My Health - Giving babies and toddlers antibiotics can increase the risk of obesity

Antibiotics can be lifesaving, but they can have serious downsides — including increasing the risk of obesity when they are given early in life, according to a recent study.

Antibiotics kill bacteria. That can be a very good thing when the bacteria are causing a serious infection. But antibiotics don’t limit themselves to killing infection-causing bacteria; they kill other bacteria in the body, too. And that can be a very bad thing.

Our bodies are full of bacteria. These bacteria, part of our microbiome, are important. Along with other micro-organisms in our body, they play a role in how we digest foods, in normal growth, and in our immune system. When we take antibiotics, we inadvertently kill some of those bacteria. At first glance, it seems like this wouldn’t be such a big problem; after all, the world is full of bacteria, can’t we replace them? But as we learn more about our microbiome, it appears that the way it gets started — meaning the bacteria that we gather and grow early in life — is very important and can have lifelong effects.

Studies have shown that babies who are born by caesarean section are more likely to be obese as they grow, and part of the reason is thought to be that because they aren’t born through the birth canal, they don’t get that natural birth dose of bacteria to get them started in the right direction.

In the study, researchers looked at more than 300,000 infants born into the military health system. They looked at whether they were given antibiotics during the first two years of life. They also looked at whether they were given either of two medications used to decrease stomach acid, commonly prescribed to treat stomach reflux in babies. Giving antacids can alter bacteria, both by allowing the bacteria from the mouth and nose that usually get killed by stomach acid to move into the intestine, crowding out other species — and by killing bacteria themselves.

In the study, children who got antibiotics had a 26% higher chance of obesity. Taking one or both of the two kinds of antacid also increased the risk of obesity, although to a lesser extent. Taking antibiotics along with one or both kinds of antacid increased the risk, as did being on the antacids for longer periods of time.

Interestingly, farmers have been using this to their advantage for some time. Giving livestock antibiotics early in life makes the animals heavier, which means there is more meat on them. This use of antibiotics in livestock may mean more profits for farmers, but it has been a significant contributor to the problem of antibiotic resistance.

It’s not just obesity; giving antibiotics and antacids early in life increases the risk of food allergies and other allergic disease like asthma. Bottom line: we need to be very careful before we do anything that messes with the bacteria in our bodies.

As I said before, antibiotics can be lifesaving, and messing with the bacteria in our bodies is a risk absolutely worth taking — sometimes. But too often we use antibiotics when they aren’t really needed: many prescriptions, for example, are written for the common cold, something caused by viruses. Some infections, like ear infections, can get better without antibiotics — and even when we do need to use antibiotics, we often use them for longer than is necessary, or use stronger antibiotics than are necessary.

Since doctors write the prescriptions, it’s mostly doctors that need to make the change. But parents can play an important role, by asking if a prescription for antibiotics (or antacids) is truly necessary. If the answer is yes, parents should give it — but they should also ask about giving the shortest course possible.

We are in the midst of an obesity epidemic, one with so very many health implications for us and our children. As with any epidemic, we have to fight it in every way possible.

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My Health - Eat more plants, fewer animals

Science has shown us over and over again that the more meat we eat, the higher our risk of diabetes, heart disease, and strokes. Conversely, the more fruits and vegetables we eat, the lower our risk for these diseases, and the lower our body mass index.

Why is eating meat bad? High-quality research shows that red meats (like beef, lamb, pork) and processed meats (bacon, sausage, deli meats) are metabolized to toxins that cause damage to our blood vessels and other organs. This toxic process has been linked to heart disease and diabetes. (Want to know more? Read about how these animal proteins harm the body here and here).

Should we all become vegetarian or vegan?

Not necessarily. One can be 100% perfectly vegetarian or vegan and still have an unhealthy diet. Many foods that aren’t made with animals are still unhealthy. Think candy, soda, and pasta, and baked goods made with refined flour. Sugar-sweetened beverages and refined grains are also toxic to the body and associated with significant health risks.

A better approach is a plant-based diet. This means consuming mostly fruits and vegetables, including beans and legumes, nuts and seeds, and whole grains. A plant-based diet is well associated with a lower risk of diabetes, high blood pressure, heart disease, stroke, and death from any cause.

An estimated 90% of the population of the United States is omnivorous, and the vast majority of people aren’t going to give up meat. The good news is, they don’t need to. A 2017 study published in JAMA showed that consuming just 3% less animal protein and replacing it with plant protein was associated with up to a 19% lower risk of death from any cause.

Not only that, but a plant-based diet can protect us when we do occasionally eat meat. Fruits and vegetables contain special plant nutrients that neutralize toxins. These are antioxidants, and they are really good for us. But they cannot be isolated and packed into a capsule or pill — supplements don’t work. A balanced diet that includes a wide variety of colorful fruits and vegetables is what works. Just eat more plants that anything else, and minimize the meats, and you’ll be doing your body a huge favor.

Where will I get my protein?

Protein does not have to mean meat. As a matter of fact, many plant foods are excellent sources of protein. And no, it doesn’t have to be tofu. Think beans, lentils, peas, and edamame! Nuts and nut butters, seeds and seed butter! Whole grains contain a fair amount of protein as well.

Having trouble envisioning meals without meat? You can enjoy the same classic meals, just substitute in plant protein. For example:

If you love tacos, replace the meat filling with spiced lentils. (Try my Easy Spiced Lentil Taco Filling recipe below.)

If you love shepherd’s pie, use finely diced mushrooms instead of ground meat.

If you love fajitas, switch out the steak or chicken for portabella mushrooms.

Classics like minestrone soup, chili, spaghetti, and lasagna are easily converted into healthier, animal-free meals. Use whole grain pasta where pasta is called for, and add extra veggies. Even if you prepare any of these dishes using animal protein, add extra veggies and you will be benefiting.

Going to a plant-based diet doesn’t have to mean eating plants exclusively. Just aiming to eat more healthful plant foods, focusing on overall nutrition, decreases health risks significantly. Even a little improvement can have big results.

Resources:

A Plant-Based Diet, Atherogenesis, and Coronary Artery Disease Prevention. The Permanente Journal, Winter 2015.

Healthy Dietary Patterns for Preventing Cardiometabolic Disease: The Role of Plant-Based Foods and Animal Products. Current Developments in Nutrition, December 2017.

Association Between Dietary Factors and Mortality From Heart Disease, Stroke, and Type 2 Diabetes in the United States. JAMA, March 7, 2017.

Animal and plant protein intake and all-cause and cause-specific mortality: results from two prospective US cohort studies. JAMA Internal Medicine, October 2016.

Intestinal microbiota metabolism of L-carnitine, a nutrient in red meat, promotes atherosclerosis. Nature Medicine, April 7, 2013.

Intestinal Microbial Metabolism of Phosphatidylcholine and Cardiovascular Risk. New England Journal of Medicine, April 25, 2013.

Easy Spiced Lentil Tacos

Serves: 4-6

This dish cooks up fast, faster than meat. Red lentils are cheap; I always keep several bags in our pantry for soups and taco filling.  This hearty, satisfying, high-protein meal can be made from scratch in under 30 minutes.

Ingredients:

1 tablespoon olive oil

1 small yellow onion, grated or finely diced

3 cloves garlic, finely diced or pressed (or, 1 teaspoon of garlic paste from a tube)

2 cups of red lentils, dry

5 cups of water

4 tablespoons of taco/fajita seasoning (buy it ready-made, or make your own — see recipe below)

8 corn tortillas

1 jar low-sodium salsa (less than 90 mg sodium per 2 tablespoon serving; examples include Newman’s Own, Green Mountain Gringo)

Chopped lettuce, lime slices, chopped green onions, plain Greek yogurt and/or red pepper flakes for serving, if desired

Optional:

Homemade Taco/Fajita Seasoning:

3 tablespoons chili powder

3 tablespoons ground cumin

1 teaspoon garlic powder

1/2 teaspoon black pepper

1/2 teaspoon salt

1/4 teaspoon cayenne (or to taste)

Easy Spiced Lentil Taco Filling

Pour the lentils into a colander and rinse under cool water, swishing around. This removes any debris that may be mixed in. Classically, red lentils are known to have debris mixed in, and so people often call for washing them prior to cooking. You can choose whether or not to rinse the lentils in a colander first. I’ll admit I often skip this step, and haven’t come across any rocks yet.

Heat a large sauté pan or medium saucepan (that has a cover) over medium-high heat. Add the oil and swish around for a couple of seconds. Add the onion and sauté until soft. Add the garlic and sauté until fragrant.

Add the lentils and water, and bring the water to just boiling, then turn down to a simmer. Simmer for five minutes, then add the fajita seasoning and stir. Cover the pan and turn off the heat. The lentils will absorb the rest of the water while you prep the rest of your meal.

Put the meal together

Wrap the tortillas in a clean towel or paper towel and microwave for thirty seconds to heat.

Chop some lettuce (romaine is a good choice here), slice a lime, and set out plain Greek yogurt and the salsa. Let people put together their own tacos. Enjoy!

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My Health - Picking your skin? Learn four tips to break the habit

If you can’t stop picking your skin, you may have a very common condition called skin picking disorder (SPD). We all pick at a scab or a bump from time to time, but for those with SPD, it can be nearly impossible to control those urges. Apart from the cosmetic impact of recurrent skin lesions and scarring, SPD can lead to serious infections, shame, depression, and anxiety.

You may be feeling alone or embarrassed, but you should know that this condition affects at least five million Americans. A diagnosis of SPD, also known as excoriation disorder, is made when there are repeated attempts to stop picking, and the skin picking is either distressing or interfering with social or work functioning. SPD is one of a group of disorders that is related to obsessive-compulsive disorder (OCD).

You already know that it is not a matter of will — trying to stop is the equivalent of telling one not to have high blood pressure. The good news is that therapy, medication, and dermatologic treatments can help. For most, though, no one treatment will be curative, and you will experience remission and recurrence.

Having realistic expectations and arming yourself with a variety of skills for skin picking flares will make this condition much more manageable. Here are four tips that can help you tackle your picking.

1. Know your triggers

You may be tempted to pick for a variety of reasons, from boredom, itch, or negative emotions, to blemishes or simply looking at or feeling your skin. You may even find the experience of picking itself pleasurable. Understanding your triggers can be a first step in deciding which treatments to pursue. For example, if your picking is triggered by a skin condition such as acne or itch, you might be best served by first seeing a dermatologist. If, however, your picking is triggered by depression, anxiety, or more of an urge, you should consult with a mental health professional with expertise in skin picking.

2. Make it harder to pick

One simple strategy to reduce picking, called stimulus control, involves changing your environment to make it harder to pick. Examples of this technique include keeping your nails short, wearing gloves at times when you are most likely to pick, and making the skin more difficult to access by wearing tight-fitting clothing or long-sleeve shirts. You can also try distracting your hands with any number of items including silly putty, stress balls, fidgets, and tangle toys. Once you have found an item that works for you, make sure to have one everywhere you spend time such as work, home, and your bag, so you are fully covered.

3. Get therapy

Cognitive behavioral therapy (CBT) is a structured type of psychotherapy that aims to produce healthier behaviors and beliefs by identifying unhelpful thoughts and behaviors. A specialized type of CBT has been developed for SPD. This type of CBT includes more of the stimulus control techniques described above, as well as habit reversal training, in which individuals are taught to engage in a harmless motor behavior (like clenching one’s fists) for one minute when triggered to pick. Clinical trials have demonstrated that skin-picking for CBT can be extremely effective. But because it is different than other types of CBT, it will be important to work with a therapist who is trained in treating SPD. You can find skin-picking experts at the TLC Foundation for Body-Focused Repetitive Behaviors.

4. Consider medication with your providers

While no medication has been formally approved by the FDA to treat SPD, there is evidence to suggest that selective serotonin reuptake inhibitor (SSRI) antidepressants and N-acetylcysteine (NAC), an antioxidant supplement, can be helpful. Owing to the limited and evolving research on medication treatments for SPD, you may find that your provider is not up to date on current skin picking treatments. If you or your provider would like more information about these medication treatments and others, you can look here.

Please be aware that even over-the-counter, well-tolerated supplements like NAC should always be taken under the supervision of a medical professional for guidance on dosing, duration of treatment, drug interactions, and side effects.

For more on overcoming SPD, visit the TLC Foundation for Body-Focused Repetitive Behaviors and the International OCD Foundation.

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My Health - Can a low-carbohydrate diet help keep weight off?

For your entire life you have been bombarded with information about which diet is the best to help you lose weight. Like many other people, you might have tried one or even a dozen diets, but it took a bit of trial and error for you to find which diet worked for you. Now, you are on to the hard part. You have finally lost the weight, but how do you keep it off? That is the million dollar question, right?

In a new study in BMJ, researchers sought to determine if a low-carbohydrate diet might help mitigate the dreaded weight regain that occurs when a person loses weight. We know that when a person loses weight their energy expenditure, or metabolism, decreases. Until now, we have not known whether a certain diet composition would affect this metabolic adaptation that inevitably occurs.

The BMJ study researchers studied 164 adults with overweight or obesity — classified as a body mass index (BMI) of 25 or greater — between August 2014 and May 2017. Individuals in the study were assigned to one of three test diets:

• high carbohydrate content (60% carbohydrate diet)
• medium carbohydrate content (40% carbohydrate diet)
• low carbohydrate content (20% carbohydrate diet)

The investigators then measured several factors during the participants’ weight loss maintenance phase. The results were very interesting. Here is what they discovered:

• The total energy expenditure (TEE) of persons on a low-carbohydrate diet was much higher than persons in the medium or high carbohydrate groups.
• Ghrelin, a hormone that causes one to feel hunger and takes one longer to feel full, was lower in the low-carbohydrate group.
• Leptin, a hormone that causes one to feel full quickly, was lowest in the low-carbohydrate group.

Overall, the study demonstrates that, in the short term, a low-carbohydrate diet might make it easier for persons who have lost weight to keep it off, compared to moderate- and high-carbohydrate diets.

So, you’ve lost weight. Should you switch to a low-carbohydrate diet? The jury is still out. While the results clearly demonstrate that a low-carbohydrate diet fared best with regard to weight maintenance, the study was only performed over the course of 20 weeks. What would happen if the study was lengthened to a year, or two years? Would we still see such a clear difference in TEE after a much longer period of time? I think we must wait to see those results.

In the meantime, it might be a good idea to evaluate the carbohydrate content of your diet if you are struggling to maintain weight loss. If your carbohydrate content is moderate or high, you might consider decreasing your carbohydrate intake. However, remember that there is not a “one size fits all.” Just because one person responds to a low-carbohydrate diet, it does not mean that you will too. Listen to your body cues. You and your body cues are the most important part of the equation.

If you continue to struggle, seek out care with an obesity medicine physician who can help tailor your plan to fit you. You can search for a board-certified obesity medicine physician in your area on the American Board of Obesity Medicine website.

Follow me on Twitter @fstanfordmd

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My Health - Smoking tied to more aggressive prostate cancer

If you’re a smoker looking for another reason to quit, consider this: in addition to raising your risk of heart and lung disease, as well as cancers of the bladder and kidney, smoking could boost the odds that you will develop aggressive prostate cancer that metastasizes, or spreads through your body. That’s according to research published by an Austrian team in 2018.

The evidence connecting tobacco use with prostate cancer (which tends to grow relatively slowly) isn’t as strong as it is for other smoking-related diseases. Researchers first detected the link only after pooling data from 51 studies that enrolled over four million men. Published in 2014, this earlier research showed that smokers have a 24% higher risk of death from prostate cancer than nonsmokers, but it left an open question: did the men who died from these other causes also have high-grade prostate cancers that had not yet been detected? Experts suspected that since smoking kills in different ways, some of those who pick up the habit simply may not live long enough to die from prostate cancer.

To investigate, the Austrian researchers limited their analysis to just over 22,000 men who had recently been treated surgically for prostate cancer, but were otherwise healthy. This was a smart move. By focusing on prostate cancer patients instead of just smokers and nonsmokers, they excluded the men who were at higher risk of death from competing causes.

After roughly six years of follow-up, the data told a clear story: prostate cancer patients who smoked were nearly twice as likely to die of their disease (89% higher risk) than nonsmokers. In addition, the risk that their cancers would spread was 151% higher, and there was a 40% higher risk that their prostate-specific antigen levels would rise again after surgery, signaling the cancer’s return.

The biological link between smoking and prostate cancer is not clear. The cancerous pollutants that smokers inhale are excreted to some extent in urine, which flows through the prostate. Smoking might boost levels of toxic inflammation. Or perhaps it’s not even the smoking itself, but the poor lifestyle choices that often accompany it, such as inadequate exercise, or excessive alcohol use..

“I continue to try to understand why some smoking patients are so concerned about simple modifications in diet and querying about supplements (most of which have never been proven to be of any benefit for prostate cancer patients) yet continue with their habit,” says 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/ “The message is clear – if you have prostate cancer and are concerned about how you can modify risk for cancer progression, and you are a smoker — simply STOP.”

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My Health - The new cholesterol guidelines: What you need to know

The new cholesterol guidelines from the American College of Cardiology and American Heart Association are out! These guidelines — last updated in 2013 — have been highly anticipated by the cardiology and broader medical community. They have been approved by a variety of additional professional societies, including the American Diabetes Association. Thus, the majority of physicians are very likely to follow them. So, what exactly is new and what do you need to know?

It starts with a healthy lifestyle, with statins for those who need them

A healthy diet and regular physical activity are recommended for all age groups as the foundation to prevent cardiovascular disease (CVD) and CVD risk factors such as high cholesterol.

However, once there is atherosclerotic cardiovascular disease (plaque in the arteries), the new guidelines recommend that high-intensity statin therapy or maximally tolerated statin therapy should be used, in addition to lifestyle modification, to reduce low-density lipoprotein cholesterol (LDL-C). For example, this recommendation applies to patients with a history of prior cardiovascular events such as heart attacks, or of procedures such as stenting. The goal is to lower LDL-C levels by 50% or more.

Cholesterol targets are back!

Much to the delight of physicians, concrete LDL-C targets have been reintroduced into this version of the guidelines. For individuals with atherosclerotic cardiovascular disease who are at very high risk of cardiac complications, drug therapy beyond statins is recommended to achieve a target LDL-C of 70 mg/dl.

The first addition beyond high-intensity statins would be the now generic ezetimibe, a cholesterol-lowering drug that works by preventing the absorption of cholesterol in the intestine. If that does not do the trick, the injectable PCSK9 inhibitors are considered a reasonable next step, with the caveat that the drugs are expensive and their long-term safety beyond three years is not well established. However, since the guidelines were finalized, one of the two companies that makes PCSK9 inhibitors has lowered the list price. This may ultimately help make these potent cholesterol reducing drugs more cost-effective.

The same algorithm as above is recommended for otherwise healthy people whose LDL-C is greater than or equal to 190 mg/dL. In this case, however, the target is 100 mg/dL instead of 70 mg/dL, presumably because there is no evidence (yet) of actual atherosclerosis.

In people 40 to 75 years of age with diabetes who have an LDL-C greater than or equal to 70 mg/dL, a moderate-intensity statin is recommended. If there are additional risk factors or the person is 50 years or older, then a high-intensity statin is considered reasonable.

The above recommendations are not controversial among expert physicians in the field. In fact, some may say that these guidelines are not aggressive enough in terms of wanting lower cholesterol targets in very high risk patients. But none who understand the data would disagree with the above guidelines as general starting points. If you have atherosclerotic cardiovascular disease, a very high cholesterol level, or diabetes, then, in addition to a healthy lifestyle, you really ought to be on a statin, assuming you can tolerate it, and maybe additional medications, depending on your cholesterol level.

What about healthy people with moderately elevated cholesterol levels?

What about healthy people who don’t fit into the above categories? The guidelines provide clear guidance, but things do get a bit more nuanced. Here, there really needs to be a discussion between the patient and their doctor.

Whether to start a statin or not depends on whether there are other cardiovascular risk factors, such as smoking, high blood pressure, or diabetes, and the actual LDL-C level. A family history of premature atherosclerotic cardiovascular disease would be another factor to consider, as might South Asian ethnicity or premature menopause (before age 40). Other blood test abnormalities, such as elevated triglycerides or elevated high-sensitivity C-reactive protein levels (a marker of inflammation), might also push towards starting someone on a statin. Another recommendation in the new guidelines is for potential use of coronary artery calcium (CAC) scans to decide whether or not to initiate statin therapy in select cases where the decision based on clinical risk factors is unclear. Patient preferences and cost (though most statins are now generic) are other potential issues to weigh. Online risk calculators may help.

Bottom line: If you are one of the large number of people who fall into this category, talk to your doctor about whether you should be on medications to lower your cholesterol, or whether lifestyle changes are enough.

Follow me on Twitter @DLBHATTMD

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My Health - What’s good for the heart is good for the mind

Right now the world is experiencing an epidemic that is projected to get much, much worse. It’s an epidemic of dementia, affecting 40 million people — and millions more of their caregivers — staggering numbers that will likely triple by 2050.

Dementia is a progressive deterioration of brain functioning associated with aging. While there are different causes, the most common — Alzheimer’s and vascular dementias — are now thought to be closely related.

How is heart health related to cognitive health?

We have long known that the diseases and conditions that clog the arteries of the heart also clog the arteries of the rest of the body, including the brain. It all boils down to damage of the arteries, the blood vessels that are critical for blood flow and oxygen delivery to the organs. Arterial damage leads to arterial blockages, which leads to heart disease and heart attacks, strokes, peripheral vascular disease, and vascular dementia.

Meanwhile, Alzheimer’s disease used to be thought of as a different process, because the brains of people with Alzheimer’s seemed to be full of tangled tube-shaped proteins (neurofibrillary tangles). However, more and more research is linking Alzheimer’s dementia to the same risk factors that cause heart disease, strokes, peripheral vascular disease, and vascular dementias: these risk factors are obesity, high blood pressure, high cholesterol, and diabetes.

The evidence is substantial: studies show that people with these conditions are significantly more likely to develop Alzheimer’s disease. Meanwhile, studies also show that people with Alzheimer’s disease have significantly reduced brain blood flow, and autopsy studies show that brains affected by Alzheimer’s can also have significant vascular damage.

Researchers are now focusing on why this is — what is the connection? It appears that good brain blood flow is key for clearing those tubular proteins that can accumulate and become tangled in the brains of Alzheimer’s patients, and so one solid hypothesis is that anything that reduces that blood flow can increase the risk for Alzheimer’s, and conversely, anything that increases blood flow can reduce the risk for Alzheimer’s.

Healthy heart behaviors can lower your risk of dementia

And it is true that exercise lowers the risk of dementia, even Alzheimer’s. Studies show that people who exercise more are less likely to develop dementia of any kind, and this stands even for adults with mild cognitive impairment.

And it is true that exercise lowers the risk of dementia, even Alzheimer’s. Studies show that people who exercise more are less likely to develop dementia of any kind, and this stands even for adults with mild cognitive impairment. There is also substantial research evidence showing that eating a Mediterranean- style diet high in fruits, vegetables, whole grains, healthy fats, and seafood is associated with a significantly lower risk of cognitive decline and dementia.

The take-home message here is, even if someone has a family history of dementia, particularly Alzheimer’s dementia, and even if they already have mild cognitive impairment (forgetfulness, confusion), they can still reduce their risk of developing dementia by simply living a heart-healthy lifestyle. That means a Mediterranean-style diet with 4 or 5 servings of fruits and veggies daily, and 150 minutes per week of activity. Lifestyle factors that help to reduce stress can also help: enough hours of good sleep, positive relationships, and social engagement have been shown to protect cognition.

Resources:

Association of obesity, diabetes, and hypertension with cognitive impairment in older age. Clinical Epidemiology, July 25, 2018.

Vascular and metabolic factors in Alzheimer’s diseases and related dementias. Cellular and Molecular Neurobiology, March 2016.

Defining the relationship between hypertension, cognitive decline, and dementia: a review. Current Hypertension Reoprts, March 2017.

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My Health - Healthy eating through the holidays

Holiday time is here again! So are the joys and challenges of holiday eating. The big challenge is to have fun at special occasions without jeopardizing some of the healthy practices you have worked on throughout the year.

Here are some tips to help you survive the holiday season.

Do not arrive hungry to the party! Skipping meals before a holiday party in an effort to save calories for the big party will only make you overeat. Eat a light meal or snack before arriving to the party. A snack or meal that is high in fiber and contains lean protein is ideal because it can help control your appetite and help you avoid overeating.

Choose the right plate. You are more likely to eat food that ends up on your plate. Thus, choosing a smaller plate will not only prevent you from filling your plate with more items then you really need, but it will also make the amount of food on your plate seem larger.

Be merry. Spread holiday cheer by spending time enjoying the company of others at the party. The more you talk, the less time you will spend eating.

Balance your plate. Aim to fill half your plate with vegetables, a quarter with lean protein, and a quarter with starch.

Bring something to the party. Offer to bring an appetizer, side, or dessert to the party. Not only will the host or hostess appreciate the help, but you’ll also have control over what goes into the dish.

Fill up on vegetables and fruits. Not only do these foods have plenty of vitamins and minerals, but they also contain fiber, which helps keep you full longer and may leave less room for other high-calorie foods.

Watch the liquid calories. For some, a holiday party is not complete without traditional drinks and cocktails. Beware that these drinks often contain a large number of calories. One cup of eggnog can set you back around 360 calories, while hot chocolate can contain around 200 calories. Alcoholic mixed drinks and punches can easily contain over 200 calories. Opt instead for a glass of sparkling water with a splash of your favorite juice or wine.

Be choosy. If you are at a buffet, scan the table before you enter the line. Choose small servings of the foods you want, but try not to return for seconds.

Food gifts. With the holidays come tins full of cookies and sweets. If you know that these will be trouble once you bring them home, open them up at work and pass them around for all to enjoy. If you are in the position of giving a gift to someone that is trying to eat healthy or lose weight, why not give them a non-food gift like a plant, balloons, or a healthy cookbook.

Be active. A short trip over the holidays doesn’t have to mean taking a vacation from your workout. Pack your sneakers or walking shoes and make a plan to fit in some activity each day.

Modifying the celebration Look at the difference portion size can make.
Food	Original portion	Calories	New portion	Calories
Roasted turkey (white meat, no skin)	7 ounces	380	3.5 ounces	190
Cranberry sauce	1/4 cup	90	2 tablespoons	45
Gravy	1/4 cup	129	2 tablespoons	64
Stuffing	1/2 cup	118	1/4 cup	59
Mashed butternut squash	1/4 cup	35	1/4 cup	35
Whipped potato	1/2 cup	94	1/4 cup	47
Vegetable salad	1 cup	25	1 cup	25
Salad dressing	1 tablespoon	50	1 teaspoon	16
Dinner roll	1	70	Omit	0
Butter	1 teaspoon	45	Omit	0
Wine	2 4-ounce glasses	170	1 4-ounce glass	85
Pumpkin pie	1/8 of 9-inch pie	316	1/16 of 9-inch pie	158
Whipped cream	2 tablespoons	162	Omit	0
Coffee	1 cup	0	1 cup	0
Coffee creamer	2 tablespoons	60	1 tablespoon	30
Sugar	2 teaspoons	40	1 teaspoon	20
Total calories		1,784		774
Calories saved = 1,010

 

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My Health - Putting a stop to leaky gut

Leaky gut gets blamed for everything from everyday stomach issues to pain to anxiety, yet it is one of the most mysterious ailments to diagnosis and treat.

Part of the reason for this medical mystery is because the gut is such a vast and complex system. “Science continues to find new ways that the gut can influence everything from heart health to keeping our brains young,” says Dr. Alessio Fasano, director of the Center for Celiac Research and Treatment with Harvard-affiliated Massachusetts General Hospital. “There is much we know about leaky gut in terms of how it affects people’s health, but there is still so much that is unknown.”

What is leaky gut?

You have to begin at the cellular level. The lining of your intestine is made of millions and millions of cells. These cells join together to create a tight barrier that acts like a security system and decides what gets absorbed into the bloodstream and what stays out.

However, in an unhealthy gut, the lining can weaken, so “holes” develop in the barrier. The result is that toxins and bacteria can leak into the body. This can trigger inflammation in the gut and throughout the body and cause a chain reaction of problems, such as bloating, gas, cramps, food sensitivities, fatigue, headaches, and joint pain, to name a few.

How do these “holes” form? The biggest culprits are genes and diet, according to Dr. Fasano. “Some people may have a weaker barrier because they were born with it, or they follow an unbalanced diet low in fiber and high in sugar and saturated fats, which may be the trigger that weakens the gut lining.” Age also plays a role because as you age, cells get damaged more easily and heal slowly, if at all, so the gut becomes more vulnerable.

The role of leaky gut in overall health remains unclear

“Leaky gut could be the cause of some health problems, or a sign of something larger,” says Dr. Fasano. “The science is still up in the air.” For example, digestive conditions like inflammatory bowel disease, celiac disease, and Crohn’s disease share many of the same symptoms as leaky gut, and all are linked with chronic inflammation, but it’s not known how, or if, they are connected.

“The challenge is that it’s difficult to measure the strength of a person’s gut barrier, so you can’t know for certain when leaky gut is really present, or what influence it may have elsewhere in the body,” says Dr. Fasano.

Can you treat leaky gut?

You can, but the approach is similar to diagnosing a broken car, says Dr. Fasano. “You don’t know the exact problem until the mechanic lifts the hood, looks around, and tries different things — there is not a simple, direct approach to fixing the problem,” he says. “It’s the same with leaky gut. We have to try different strategies to see what helps.”

Your first step is to share your symptoms with your doctor. If leaky gut is a possibility, he or she can try several strategies to help relieve symptoms and reduce inflammation. The most common is to review your diet and eliminate known dietary causes of inflammation, such as excessive consumption of alcohol and processed foods, and to explore whether you have any food sensitivities — for instance, to gluten or dairy. “In theory, reducing inflammation from your diet like this also may rebuild the gut lining and stop further leakage,” says Dr. Fasano.

The best way to protect yourself from leaky gut is to invest more in your overall digestive health, he adds. This means being more attentive about following a gut-healthy diet that limits processed foods and high-fat and high-sugar foods, and includes enough fiber. Sticking to a regular exercise program also can strengthen your digestive system. For example, studies have suggested that taking a 15-to 20-minute walk after a meal can aid in digestion. “Your gastrointestinal system is complex, but caring for it doesn’t have to be,” says Dr. Fasano.

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My Health - Getting your baby to sleep through the night: The good (and maybe not-so-good) news

Getting your baby to sleep through the night: it’s the milestone all parents of infants long for.

It’s understandable, given how precious and elusive a full night’s sleep can be for new parents. The quest for a full night of sleep becomes so important that many a book has been written on how to achieve it, and it’s a common topic of conversation among new parents. Those whose babies sleep through the night feel like they have accomplished something important — and those whose babies don’t sleep through the night are often wondering if there is something wrong with their baby or their parenting. This is especially true because among Western cultures, there is a perception that by around 6 months of age, if not sooner, babies should be sleeping through the night.

This perception, it turns out, is not exactly correct. And that’s where the good news/bad news thing comes in. According to a study published in the journal Pediatrics, if your baby doesn’t sleep through the night at 6 months, or even at 12 months, it’s perfectly normal.

It’s always good news to hear that your baby is normal — but for some parents, it may understandably feel like bad news that a full night of sleep is further out on the horizon than they had hoped.

Researchers from Canada studied 388 infants at 6 months, and 369 infants at 12 months. They defined sleeping through the night as six or eight hours of sleep without any waking. They found that at 6 months, 38% of the babies couldn’t make it six hours without waking — and a full 57% didn’t sleep eight hours at once. At 12 months, those numbers were better but still not great: 28% didn’t sleep six hours straight, and 43% didn’t sleep eight hours.

It’s not a baby problem and it’s not a parenting problem — it’s not actually a problem at all

As cranky as being woken up at night can make a parent feel, the researchers did not find a correlation between waking at night and the “postnatal mood” of the mothers. They also found that babies that woke up at night didn’t lag behind the sound sleepers when it came to their cognitive, language, or motor development. The babies did fine either way.

They also found that babies who woke up at night were more likely to be breastfeeding. This makes sense, given that breast milk is more easily and quickly digested than formula, causing breastfed babies to get hungrier sooner. Given that breastfeeding has known health benefits, a little extra waking could end up working out for baby (and for the mother, given that breastfeeding has benefits for mothers too).

Now, for some parents waking up at night is a problem, and that’s where sleep training comes in. There are certainly various techniques and methods that can help teach babies to sleep longer and more independently. Many of them, though, involve letting the baby cry for a while — and while studies have shown that this doesn’t harm babies, it can be hard and stressful for many parents.

What this study shows is that if your baby is waking during the night and you’re doing okay with it, you don’t need to do anything. With time, it will get better. While those first few months of life can feel like an eternity, they aren’t. Before you know it you will be up at night for an entirely different reason: waiting for them to get home from a night out with friends. And when that does happen, those days of waking up with them as babies won’t seem so bad at all.

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My Health - 9 Best Herbal Tea To Treat Diarrhea Naturally

9 Best Herbal Tea To Treat Diarrhea Naturally

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 - Types and Benefits Push-Ups For Women Who Are Beginners

Types and Benefits Push-Ups For Women Who Are Beginners

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 - Hormone therapy for depression: Are the risks worth the benefits?

When you think of menopause, you might think of hot flashes and night sweats. But many women also experience symptoms of depression. The risk of depression doubles or even quadruples during the menopausal transition, which has researchers looking for ways to address — or even prevent — the problem.

One study published in JAMA Psychiatry found that hormone therapy may help ward off symptoms of peri- and postmenopausal depression in some women. Researchers found that perimenopausal and early postmenopausal women who were treated with hormones were less likely to experience symptoms of depression than women in the study who were given a placebo.

But unfortunately, the findings present a far-from-perfect solution. Hormone therapy brings its own set of risks, and for this reason it likely shouldn’t be widely used for preventing depression in women at this stage of life, says Dr. Hadine Joffe, the Paula A. Johnson Associate Professor of Psychiatry in Women’s Health at Harvard Medical School, who wrote an editorial accompanying the study. “It’s not a ‘never,’ but it shouldn’t be a standard approach; in general, all of medicine has moved away from using hormones for prevention,” she says.

About the study

The study included 172 perimenopausal and early postmenopausal women ranging in age from 45 to 65 who were experiencing low-level symptoms of depression. Roughly half used a skin patch containing the hormone estradiol for 12 months, as well as intermittent oral progesterone pills. The rest received a fake skin patch and placebo pills.

The women were evaluated at the beginning of the trial and throughout for symptoms of depression, using the Center for Epidemiologic Studies Depression Scale. Researchers found that only 17% of women in the hormone group developed clinically significant depression, compared with 32% of those in the placebo group.

Untreated depression can cause physical symptoms, such as headaches and fatigue, in addition to emotional symptoms, including persistent sadness and even suicidal thoughts. It can interfere with daily function and reduce quality of life. However, hormone use brings its own health risks, such as a greater chance of blood clots and stroke. “It would be irresponsible to recommend this as a blanket prevention treatment for women,” says Dr. Joffe, who is also executive director of the Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital.

Lessons learned

Despite the caveat about hormone therapy, the findings should not be ignored. Rather, the key message for women is that depression during perimenopause and early postmenopause should be taken seriously, and women at this stage of life should be more closely monitored for depressive symptoms. In addition, study authors identified at least one risk factor for depression that stood out among women in this group — recent life stress. “A lot of people have stress, so I think it’s an important message that stress contributes to depression,” says Dr. Joffe.

Depression symptoms are not a sign of someone’s failure to cope. “This really is a brain phenomenon,” says Dr. Joffe. So here are some action points based on the findings.

• Be aware of depression risk. Knowing that depression is more common during perimenopause and early postmenopause can help you identify worrisome symptoms and act quickly. If you are perimenopausal or in early postmenopause, your doctor should ideally be screening you for mood symptoms at your regular visits. If not, bring up the topic yourself. If symptoms do develop, ask your doctor for a referral to a mental health specialist.
• Weigh hormone therapy’s pros and cons. Hormone therapy may be the right choice for some women. Talk to your doctor about the potential benefits and risks. Consider how long to use hormone therapy and whether there are other medical reasons to consider taking it. Keep in mind that more research is needed to fully understand the potential benefits and drawbacks of using this therapy to prevent depression, says Dr. Joffe. Talk with your doctor about whether behavioral strategies or antidepressant drugs might be a good alternative choice for you.
• Consider lifestyle changes and treatment. Regardless of whether you opt for hormone therapy or not, nondrug strategies can also be used to reduce the likelihood of depressive symptoms, including managing stress and boosting physical activity.

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My Health - Inducing labor at full-term: what makes sense?

For generations, midwives and doctors have looked for ways to imitate human physiology and nudge women’s bodies into giving birth. Synthetic hormones can be used to start and speed up labor. Soft balloons and seaweed sticks placed alongside the cervix can shape a pathway through the birth canal. Self-stimulation can spontaneously spark natural labor transmitters.

But the start of labor remains a complex and mysterious process. And part of this mystery is figuring out which women to induce, when to induce labor, and how. Now, a landmark study known as ARRIVE has brought a bit of clarity.

What does the study tell us about inducing labor?

This multicenter, randomized, controlled trial involving thousands of women compared outcomes of induced labor versus “expectant management” — just waiting for labor to begin. All participants in the study were expecting their first baby, and all were within one week of their due date. For most of the women, their cervix wasn’t really open yet. No special methods were used to induce labor, just what was standard at each institution.

The results were interesting. For the baby, similar numbers of complications and need for intensive care occurred in both groups. However, when compared with waiting for labor, induction decreased the likelihood that the baby would need help with breathing. Breastfeeding success was no different between the two groups.

The big news? Inducing labor was associated with a lower rate of cesarean delivery(approximately  19% versus 22%).

What else is important to know?

It’s worth pointing out that the overall rate of cesarean birth among women in the study is quite a bit lower than the national average. The study participants were also younger, more likely to be black or Hispanic, and more likely to have public insurance than the general population of women having their first baby. So these results would not apply to all women equally. Also, of all the patients who were initially eligible and asked to join the study, only about one-third chose to participate. It could be that women opting to participate in a study of induction of labor had a particular leaning that could skew the results. It also tells us that many women may not want to have labor induced. And, while the chance of cesarean was lower in the induced patients, labor took longer than it did for those women who waited for labor to kick in on its own.

Doctors sometimes recommend inducing labor and birth for the benefit of the baby, mother, or both. Hypertensive diseases, including chronic high blood pressure and preeclampsia, are dangerous conditions that may require accelerated delivery. Over time, the health of the placenta that nourishes the fetus can deteriorate, leading to lack of growth and low amniotic fluid levels. When problems like these occur, inducing birth is appropriate. Other conditions — such as diabetes requiring insulin and, at times, the age of the mother — may be good reasons to induce. But even without a medical reason, the ARRIVE trial tells us it may actually be safer to induce labor in some women than to wait for labor to happen.

Should a woman choose to have labor induced?

So, should a woman choose to be induced? The answer may be yes if she is having her first baby, is not opposed to the idea of inducing labor, and is within one week of her due date. However, the benefits become less clear if her characteristics differ from those of the study participants in the ARRIVE trial. It’s best for a woman to discuss the options with her health care team.

We also don’t yet know how the longer labor and length of hospital stay associated with induction affect the cost of care. And most labor and delivery units are not built or staffed appropriately to accommodate the increase in occupancy that would result if many more first-time mothers were induced at full term. So, while the ARRIVE trial has answered some critical questions about inducing labor, some of the mystery remains.

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My Health - The introvert’s guide to social engagement

Given the choice of interacting with people or watching the new episodes of Agatha Christie’s Poirot on PBS, well, let’s just say I think David Suchet is better company. If you are an introvert like me, you relish your time alone. But we should also understand the dilemma we face when it comes to long-term health. Research continues to show that regular interactions can lower your risk for heart disease, depression, and early death.

But what if being social is not who you are?

An introvert is someone who enjoys solitude and focuses more on internal thoughts and feelings. Unlike extroverts, who gain energy from social interaction, introverts often expend energy in social situations. After being with a large group, people who are introverted often feel a need to recharge by spending time alone.

While people who by nature are more introverted are not necessarily at a higher risk for problems related to isolation, they should make efforts to stay engaged with others on some level, according to Dr. Steven Schlozman, an assistant professor of psychiatry at Harvard-affiliated Massachusetts General Hospital. “You don’t always have to be more social if you don’t miss it, but humans are social beasts by nature. We really do well when we connect with others, even for brief periods.”

Find social opportunities that work with your personality

Don’t feel you have to change your nature in order to socialize more. In fact, it’s almost impossible to do. Many studies have shown that a person’s core traits tend to remain constant throughout life. “If you were an introvert when you were younger, odds are you will be later in life,” says Dr. Schlozman. He suggests that instead of fighting your personality, work with it, and focus on the type and level of interactions you can do and enjoy. “Was it one-on-one time to discuss last night’s game, or was it being part of a group where the attention wasn’t focused on you? Once you can identify those types of engagement, you can create strategies to achieve them. Being stressed defeats the purpose of socializing, so you should make sure you are comfortable with the level of engagement and have the chance to back off or do something else if it doesn’t feel right,” says Dr. Schlozman. Here are some suggestions:

• Know your boundaries. You may be more comfortable with social settings that have a defined beginning, middle, and end. Introverts are often not comfortable with uncertainty about when something will end, and these boundaries help them engage in conversation.
• Control the setting. If going out is not easy, have people come to you. For instance, invite someone to your home for dinner, or have a small group over to watch the game. This puts you in control of the environment as well as the amount of socializing.
• Focus on activities. Signing up for class at a local college or community center can help you place your energy and attention on the activity rather than conversing with others. “Sometimes just being around people is enough,” says Dr. Schlozman.
• Join a club. Find an organization based on your personal interests or hobbies, like a golf league, civic club, or volunteer group. “It is often easier to interact with people who share your passions,” says Dr. Schlozman.
• Socialize from afar. Social media is another way for introverts to stay connected. For example, Facebook has groups devoted to specific activities or interests that people can join and participate in at whatever level they wish. You can watch from afar and choose when to interact, and come and go as you please, without the worry of commitment. For the record, I’m told Facebook has several fan pages devoted to Poirot.

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My Health - Is hand sanitizer better at preventing the flu than soap and water?

Frequent use of hand sanitizer, instead of soap and water, may lead to fewer respiratory infections, fewer sick days, and less antibiotic use — at least if you’re a toddler. A Spanish study enrolled 911 children who attended day care, from newborns up to three-year-olds, and randomly assigned them to one of three groups.

In the control group, parents and caregivers continued usual hand care for the toddlers. In the two intervention groups, children were assigned to either labor-intensive hand sanitizer use or soap and water handwashing. Parents and caregivers were instructed to either apply hand sanitizer or wash the toddlers’ hands when they arrived at the classroom in the morning; before and after lunch; after playing outside; after coughing, sneezing, or blowing their noses; after diapering; and before they left for home. In both groups, handwashing with soap and water was mandatory after using the toilet or when hands were grossly soiled.

Outcomes in the hand sanitizer group were significantly better than either the soap and water group or the control group. The hand sanitizer group had lower rates of respiratory infections and missed fewer days of school, compared to the other two groups. Kids in the hand sanitizer group were also less likely to be prescribed antibiotics for respiratory infections.

The families or day care providers in the hand sanitizer group went through 1,660 liters of hand sanitizer during the eight-month study. Based on this, the researchers estimated that each toddler used hand sanitizer six to eight times daily, on average.

There are reasons to take the results of this study with a grain of salt. A great deal of time and effort went into reinforcing the importance of hand hygiene. Researchers visited the day care centers every two weeks to tell stories and sing songs about germs and cleanliness. This probably led to levels of hand sanitizer use that would be difficult to duplicate in a real-world situation. As well, some, but not all previous studies of hand sanitizer use in preschoolers have shown lower rates of cold and flu infections.

The researchers did not assess how often the kids in the handwashing group actually washed their hands. It is possible that the better outcomes in the hand sanitizer group were related to the greater ease of use of hand sanitizer, compared to handwashing, which usually requires a little more time and effort.

Take-home points

• Hand sanitizer use in toddlers may be associated with lower rates of respiratory infections than handwashing with soap and water alone.
• Hand sanitizer use probably has to be fairly compulsive for users to see significant benefits.
• Hand sanitizer should contain 70% ethyl alcohol to reliably kill bacteria and viruses; some bacteria have shown tolerance to lower amounts of ethyl alcohol.
• Although there is little high-quality evidence on the benefits of hand sanitizer use in the community at large, the use of hand sanitizer, along with handwashing and flu vaccination, is a reasonable measure to reduce the risk of respiratory infections in adults at risk.

Follow me on Twitter @JohnRossMD

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My Health - Behavioral weight loss programs are effective — but where to find them?

The US Preventive Services Task Force (USPSTF) is a team of volunteer experts from various primary care medicine and nursing fields. They identify big medical problems, review the research, and translate it into action plans (called practice recommendations) for doctors like me.

Just this fall, they tackled obesity, with the goal of identifying effective ways we in primary care can help people to lose weight.

And it’s not about aesthetics. This is about disease prevention, especially diabetes, high blood pressure, and heart disease, which are particularly associated with obesity.

They were NOT looking at surgeries or other procedures, only research trials involving either behavioral or medication-based weight loss programs.

The task force analyzed 89 behavioral weight loss program trials from all over the world, and these included participants of both genders as well as many racial and ethnic groups, with ages between 22 and 66, and body mass index between 25 and 39.

What was involved in a behavioral weight loss program?

The programs studied lasted between 12 and 24 months, and involved at least 12 sessions (face-to-face, group meetings, or web-based). A variety of specialists were involved (behavioral therapists, psychologists, registered dietitians, exercise physiologists, lifestyle coaches, as well as physicians) who provided counseling on basics like nutrition, physical activity, and self-monitoring, as well as psychological components like identifying obstacles, planning ahead, problem solving, and relapse prevention. Email, telephone, and/or peer support were typically included. Basically, these are intensive programs that focus on lasting diet and lifestyle change.

And intensive diet and lifestyle programs work well for weight loss. Participants had significant weight loss compared to controls, averaging between 1 and 20 pounds, with an average weight loss of 5 pounds overall, and were more likely to have lost 5% of their total body weight at 12 to 18 months. Thirteen trials looked at diabetes risk, and pooled results showed that participants had a significantly lower risk of developing diabetes.

Here’s the most important part: the risks of participating in these studies were minimal. This is a major plus to behavioral interventions: no side effects or drug complications.

How did behavioral programs compare with medications?

That is considerably different from studies featuring weight loss medications. Thirty-five studies looking at a variety of medications (like liraglutide, lorcaserin, naltrexone and bupropion, orlistat, and phentermine-topiramate) had stringent inclusion criteria and high dropout rates. Why? Because of the many medical contraindications of some of these medications, and the side effects, some quite serious.

Yes, the medication studies demonstrated significant weight loss, ranging from 2 to 13 pounds. But in the end, the USPSTF has to weigh effectiveness as well as potential risks, and they concluded that “intensive, multicomponent behavioral interventions in adults with obesity can lead to clinically significant improvements in weight status and reduce the incidence of type 2 diabetes among adults with obesity and elevated plasma glucose levels …[]… and that the harms of intensive, multicomponent behavioral interventions (including weight loss maintenance interventions) in adults with obesity are small to none.”

Basically, intensive behavioral programs aimed at lasting lifestyle changes work well for weight loss, and are extremely low-risk to boot.

So where can you sign up for such programs?

Okay, here’s where the gap between science and practice comes in.

Few of these behavioral weight loss programs exist, and not everyone meets the criteria for insurance to cover them. So for most people, unless they can afford to pay out of pocket, these programs are only available through research studies.

For example, the Diabetes Prevention Program (DPP) is an excellent intensive lifestyle change behavioral weight loss program that has been studied for literally decades and works very well. It’s a year-long commitment including 22 learning sessions (in-person or online) and frequent contact with a lifestyle coach. Insurance will cover this program for people who have a BMI over 25 and a confirmed diagnosis of prediabetes. Not diabetes, only prediabetes. The DPP curriculum is available for free on the Centers for Disease Control (CDC) website. Anyone could establish a program.

But a program has to meet a lot of requirements over a significant amount of time before it’s officially recognized by the CDC, and insurance companies won’t cover a program until it’s recognized by the CDC. Even then, reimbursement rates can vary. As a result, there aren’t many of these programs up and running, but there are some. To find a recognized DPP program in your state or online, check out the CDC’s registry.

Many hospitals offer less intensive, shorter behavioral lifestyle change programs, but these are pay-out-of-pocket and generally cost upwards of $500.

What can you do if you can’t access a behavioral weight loss program?

You can work with your doctor and create your own program by consulting with relevant specialists (for example, a nutritionist, personal trainer, and therapist), following your own progress (for example, at the doctor’s office or using an app), and arranging your own peer support (ask friends and family to join you on your health journey, or join a group like Weight Watchers). I have had patients who have succeeded in making lasting lifestyle changes — including weight loss — using this approach.

Mobile phone apps are a relatively new but promising tool. In one 2015 research review, studies of various weight loss phone apps, used for six weeks to nine months, showed a significant average weight loss of 2.2 pounds. Some free, widely available apps include MyFitnessPal, Lose It, Noom, Weight Watchers, and Fooducate (note that these were not necessarily the ones studied in that review article).

I am hopeful that soon, guidelines-based intensive lifestyle change programs will become more widely accessible to everyone who needs this support.

Resources

There are books that can help you. I have written an evidence-based book expressly for self-guided diet and lifestyle change, Healthy Habits for Your Heart.

But my book is not the only one; other quality examples address behavioral factors for lasting lifestyle change:

Disease-Proof by David Katz, MD, MPH

The Spectrum by Dean Ornish, MD

Eat, Drink, and Be Healthy by Walter Willet, MD, DrPH

Smart at Heart (for women) by Malissa Wood, MD, FACC

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My Health - AFM: The scary polio-like illness

It is a scary illness, not just for parents but for doctors, too: Acute flaccid myelitis (AFM) causes sudden weakness and loss of muscle tone in the arms and legs and can go on to cause even more serious problems.

It’s not just the symptoms that are scary. It’s also scary because we don’t know what causes it. Although the symptoms are similar to polio, patients with AFM have tested negative for polio. At one point it was thought that it was caused by another enterovirus, but that didn’t end up being the explanation. It may be another virus, or it may be some sort of toxin, or something else entirely — or perhaps a combination of factors.

What we do (and don’t) know about AFM

We know that AFM is more common in children, and we know that cases spike in summer and fall. We know that the symptoms are like those caused by viruses such as enterovirus, adenovirus, or West Nile virus, but after that there’s not much we know. Because we have been following this illness only since 2014, we don’t know the long-term effects of it either. Some patients recover quickly and completely, but for others the weakness doesn’t go away.

AFM symptoms

The symptoms of AFM include:

• weakness in the arms or legs or both
• loss of muscle tone in the arms or legs or both. This means that not only are the arms or legs weak, they seem looser or floppier than usual.
• In some cases, symptoms can also include:
  • weakness of the muscles of the face, which may cause the face to droop
  • trouble moving the eyes
  • weakness of the eyelids, so that they droop
  • trouble talking
  • trouble swallowing
  • trouble breathing.

If your child shows any of these symptoms, call your doctor right away.

Treating AFM

Because we don’t know exactly what is causing AFM, we don’t have a definitive treatment. We support patients when they are sick, giving medicines to help their symptoms, and physical therapy and other such treatments that may help with weakness, but there is no medicine we can give to cure or even treat the illness itself.

AFM and public health

And to make things even scarier, the number of cases is on the rise. So far in 2018, there have been 62 confirmed cases (127 have been reported as possible cases, but 62 have been confirmed). In all of 2017, only 33 cases were confirmed. Since 2014, there have been 368 confirmed cases. Getting exact numbers on this illness is hard, as there is no clear test for it. The Centers for Disease Control and Prevention (CDC) uses clinical symptoms as well as findings on MRI (magnetic resonance imaging) of the brain to decide whether someone has AFM. Because not all patients get MRI testing, and because not all patients get reported to the CDC, it’s likely that the numbers are higher.

What parents need to know

Since we don’t know exactly what causes AFM, it’s hard to tell people how to prevent it. You can prevent polio by being vaccinated, and everyone should be vaccinated. West Nile virus can cause similar symptoms and avoiding mosquito bites is the best way to prevent that. The best advice we can give now to prevent the viruses that might cause AFM is the simplest: wash your hands, well and often.

Despite all this scary stuff, it’s important to remember that overall this is a rare disease — less than one in a million people get it.

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My Health - Personal sound amplification products: For some, an affordable alternative to hearing aids

Growing up I had to wear glasses. Back then it was considered socially unacceptable, but necessary to be able to see. Sixty years later, everyone wears glasses and they are a fashion statement. Now as an aging adult, I need to wear hearing aids. This was and still is in many age groups considered socially unacceptable — a sign of being old and maybe a little senile. But it appears that hearing aids are in the process of a similar transformation. A pared down, more affordable category of products — personal sound amplification products (PSAPs) — may lead to greater use of hearing enhancers at a younger age.

Hearing aids: Enhanced hearing, at a price

One of the major complaints about hearing aids is that they are expensive; they can run from $1,000 to $6,000 apiece. Their average lifespan is about five years, making this a recurring expense. Not everyone can afford or wishes to spend that amount to improve their hearing, especially if their hearing loss is mild and they can get by without aids.

There is a large segment of the population that has such a mild hearing loss. They struggle in certain situations, such as when there is a lot of background noise — in noisy restaurants, large crowds, and large rooms. They do fine in quiet situations with small groups or one-on-one conversation. They could benefit from “readers” for the ears — inexpensive help that they can use occasionally, or even continuously, for a little boost.

Until recently, the laws have been a barrier for development of such help. Hearing aids have been defined by law and regulated. High certification costs have served as a barrier to market entry. Hearing aid prices have not come down much over the years, though the quality of the aids and the sophistication of the instruments have improved as fast as any electronic device available. What you get now for the same price you would have paid 10 years ago is a far superior device. What’s more, the cost to dispense, service, and maintain the devices has increased with the cost of living. All of this has led to a gap between the demand for and supply of inexpensive hearing aids.

PSAPs: A more affordable option

Along come PSAPs, which have the potential to fill a large gap in the existing hearing aid product offerings. They provide a lesser certified, less feature-filled, but lower-cost entry for hearing loss sufferers. PSAPs cannot be called or marketed as “hearing aids,” as they do not meet the definition and rigorous manufacturing and safety standards of hearing aids.

PSAPs range from simple volume amplification devices to more sophisticated devices that can do many of the simpler tasks that hearing aids can perform. They are self-fitting and can be self-programmed using a smartphone or computer app. They are sold over the counter, and thus eliminate the expense of fitting. They are not as electronically sophisticated as hearing aids, and so can be sold cheaper. Lowering the cost of entry will allow most people to enjoy better hearing at a younger age.

PSAPs are not a replacement for hearing aids. They cannot replace the sophistication of hearing aids, or the skill in fitting them that audiologists bring to the job. They are devices that can fill the need for those with mild hearing loss, who just need a little more volume in certain situations. The good ones — the ones you should try — will be marketed as hearing aids in the near future.

Getting started with your PSAP

Suppose you want to try a PSAP. How do you know you are getting what you are being told you are getting? How do you know that what these products advertise is actually what they deliver? How do you know that they are safe? The FDA has stepped in to regulate this new market. Legislation was passed in 2017 and goes into effect in 2020 to allow for marketing of these low-end hearing aids to be advertised as such, if they meet certain (still-to-be finalized) criteria on performance and safety. Many of the devices are on the market today without any such oversight. That will change in 2020 to allow those devices that meet the established criteria to be marketed as hearing aids and not PSAPs.

Many of the new devices require some sophistication in setup and maintenance. You become the dispenser, fitter, and maintainer of the devices. You provide yourself with the services that an audiologist provides for hearing aids. YouTube videos and online support can resolve most if not all issues that may come up. Mandated trial periods can allow for return of goods when the issues cannot be resolved.

Better hearing, younger

In countries where hearing aids are free, more than half of the people who could use hearing aids do not use them. Money is clearly not the only issue preventing hearing aid use. Starting people earlier in the process and giving them control over the use of such devices can only encourage a greater long-term acceptance and usage of hearing aids as we age. Having more people use the devices eliminates the social stigma that has surrounded hearing aids.

I am hopeful that PSAPs are the intermediate steps that will lead to greater hearing aid use for the majority of us who should be using hearing aids, but do not.

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My Health - Medical scribes let the doctor focus on you

It’s a gorgeous weekend and you are playing a game of basketball with friends. You take a jump shot, scoring two points, but twist your right ankle on landing. You feel immediate pain and stop playing. After resting for an hour, you notice increased swelling and are having difficulty walking, so you go to the nearby urgent care center. The physician comes to see you, introduces herself, then introduces the medical scribe, who moves to the corner of the room in front of the computer. As the doctor starts asking you questions, the scribe begins typing.

Scribes are becoming increasingly common in doctor’s offices. But what do they do, what type of training do they have, and why are they gaining in popularity?

What are medical scribes?

Scribes are assistants to physicians and other healthcare providers. Their roles include entering electronic documentation (notes) into the computer, including patient history, physician examination findings, test results, and other information pertinent to your care. While the scribe’s primary role is to enter medical documentation, they may also check for test results and assist with assigning diagnoses and billing. The physician is then responsible for carefully reviewing the scribe’s notes, correcting any misinformation or omissions, and signing the notes.

Scribes are often college students or recent college graduates seeking additional exposure to the healthcare field before applying to medical school or other graduate training programs; however, scribing can also be a full-time career. They receive training on how to document as well as on medical coding and billing rules. In general, scribes do not have healthcare provider training or certification. Unless your scribe is also a nurse, medical assistant, or other certified medical professional, they should not be providing medical advice or delivering care to you.

Scribes are members of the healthcare delivery team, and are therefore accountable to all applicable institutional policies and are expected to act professionally. For example, scribes are held to the same standards to protect patient privacy as other health care professionals. Scribes should be introduced to the patient when they enter the room. If you are uncomfortable with a scribe being present during your visit, you should request to be seen by the healthcare provider privately.

Why are scribes gaining popularity?

The practice of medicine requires a large number of administrative tasks, including thorough documentation of all patient visits. As the majority of US hospitals and physician offices have now transitioned to electronic documentation, physicians are spending an increasing amount of time on the computer instead of with the patient.

Adding a scribe to the team enables physicians to spend more time directly talking with patients, while the scribe documents the visit. Scribes are being used in all care settings, including the primary care office, specialist offices, urgent care, emergency departments, and inpatient hospitals. A recent study in the primary care setting found reductions in the amount of time spent with electronic documentation and improvements in physician productivity and work satisfaction associated with the use of medical scribes.

The future of scribes

Today, scribes typically accompany the physician and patient in the room. In-person scribes are also being supplemented by virtual scribes, where the scribe is not physically present in the room with the patient. For example, physicians may use a recording device to capture their interview and examination of the patient. The electronic recording can then be sent to the scribes (who are offsite), and then transcribed and entered into the computer. Newer video teleconferencing software and smart glasses are also being used to allow the scribe to view and transcribe the visit into the computer from an offsite location. The latter technology has the benefit of allowing the scribe to work in real time, asking clarifying questions to the providers, and entering the notes faster. Importantly, with both these scenarios, physicians are still responsible for the content of the notes and must review and sign off on the notes.

The US Centers for Medicaid and Medicare Services, which oversees federal health insurance programs, is currently working to reduce documentation requirements for billing, which may help decrease physician workload. In addition, advances in technology may one day completely automate documentation of patient visits.

In the meantime, scribes provide the ability for physicians to focus more on the patient relationship and interaction and less on computer data entry.

Follow me on Twitter @landmaad

References

Association of Medical Scribes in Primary Care With Physician Workflow and Patient Experience. JAMA Internal Medicine, September 17, 2018.

Use of Medical Scribes to Reduce Documentation Burden: Are They Where We Need to Go With Clinical Documentation? JAMA Internal Medicine, September 17, 2018.

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My Health - Mindfulness apps: How well do they work?

You’ve heard of mindfulness, but what is it, really? How is it different from meditation? Is mindfulness really helpful? Is it hokey? And can you learn it? Do you need to go to a week-long camp or a psychotherapist or a guru? The answer could be on your smartphone.

What is mindfulness?

There’s no specific definition of mindfulness or meditation, although most writers see mindfulness as one form of meditation, which includes many other activities such as visualization and contemplation. Mindfulness involves focusing completely on what’s going on inside you and outside you — being an observer without getting wrapped up in what you’re observing.

A helpful website to learn about mindfulness is provided by the National Health Service of the UK. The creators of this site suggest that watching your thoughts come and go without getting wrapped up by them is like standing at a bus stop watching the buses come and go without getting on one. You can observe your thoughts or worries come up without getting consumed by them and distracted from the world around you.

In-person mindfulness training typically involves spending a great deal of time in silence, often with eyes closed, learning to note what is going on around you, such as the humming of a light or the sound of cars outside, or the feel of air flowing past your face from the AC. It often involves also noting what is going on inside your body, especially your breath and the sensation of air coming in through your nose or out your mouth. The goal is to be present with these observations, not distracted by worries about your to-do list, your relationships, or some recent event. Often mindfulness sessions are started and concluded with the sound of a chime, which is a tradition that comes from Buddhist meditation practices.

If you learn mindfulness techniques — paying attention to your physical sensations and your sensory perceptions, while learning to observe your thoughts and feelings — you’re likely to manage stress better, have fewer episodes of depression, and less anxiety. Research also shows you may experience a better quality of life and improved health, although less so than for the mental health benefits.

Which app is best, and for whom?

Wearing headphones or being buried in your phone all the time is the opposite of mindfulness. Nonetheless, there are about 280 mindfulness apps in the Apple iTunes app store. These seem like they could be a great way to learn a healthy skill. But how do you pick one?

A recent study by researchers from Lancaster University in the UK examined the most popular mindfulness apps. Of the 280 they found in the iTunes store, they narrowed these down to only include apps that are in the Health and Fitness category, only those with 100+ user reviews, and only those with ratings above 3 on a 5-star scale. This left them with the 16 most popular and potentially helpful mindfulness apps — 14 of which also are available for Android users. (These apps are listed here). Notably, only one of the apps has been experimentally studied — Headspace, which showed decreased depression and increased positive emotions after use for 10 days. However, this does not mean other apps don’t work; they just haven’t been studied yet.

The Lancaster team of two computer scientists reviewed the apps on a number of dimensions to categorize what they actually do and how they do it, and presented its findings at the prestigious Association for Computing Machinery’s Computer Human Interaction (CHI) conference in Montreal this year. They found that apps recommend daily practice of 10 minutes, and they essentially offer pre-recorded audio clips (a female or male voice talking you through mindfulness exercises) or timed sound effects (chimes that sound at the beginning, middle, and end of a mostly silent mindfulness practice session). They also offer ways to keep track of your practice sessions. None of them, however, offer any way of tracking how well you are learning mindfulness or its impact on your life.

Keeping in mind that the crux of mindfulness is noticing what is going on around you, and what is going on inside you, it is striking that only three of the 16 apps emphasized intrinsic or self-directed, silent practice of mindfulness. These three, Insight Timer, Meditation Timer, and Tide, really serve as timers with chimes to start and end your silent practice sessions. The other 13 apps provide audio recordings of someone talking you through focusing on breathing or other physical sensations.

It’s hard to notice what’s going on inside or around you if you’re distracted by someone speaking, even if it is soothing speech, and some reviews of these apps point this out. Research also indicates that the self-directed, silent form of mindfulness practice is more effective than externally guided exercises. Being talked through a breathing exercise is actually a form of relaxation training (learning to release tension from the body), which also has value, but is different from mindfulness training.

The researchers suggest that in the future, tangible objects (like meditation balls or wheels, which are used in traditional practices) could be incorporated into mindfulness training, as well as physiological sensors to track the body’s activity during practice sessions. Look for enhanced mindfulness apps on the horizon.

Which app should you try?

There’s no single best app for everyone. It may be helpful to try a self-guided app first, but if you don’t click with it, then try an app that has verbal instructions or guidance, returning to the self-guided silent app later when you’ve gotten the hang of it.

Even with an app, mindfulness takes practice. Like playing an instrument or a sport, the more you practice, the better you get and the more you get out of it. That’s where the 10 minutes every day comes in. Whatever you try, mindfulness training is considered very safe, and has a good chance of increasing your happiness and peacefulness, and reducing your depression, anxiety, and stress.

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