the beginning. In fact, the time could soon come when CBD (and, perhaps, marijuana) make it into widely available foods and beverages, including those sold in supermarkets. With the legalization of marijuana spreading like a weed (sorry, couldn’t resist!), it may be just a matter of time before it’s viewed a bit like alcohol. And that means it could soon be in the food supply. I just hope that by the time that happens, we have a better understanding of its risks and benefits.

As for CBD, you can expect claims of health benefits to multiply as it morphs from a component of an illicit drug to a financial opportunity in the growing “wellness” food and beverage industry. But I’ll still be looking for more studies confirming its safety and health benefits before I’ll buy anything containing CBD.

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My Health - How to feel better about yourself if you are depressed

Today is National Depression Screening Day. If you are experiencing symptoms of depression, you should know that there are effective treatments and help is available.

When you are depressed, your self-esteem wanes and you may start to dislike yourself. People with depression often think of themselves as “worthless, incapable of any achievement, and morally despicable.” Why do people who are depressed have this negative self-appraisal? And what could be happening in their brains?

The study: In 2017, researcher and psychiatrist Christopher Davey and his colleagues compared the brain blood flow of 86 unmedicated depressed patients with that of 95 healthy control participants using a type of magnetic resonance imaging (MRI) called functional MRI. Depressed patients were in the early stages of their illness, but, as is often the case, two-thirds of them had an anxiety disorder as well.

The tasks: The researchers asked participants to lie in an MRI machine, and then gave them several tasks to complete while they imaged their brain blood flow. The first task involved self-appraisal. During this task, participants had to indicate whether a certain descriptor fit them or not by pressing a left or right button that corresponded with “yes” or “no.”

Then, they were asked whether words had four or more vowels (a task to test external attention). As you can imagine, this does not require internal attention like the self-reflection task did. The answers are in the words themselves.

As they answered these questions, the researchers documented whether the connections between different brain regions were affected.

What did we learn about people who are depressed?

There were no differences in reaction times to the self-descriptors in the depressed and control groups, and they were similarly accurate about the vowel test too. However, depressed participants said that the negative adjectives described them far more often than the control subjects, and more often than not, the adjectives indicated that they did not like themselves.

Choosing a self-descriptor means that you have to match the word with an impression that you already have of yourself. This matching process involves brain regions at the front and back of the brain. Like a well-coordinated rowing team, these different regions in the brain must be flexible and coordinated so that this matching can occur. In the case of self-appraisal, activation at the front of the brain (the medial prefrontal cortex) often moderates activation at the back of the brain (posterior cingulate cortex.)

As researchers had expected, when depressed patients reflected on themselves, the brain’s front and back rowing teams were not coordinated. When the brain region at the back of the brain was activated by a self-descriptor, the front region overreacted when trying to control it. The greater the overreaction, the worse depressed people felt about themselves compared to control subjects.

But that was not all. The assessment itself was also less stable. As a result, the brain had to work harder to establish some order too. (No wonder depressed people are often fatigued!) Although it was not entirely clear what specific aspect of depression was associated with this brain overreaction, the researchers found that it was highly likely that difficulty concentrating, and a sense of inner tension, were both affected in concert with these brain changes.

What can you do?

If you’re depressed, know that the unstable connection between the front and back regions of your brain is making you dislike yourself and disturbing your emotional control. Your brain has lost its flexibility and accuracy.

That’s why a relatively new treatment called self-system therapy (SST) has been shown to be so effective for depression. With this therapy, people who are depressed can achieve better control of their emotions. They learn to counteract their negative self-impressions. Unlike cognitive therapy, which focuses on reframing these negative ideas, SST doesn’t focus on these negative ideas at all. Instead, it helps patients feel better by teaching them to focus on making good things happen by pursuing “promotion” goals that involve advancement, growth, and achievement. In fact, it is far more effective than cognitive therapy.

So, being aware that your brain distorts your self-impression in the first step in this therapy. Once you understand this, you can learn how to switch your attention to positive goals so that you can feel better about yourself again.

If you are depressed, look up SST or ask your healthcare provider about it. It may help restore emotional control and help you feel less depressed again.

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