My Health - Colorectal cancer screening before age 50?

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. There is strong evidence that screening for CRC with colonoscopy, other visual exams, or stool-based tests can reduce CRC mortality. As a result, several expert organizations have long recommended regular CRC screening for US adults ages 50 to 75.

In 2018, the American Cancer Society (ACS) became the first major organization to recommend CRC screening starting at 45.

Why did the ACS recommend CRC screening starting at 45?

The incidence of CRC and mortality from the disease has declined over the last several decades among adults over 50, which may reflect the effectiveness of screening in this age group. In contrast, since the early 1990s, there has been an increase in CRC incidence and mortality among individuals younger than 50.

The absolute risk of any given individual younger than 50 developing CRC remains substantially lower than in older adults. But due to delays in diagnosis, younger patients are often diagnosed at later stages, when the disease is more challenging to treat. And they tend to experience greater loss of high-quality and productive years of life due to premature death from CRC.

The ACS recommendation was based, in part, on a prediction model that considered the trend of increasing CRC incidence in younger individuals. Theirs was a “qualified” recommendation, by which the ACS indicates that “there is clear evidence of benefit of screening but less certainty about the balance of benefits and harms or about patient’s values and preferences, which could lead to different decisions about screening.”

What accounts for the increase in early-onset CRC?

The bottom line is that we still do not know why more people are being diagnosed with CRC before 50. There are established genetic risk factors for CRC, including hereditary syndromes that increase the risk of developing CRC at a young age. However, the vast majority of early-onset CRCs occur among individuals with no family history.

Thus, recent trends in early-onset CRC are likely due to changes in environmental exposures. Initial epidemiologic studies point to risk factors such as childhood obesity, dietary habits, and antibiotic usage early in life.

Will starting screening at an earlier age reduce early-onset CRC?

It is still too early to tell. Modeling studies, like the one considered by the ACS, rely on assumptions and are limited by inherent uncertainties. For example, the ACS model assumes that screening will have a similar level of benefit in those younger than 50 as it does on those 50 to 75. But there are no direct clinical data to support this. In addition, the potential harms of screening in those younger than 50, such as false positive results that could lead to additional testing, are not well quantified.

Other organizations with established expertise in assessing the risks and benefits of CRC screening have yet to modify their recommendations. Thus, for the time being, individuals between 45 and 50 should discuss with their doctors whether to begin screening at 45 or wait until 50.

What else can people do to prevent CRC?

In addition to screening, quitting smoking, maintaining a high level of physical activity, avoiding overweight and obesity, and consuming alcohol in moderation are all known to reduce the risk of CRC. Limiting consumption of processed meats and red meat, particularly those that are prepared at high temperatures (such as through grilling and charring) is also prudent.

Finally, there are strong data supporting the use of aspirin to prevent CRC. The US Preventive Services Task Force has recommended regular aspirin use for the prevention of CRC. However, given potential risks associated with aspirin, such as bleeding, anyone considering aspirin for disease prevention should discuss this with their doctor.

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My Health - Trouble reading? Try these workarounds

Once you learn how to read, it’s easy to take the skill for granted. Like breathing or walking, we don’t give the ability much thought unless it begins to deteriorate. But trouble reading can develop at any age for a variety of reasons, including difficulty concentrating, mild cognitive impairment, and physical changes.

Mental roadblocks can cause trouble reading

Fuzzy thinking and difficulty concentrating can get in the way of reading. “If your attention isn’t focused on the sentence you’re reading, you’re not likely to register enough of the sentence to understand what your eyes just passed over,” notes Dr. Joel Salinas, a neurologist at Harvard-affiliated Massachusetts General Hospital.

You might experience fuzzy thinking or difficulty concentrating because of

• a lack of sleep
• stress
• nutrient deficiency
• a medication that makes it harder to concentrate
• reading or learning disabilities.

Sometimes age-related cognitive changes affect reading skills. Reading requires attention, short-term memory, and recall, which decline a little as we get older. “It’s normal when you’re older that your reading might be slower or that you have to occasionally read a sentence more than once to get its meaning. Your ability to read and retain information may take more effort,” Dr. Salinas explains.

Mild cognitive impairment can cause trouble reading

Mild cognitive impairment (MCI) may also be behind a decline in reading skills. MCI can make it harder to understand or retain what you’re reading.

MCI is a noticeable change in thinking and memory skills, but not enough that it becomes a huge barrier to your ability to take care of yourself and accomplish your daily tasks. You may miss some appointments, lose things often, have more difficulty recalling names or words you’d like to use, or have a harder time finding familiar places and keeping track of important dates.

Physical challenges can cause trouble reading

Physical changes, such as accidents or chronic disease, can also affect your ability to read. Examples include:

• Poor vision. Maybe you have double vision, or you can’t see up close, or maybe it’s hard to read in a room that isn’t well lighted.
• Arthritis. “Osteoarthritis at the base of the thumb, wrist, or fingers is common with age and can affect your ability to hold a book,” says Dr. Robert Shmerling, a rheumatologist at Harvard-affiliated Beth Israel Deaconess Medical Center.
• Neuropathy (pain or numbness in the extremities). This may result from diabetes or back pain, and can make it uncomfortable to hold reading material for extended periods.
• Traumatic brain injury. A concussion that you suffer from a sports injury, fall, or car accident might create difficulties concentrating or seeing (such as blurry vision).
• Shaky hands from essential tremor, multiple sclerosis, or other conditions may keep you from holding a book still enough to read the words.

When to seek help

Talk to your doctor when you notice trouble reading. Start with your primary care doctor, who can perform a mini evaluation or send you to a neuropsychologist for a thorough evaluation. “Neuropsychologists can test for how fast you read, how much you understand, and what you recall from what you read,” Dr. Salinas says.

When physical changes are the problem, treating the underlying condition can help you read better. For instance, maybe you just need a new pair of glasses.

Try these workarounds

Sometimes using a few simple strategies can make reading easier. If you have pain or tremors, Dr. Shmerling recommends propping up a book on a pillow or book holder. If you find it’s hard to flip pages, try an electronic reading device like an iPad or Kindle. With an electronic device, the page stays steady, and it’s just a tap to turn the page. For vision challenges, electronic reading devices and large-print books can help greatly.

When attention is the challenge, Dr. Salinas suggests reading in a quiet space, reading out loud, mouthing the words as you read, listening to the audiobook recording while you read, or using a sheet of paper to reveal one line of text at a time so you don’t skip ahead.

The important thing is to try. “There are solutions that work for most obstacles to reading,” says Dr. Shmerling, “and for most people, it’s a great way to keep up with what’s happening in the world and to keep the mind working.”

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My Health - Showering daily — is it necessary?

Do you shower or bathe daily? If you do, you’re not alone.

Approximately two-thirds of Americans shower daily. In Australia it’s over 80%. But in China, about half of people report bathing only twice a week.

In the US, the daily shower tends to start around puberty and becomes lifelong. But have you ever stopped to ask yourself why?

Perhaps your answer is: “because it’s healthier than showering less often.” Think again. For many — perhaps most — the daily shower is more about habit and societal norms than health. Perhaps that’s why the frequency of bathing or showering varies so much from country to country.

Are there reasons to shower every day?

Besides considering it healthier, people may choose to shower daily for a number of reasons, including:

• concerns about body odor
• help waking up
• a morning routine that includes working out.

Each of these has merit, especially considering that personal or work relationships can be jeopardized by complaints about body odor or personal hygiene. But what is considered acceptable in this regard varies from culture to culture. And some (perhaps a lot) of what we do when it comes to cleaning habits is influenced heavily by marketing. Ever notice that directions on shampoo bottles often say “lather, rinse, repeat”? There is no compelling reason to wash your hair twice with each shower, but it does sell more shampoo if everyone follows these directions.

When it comes to concerns about health, however, it’s not at all clear that a daily shower accomplishes much. In fact, a daily shower may even be bad for your health.

What are the health impacts of showering (or bathing) every day?

Normal, healthy skin maintains a layer of oil and a balance of “good” bacteria and other microorganisms. Washing and scrubbing removes these, especially if the water is hot. As a result:

• Skin may become dry, irritated, or itchy.
• Dry, cracked skin may allow bacteria and allergens to breach the barrier skin is supposed to provide, allowing skin infections and allergic reactions to occur.
• Antibacterial soaps can actually kill off normal bacteria. This upsets the balance of microorganisms on the skin and encourages the emergence of hardier, less friendly organisms that are more resistant to antibiotics.
• Our immune systems need a certain amount of stimulation by normal microorganisms, dirt, and other environmental exposures in order to create protective antibodies and “immune memory.” This is one reason why some pediatricians and dermatologists recommend against daily baths for kids. Frequent baths or showers throughout a lifetime may reduce the ability of the immune system to do its job.

And there could be other reasons to lose your enthusiasm for the daily shower: some people suggest that the water with which we clean ourselves may contain salts, heavy metals, chlorine, fluoride, pesticides, and other chemicals. These may cause problems, too.

The case for showering less

Overcleaning your body is probably not a compelling health issue. Yes, you could be making your skin drier than it would be with less frequent showering. This is not a public health menace. However, daily showers do not improve your health, could cause skin problems or other health issues — and, importantly, they waste a lot of water. Also, the oils, perfumes, and other additives in shampoos, conditioners, and soaps may cause problems of their own, such as allergic reactions (not to mention their cost).

While there is no ideal frequency, experts suggest that showering several times per week is plenty for most people (unless you are grimy, sweaty, or have other reasons to shower more often). Short showers (lasting three or four minutes) with a focus on the armpits and groin may suffice.

If you’re like me, it may be hard to imagine skipping the daily shower. But if you’re doing it for your health, it may be a habit worth breaking.

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My Health - Thunderclap headache: The “worst headache of my life”

Not all headache disorders are the same. An excruciating, sudden-onset headache known as thunderclap headache (TCH) is a medical emergency, very different from more common headache disorders such as migraine and tension headache. If you develop TCH, you should call 911 or immediately go to the closest hospital.

TCH is associated with a variety of causes, ranging from benign to potentially fatal. Urgent evaluation in an emergency setting is needed to quickly identify and treat any underlying condition.

Diagnosing and treating secondary thunderclap headache

When you arrive at the hospital, the medical team will want to confirm or rule out a potentially serious, secondary cause of the TCH. The initial history and examination will focus on red flags that suggest specific secondary causes.

A secondary TCH has an underlying cause, other than the headache itself. For example, neck stiffness or sleepiness may suggest a ruptured brain aneurysm or infection; a drooping eyelid may indicate a tear in the carotid artery (the main artery supplying the brain); seizures or sudden limb weakness may suggest clots in a blood vessel, or bleeding in the brain (hemorrhage). Absence of these signs and symptoms does not definitively rule out these causes, which is why you will likely undergo imaging of the brain and its blood vessels with either computed tomography (CT) or magnetic resonance imaging (MRI). If imaging does not reveal a clear secondary cause, a lumbar puncture, or spinal tap, may be needed.

If a secondary cause is identified, the underlying problem will be treated. For example, if your TCH was caused by a blood clot in an artery, it would be treated with clot-busting medications or the clot would be removed via a catheter-based procedure.

Primary thunderclap headache and RCVS

If no obvious cause is found, TCH is considered “primary,” or “idiopathic.” Primary TCH typically affects young adults. It is commonly associated with physical triggers such as cough, exercise, and sexual activity.

Rarely, people can develop multiple, recurrent TCHs within a span of a few days. In such cases, imaging invariably shows alternating areas of narrowing and dilation (the appearance is described as “a sausage on a string”) of multiple brain arteries. This condition is called reversible cerebral vasoconstriction syndrome, or RCVS. RCVS can also develop in patients with a single TCH.

Approximately 30% to 50% of patients with RCVS go on to develop brain hemorrhage, strokes, and brain swelling. Thus, if you are diagnosed with RCVS, you will likely be admitted to the hospital for a few days of observation. Despite these possible complications, people with RCVS generally do well; the flurry of TCHs usually subsides within days, and the arterial narrowing resolves on its own within a few weeks.

Treating primary thunderclap headache and RCVS

There is no known preventive medication for primary TCH or RCVS. Bed rest is recommended, since exercise, anxiety, and sexual activity can precipitate more TCHs. Laxatives and stool softeners are also recommended, since straining or bearing down can trigger TCH.

The extreme head pain usually settles in a few minutes, but moderate to severe headache can persist for several hours. Common pain relievers such as acetaminophen (Tylenol) and ibuprofen (Advil) may help. Treatment with more potent drugs, such as morphine and other opioids, may be prescribed for prolonged or very severe head pain.

Certain medications should not be used to treat TCH. These include glucocorticoids, triptans, and other anti-migraine medications, which induce narrowing of brain arteries and can worsen the situation. People with RCVS should also avoid certain drugs for several weeks. These include serotonin-enhancing antidepressants (SSRIs and SNRIs), ecstasy, cannabis, and sympathomimetic and amphetamine derivatives such as pseudoephedrine (a common ingredient in many cough-and-cold remedies, exercise stimulants, and diet pills).

Primary TCH can recur intermittently for several years. Recurrence of an episode of RCVS is extremely rare. Most people can resume routine physical activities and gradually increase the intensity of exercise two to four weeks after the sudden-onset headaches subside.

The extreme head pain of primary TCH and RCVS can understandably evoke significant anxiety. But the long-term outcome is nearly always benign.

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My Health - Fiber-full eating for better health and lower cholesterol

The American Heart Association and the FDA recommend that we all eat at least 25 grams of dietary fiber per day. But what is it, how do we know how much we’re eating, and where did that number come from, anyway?

What are the types of fiber?

Dietary fiber is a good carbohydrate, also known as roughage, found in plant foods (not supplements). There are two kinds, soluble or insoluble, and both are really good for us. Soluble fiber becomes a thick gel in our intestines, which slows digestion (which keeps blood sugars from spiking) and traps fats so they can’t all be absorbed (which lowers cholesterol levels). Sources of soluble fiber include oatmeal, beans, lentils, and many fruits. Insoluble fiber helps keep our stools soft and regular, always a good thing! Sources of insoluble fiber include whole grains, beans, lentils, and most vegetables. Both soluble and insoluble fiber make us feel full, which helps us to eat less.

Why is fiber so good for us?

But fiber does so, so much more. In a recent research study published in The Lancet, investigators pooled the results from 243 studies looking at health effects of dietary fiber. They excluded any studies about fiber supplements — this was all about fiber from food. They ended up with data from over 4,600 people, and found a very strong relationship between higher dietary fiber intake and better health outcomes. Basically, intake of at least 25 grams of food fiber a day is associated with a lower weight, blood pressure, blood sugars, cholesterol, as well as lower risk of developing (or dying from) diabetes, heart disease, strokes, and breast or colon cancer. Study results were extremely consistent, and the dose-response curve was very linear, meaning the more fiber, the better the outcomes. This makes us believe the results are very real and not due to some other factor related to study participants’ diet or lifestyle.

Consuming good carbs means more daily fiber

Unfortunately, most of us are consuming fewer than 20 grams of fiber per day. I know many people who shy away from the carbs in whole grains, beans, and fruit, thus missing out on all that healthy fiber. But here’s the deal: there’s good carbs and bad carbs, and whole grains, beans, and vegetables are all good, folks. It’s the quality of the carb that counts. Worried about gassy effects? In the short term, start low and use simethicone (a common, gentle anti-gas medication) as needed. Your body will become accustomed over time, and the effects will diminish.

Fiber-packed meals are easy

Let’s put together a very simple yet flexible meal using boiled red lentils, store-bought or homemade hummus, whole-wheat wraps, and a simple salad made with mixed greens, tomatoes, and cucumbers dressed with only lemon juice and olive oil. This meal is so easy and healthy, and it can be served to guests or packed up for lunch at the work desk. This meal has half the recommended daily fiber and almost 20 grams of protein, plus calcium, iron, and potassium.

Mediterranean-Style Heart-Healthy High-Fiber Buffet

Many of these ingredients can be purchased inexpensively or prepared super-quickly, and no one will know you weren’t cooking all day.

 

Cooked and seasoned red lentils (1 cup raw lentils to 3 cups water, bring to a boil and simmer for 15 minutes, then sprinkle with sea salt and lemon juice. Add chopped fresh herbs too, if you like. Serve hot or cold.)

Very simple salad (mixed greens, sliced cherry tomatoes, and chopped cucumber, dressed in extra virgin olive oil, lemon juice, sea salt, and black pepper. Toss it all up and serve.)

1 container hummus (or you can make your own)

Whole-wheat wraps

Optional: kalamata olives, artichoke hearts, sundried tomatoes, baba ganouj, or other Mediterranean goodies, low-salt versions preferred

 

There are many resources available to guide you on healthy high-fiber food choices. Basically, consuming fruits, veggies, beans and legumes, and nuts and seeds regularly will ensure that you get at least 25 grams of fiber every day!

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My Health - Trouble keeping information in mind? Could be sleep, mood — or age

You’re heading to the market. You need to pick up eggs, cheese, milk, bread, tomatoes, carrots, and string beans. Can you keep those items in mind by repeating them to yourself? You arrive at your usual market, but it is unexpectedly closed. A passerby gives you verbal directions to a new market. Can you close your eyes and visualize the route? Both activities tap working memory — that is, your memory for information that you need to actively keep “in mind” and manipulate often.

We use this type of memory every day. For example, when we are comparing two or more options — whether dinner entrees, health plans, or mutual funds — we are using our working memory to keep the details of the different options in mind.

The frontal lobes direct the components of working memory

The two frontal lobes of the brain play important roles in certain types of memory. Working memory is typically divided into two components, plus an executive system that shifts attention between them. One component helps you keep verbal information in your head by silently repeating it to yourself. Another component processes spatial information, such as mentally planning the route you will drive to avoid rush hour traffic.

Virtually all tasks involving working memory activate the prefrontal cortex, the part of your frontal lobes right behind your forehead. The left hemisphere of your brain is more involved when you are repeating verbal information to yourself. The right hemisphere is more involved when you are mentally following a route. Interestingly, as a working memory task becomes more difficult, both hemispheres become engaged regardless of whether the task is verbal or spatial.

New research shows sleep and mood affect working memory

Recently, researchers from California and Michigan conducted a pair of studies to understand the effects of sleep, mood, and age on working memory. Two aspects of these studies are novel. First, although each of these effects has previously been looked at separately, this research examined their combined effects and how they interact with each other. Second, the researchers examined a community sample of adults aged 21 to 77. This adds to the real-world generalizability of the results.

The first study found that poor sleep quality and depressed mood each independently reduce the capacity of working memory — the number of items that can be kept in mind. The second study confirmed the results of the first. It also found that greater age reduced the precision of working memory — the details of each item, such as whether the cheese you need to pick up is swiss or cheddar.

Improving mood may help

The implications of this research are clear. Although we cannot stop getting older, we can work to improve our sleep quality and mood. Depressed mood may be due to external life events (such as retirement, a new diagnosis, or the death of a friend), or to biological factors (such as alterations in our brain chemistry). Regardless of its cause, depression can be treated by medications or talk therapy. Studies show that combining these approaches provides the greatest benefit. Not interested in taking medications or talking with someone about your mood? Aerobic exercise,meditation, and relaxation therapy have each been shown to improve mood.

Better sleep may improve working memory

Poor sleep quality may be due to a sleep disorder, such as obstructive sleep apnea (not getting enough oxygen during sleep). Or, it could be secondary to a medical problem, such as heart failure.

Sleep disturbances may also result from habits, such as doing wakeful activities in bed. Sleep experts note that the feeling of being in bed should signal the body that it is time to go to sleep. It is best to use your bed only for sleeping and sexual activity. If you spend hours in bed talking on the phone, eating meals, or doing other activities, you are sending the wrong signals to your body about the purpose of being in bed. Learning about healthy sleep habits can help.

People may also get into a bad sleep cycle by repeatedly staying up too late at night or sleeping too long in the morning. Most people need about eight hours of sleep each night, with the average range between seven and nine. Many people think that they need more sleep as they get older, but that actually isn’t true. On average, older adults need the same amount of sleep as when they were younger — or maybe even 30 minutes less. If you sleep too long one day, you’ll often have difficulty falling asleep the following night.

The bottom line

We can improve our working memory — our ability to do things in our head — if we improve our mood and the quality of our sleep.

Follow me on Twitter@abudson

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My Health - Can a man with abnormal PSA and a negative diagnostic MRI avoid a prostate biopsy? It’s debatable

Not long ago, an abnormal PSA reading would be followed right away by a standard biopsy to search for potential cancer in the prostate. During such a procedure, doctors take 10 to 12 samples of the prostate from various locations while looking at the gland with an ultrasound machine.

These days, however, men with high PSA levels during cancer screening might be offered a specialized imaging test first. Called a multiparametric magnetic resonance imaging (mpMRI) scan, it’s particularly good at visualizing cancer in the prostate and distinguishing high-grade tumors that need immediate treatment from low-grade tumors that don’t. Furthermore, if the scan is positive for cancer, then it’s also more effective than ultrasound at guiding doctors to suspicious areas of the prostate during a subsequent biopsy, so they can take fewer samples.

But what if the mpMRI is negative? Can a man avoid having a biopsy altogether, along with the risk of infection and other complications that might come with it? Or should he still have a standard biopsy to rule out cancer that the radiologist or the MRI might have missed?

These are important questions that specialists are now grappling with.

European guidelines say yes

In newly updated guidelines, the European Association of Urology came out in favor of omitting a first biopsy for a man with abnormal PSA and a negative mpMRI, but only if his suspected risk for aggressive cancer is low, and he has discussed the pros and cons of forgoing the exam with a doctor. The UK’s national health agency reached a similar conclusion the previous December. Still, divisions in the field remain. Half of the urologists queried on the topic during a presentation at the EAU’s annual meeting in Barcelona last March (which drew 10,000 attendees) voted in favor of the standard biopsy for men with a negative mpMRI.

American guidelines say no

Here in the United States, professional organizations have also expressed their reservations: the American Urological Association, for instance, warns in its current guidelines that the risk of missing clinically significant prostate cancer on a negative mpMRI raises persistent concerns.

During a recorded conversation hosted by Grand Rounds in Urology, Dr. Sigrid Carlsson, a physician-epidemiologist from the Memorial Sloan Kettering Cancer Center in New York, acknowledged that while men would understandably want to avoid a biopsy, radiologists vary significantly in how well or accurately they read mpMRIs, and miss rates (i.e., the numbers of truly existing cancers missed either by the radiologist or by the mpMRI itself) can range up to 20%. The false negative diagnoses occur most frequently among radiologists who are just learning how to interpret the scans, and for that reason, she said, “We can’t avoid biopsy if the mpMRI is negative because the miss rate is so high.”

Dr. Anthony D’Amico, a professor at Harvard Medical School and an author on the AUA guidelines, gave the same reason to back his view that a standard 12-core biopsy should still be undertaken despite negative mpMRI readings.

However, Dr. Veeru Kasivisvanathan, a urologist from University College London, took an opposing view. He argued that if the mpMRI is of good quality and interpreted by an adequately trained radiologist, then the risk of harboring significant cancer is low enough that biopsy can be safely avoided. “Equally, some patients will value more certainty and might wish to go ahead with a biopsy despite having a low risk of cancer and a negative mpMRI — this is still a valid option,” he said.

The decision to biopsy or not could be aided with better diagnostic tools, and one cited repeatedly is PSA density, or the total amount of PSA in blood divided by the prostate volume. High PSA densities denote higher risk, and when combined with mpMRI findings, could enable patients to make a more informed choice.

According to Dr. Marc Garnick, Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org, diagnostic uses for mpMRI are only now emerging, and patients should carefully weigh their options with a doctor before deciding whether or not to proceed to biopsy in the event of a negative scan. Years of further study, he said, will reveal how outcomes vary among those who choose a biopsy versus those who don’t. However, for men who have already had a standard 12-core biopsy and require another in the future, Dr. Garnick added, then MRI guidance is helpful for targeting only abnormal areas and reducing the risk of potential complications.

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My Health - Healthy eating for older adults

Eating right can help keep your body and mind healthy and extend your quality of life. But some older Americans may face barriers to getting enough nutrients or calories.

Many ways aging can affect appetite

Physiological changes that come with aging can result in reduced calorie needs, which can lead to decreased food intake and altered body composition, even in healthy older adults. This can be compounded by diminished smell and taste, and changes in hormone levels that affect how quickly you feel full. Depression, lack of independence, and social isolation can make food less appealing, further contributing to a less than ideal intake.

Chronic diseases such as heart disease, stroke, Parkinson’s disease, cancer, diabetes, and dementia can affect appetite, energy needs, and weight. Older adults may be on multiple medications that may interact with nutrients, or produce side effects such as nausea, vomiting, and sensory changes that affect smell and taste. Oral and dental problems can affect chewing or swallowing.

All of these factors can lead to decreased intake of calories and nutrients, resulting in unplanned weight loss and lack of energy.

Overcoming barriers to healthy eating

These strategies can help overcome some of the barriers to healthy eating you may face as you get older.

• Aim for quality, using the Harvard T.H. Chan School of Public Health’s Healthy Eating Plate as a guide. At most meals try to fill half of your plate with vegetables, a quarter of your plate with whole grains such as quinoa, brown rice, or whole-wheat bread, and the final quarter of your plate with lean protein such as fish, poultry, beans, or eggs.
• Pick healthy fats, which can serve as a source of concentrated, healthy calories. Healthy fats include olive oil, canola oil, peanuts and other nuts, peanut butter, avocado, and fatty fish such as salmon, sardines, and mackerel. Limit unhealthy saturated fat including fatty red meat.
• Work dietary fiber into your diet. Fiber helps to keep bowel function normal and can help decrease risk of type 2 diabetes and heart disease. The Institute of Medicine recommends that total fiber intake for adults older than 50 should be at least 30 grams per day for men and 21 grams for women. Most fruits, vegetables, whole grains, and legumes are good sources of fiber. Nuts and seeds are also good sources, but whole-grain breads and beans may be easier to chew if you have dental problems or dentures. Make sure to drink plenty of fluids as you increase your fiber intake.
• Adjust portion sizes. If you’re trying to maintain a healthy body weight, reduce portion sizes instead of sacrificing components of a balanced meal. If you need to gain a few pounds, try to increase your portions rather than eating foods that are high in added sugar and unhealthy saturated fat.
• Some older adults find their appetite is greater in the morning and during the day, compared to evening. If so, try to have a healthy breakfast that includes protein, whole grains, and fruit along with a balanced afternoon meal. Then go light on dinner.

Troubleshooting tips

As you get older, you may need to think creatively when obstacles to healthy eating crop up. For example, if you have trouble getting out of the house or managing heavy grocery bags, try a grocery delivery service. This allows you the convenience of shopping online and having your food delivered right to your door.

If cooking for yourself every day feels like too much trouble or you find your energy flagging by evening, try to prepare a few meals on the weekend. Keep them refrigerated or frozen and ready to reheat during the week. One-pot meals are a great way to quickly cook healthy, balanced meals that are inexpensive, which may also be an important consideration as you get older.

Physical activity is important for all adults, including older adults. Exercise helps build and strengthen muscles, increase energy levels, maintain bone health, rev up your metabolism, and lift your mood. It can help boost your appetite too. Aim for at least 30 minutes of physical activity most days of the week.

Men and women are living longer. Making an effort to eat healthy can help ensure you’ll continue to enjoy an active lifestyle well into your 80s and 90s.

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My Health - Is an opioid really the best medication for my pain?

As physicians, many of our daily practices involve administration of substances that are shrouded in mystery. Certain medications, specifically opioids, have been part of tragic news stories, and have turned young children into orphans, happy spouses into widows and widowers, and once-aspirational youth into memories. The CDC reports that on average, 130 people die each day from an opioid overdose.

With such harrowing statistics, why take opioids in the first place? Well, if used appropriately, opioids can significantly improve pain with relatively tolerable side effects. A short-term course of opioids (typically 3 to 7 days) prescribed following an injury, like a broken bone, or after a surgical procedure, is usually quite safe. It’s long-term use that can lead to problems, including the risk of addiction and overdose.

National guidelines for physicians recommend the shortest duration of opioids possible for acute pain, as a person’s chances of unintentional long-term use increase with the degree of exposure. One large study found that in first-time opioid users, one in seven people who received a refill or had a second opioid prescribed were on opioids one year later.

While widespread overuse of opioids has contributed to increased scrutiny regarding their administration, careful consideration of a variety of factors can help physicians and patients determine whether opioids are the right medication.

Here are several important things you may want to discuss with your doctor when considering taking opioids for the first time.

What kind of pain am I having?

Classification: This can be tricky, since many conditions include a wide variety of pain signals that can overlap. Two of the main types are:

• Nociceptive: This is the most common form of pain. It occurs when some sort of stimulus (i.e., inflammatory, chemical, or physical) causes your skin, muscles, bones, joints, or organs to send a message by way of your nerves to your brain.
• Neuropathic: This is a type of pain that is caused by a direct injury to the nerve itself. This type of pain is commonly seen in people with diabetes, neurologic issues, or prior amputations. Opioids are not effective in treating this type of pain.

Time course:

• Acute: Pain lasting less than 3 to 6 months (often much less). It typically goes away when the underlying cause of pain is resolved. Classic examples include surgery, broken bones, and labor during childbirth.
• Chronic: Pain lasting for more than 3 to 6 months. This tends to be more difficult to treat than acute pain, since the pain signals adapt over time, which can change the way the brain perceives painful sensations. Common conditions that may cause chronic pain include arthritis, some types of back injury (such as a bulging disc), and fibromyalgia.

What are some of the most common side effects?

Many of the side effects of opioids are due to their effects on your brain and gastrointestinal tract, so you are most likely to experience constipation, nausea, sleepiness, and confusion. Some ways for you to minimize your chances of experiencing these include using the smallest dose possible and treating the side effects directly. For instance, constipation can be initially treated with a high-fiber diet and increasing fluids, though you may be directed to prophylactically start taking treatment medication like stool softeners and/or stimulant laxatives. At times, adequate treatment of any underlying constipation may resolve any nausea you might be experiencing, though this will not help if your nausea is caused by direct activity of opioids on the part of your brain that induces nausea. When this is the case, your doctor may prescribe anti-nausea medications.

What’s my risk for tolerance, dependence, and addiction?

• Tolerance occurs when a person’s response to a medication changes over time, in that they require a higher amount of a medication to achieve the same effect, such as pain control or euphoria. In the context of opioids and addiction (more below), with time the brain adjusts to the excess of the reward hormone, dopamine. As the brain adapts, it requires more opioid in order to feel the same effects or benefits. Tolerance is a gradual process that is highly dependent on the specific opioid being used, the dose of the medication, and a person’s biology. To some degree, everyone would eventually develop tolerance to opioids if taken long enough.
• Dependence happens when a person requires a substance in order to feel normal and to prevent withdrawal. Many of us have experienced this on a much smaller scale on days we are deprived of coffee. With opioids, once a person is physically dependent, abrupt cessation of the medication can lead to gastrointestinal symptoms, anxiety, and agitation. Everyone exposed to a drug long enough will become dependent, though only a small percentage of people truly become addicted.
• Addiction is a disease state that is seen when a person continues to use a drug despite harmful health, social, and/or economic consequences. Assessing individualized risk of becoming addicted is complex and involves many factors: biological, developmental, and environmental factors combine to influence a patient’s individual predisposition. Ultimately, a fatal overdose can happen when too much of the drug is taken or combined with other dangerous drugs, which may cause a person to stop breathing.

What other medications am I taking that may pose safety concerns?

As mentioned earlier, opioids affect your brain and can make you sleepy and slow your breathing. Certain medications or substances, when combined with opioids, can increase this effect. Medications commonly considered are those used to treat seizures, sleeping problems, psychiatric disorders, and muscle spasms. There are many things you can do to avoid drug interactions.

In our era of controversy related to excessive opioid use, there is a well-deserved focus on judicious prescribing. Procedural techniques, like injections and non-opioid medications, are being used more often as effective treatments for people in pain, as these interventions don’t carry the risk of serious side effects such as overdose. But there are times when an opioid is the right choice; it’s a matter of thoughtful discussion and understanding your risks.

If you find yourself on a course of treatment requiring opioids for chronic pain and are concerned about your likelihood of opioid misuse, discuss this with your doctor, along with a plan for addressing side effects of these medications. Together you can weigh the pros and cons of taking opioids and work to manage your particular type of pain.

Resources

CDC Injury Prevention & Control: Opioid Education Resources for Patients

Harvard Medical School Longwood Seminars: The Science of Pain

 

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My Health - A poor sense of smell might matter more than you thought

As one of the five major senses, you could argue that our sense of smell is the least important. Sight, hearing, touch, and taste may poll better than smell, but try telling that to someone who has lost their sense of smell entirely.

The truth is that loss of the ability to smell comes with a significant cost, because olfaction serves several purposes that affect quality of life and even safety, including

• stimulation of appetite
• enhancement of the sense of taste
• alerting you to which foods should not be eaten (if they’re rotting, for example)
• warning you of danger (as with smoke warning of fire).

Loss of smell can also be a sign of illness. For example, sinus infections, sinus tumors, and neurologic diseases (such as multiple sclerosis) may be associated with a reduced sense of smell. Smoking leads to increased mucus production, reduced clearance of airway mucus, and damage to olfactory cells in the nose responsible for the appreciation of odors. As a result, smokers often report poor olfaction and quitters may notice improvement — one more reason to quit! Certain medications (such as the statin-lowering drug atorvastatin, the blood pressure-lowering drug amlodipine, and the antibiotic erythromycin) may also impair one’s sense of smell.

About 12% of people over the age of 40 report at least some trouble with their sense of smell, and it rises with age: nearly a quarter of men in their 60s reported a diminished sense of smell.

Loss of smell may predict future illness

For years, we’ve known that people with a poor sense of smell have higher rates of death, Parkinson’s disease, and Alzheimer’s disease. The reason for this isn’t clear, but one possibility is that loss of smell might be an early indication that one of these conditions is present. Or, perhaps other conditions that affect smell increase the risk of these diseases. It could also be due to medications taken to treat symptoms of these conditions. Or there may be other explanations, but the connection remains mysterious.

New research explores connections between health and sense of smell

A new study explores the relationship between loss of smell and future disease — and attempts to explain it. Researchers tested the sense of smell of nearly 2,300 elderly people and monitored their health and cognitive function over 13 years. Compared with those who had good olfaction at the start of the study, those with the worst sense of smell

• tended to smoke, drink more alcohol, be older, and be male
• were more likely to have dementia, Parkinson’s disease, and kidney disease at the start
• had a 46% higher chance of death over 10 years
• had a higher risk of death due to dementia, Parkinson’s disease, and cardiovascular disease in the coming years.

Interestingly, sense of smell was a stronger predictor of death in those who were healthiest at the start of the study. The higher rates of neurologic disease only explained a small part of the higher rates of death among people with poor sense of smell.

Why does this matter?

These findings are interesting and confirm those of past research. But we need to figure out what do with this information. Does a poor sense of smell mean you should have extensive testing for neurologic or cardiovascular disease? Is there a direct, causal connection between problems with smell and higher rates of death — for example, does poor smell sensation indicate the presence of a fatal disease? Or might the link be indirect, with poor smell sensation and a higher risk of death due to some other factor? The answers to these questions could lead to better screening approaches to common conditions affecting the elderly, as well as insights into how these diseases develop.

The bottom line

We need more research on the links between poor olfaction and health. Until we do, let your doctor know if you notice that your sense of smell isn’t what it used to be. It doesn’t mean you have a serious disease — a 2016 study found that more than three-quarters of elderly people with the poorest sense of smell had normal brain function several years later. But losing your sense of smell warrants evaluation that could turn up something important — and possibly reversible.

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My Health - test

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My Health - Is tramadol a risky pain medication?

All medications come with a dose of risk. From minor side effects to life-threatening allergic reactions, every decision to take a medication should be made only after the expected benefits are weighed against the known risks. You aren’t on your own in this: your doctor, your pharmacist, and a trove of information are available for your review. Recently, I wrote about how newly approved drugs often accumulate new warnings about their safety, including a gout medication that garnered a new warning due to an increased risk of death. Now, according to a new study, the common prescription pain medication tramadol may earn a similar warning.

Tramadol is unique

When first approved in 1995, tramadol was not considered an opiate (like morphine or oxycodone) even though it acted in similar ways. However, because there were cases of abuse and addiction with its use, the thinking and warnings changed. In 2014, the FDA designated tramadol as a controlled substance. This means that although it may have accepted use in medical care, it also has potential for abuse or addiction and therefore is more tightly regulated. For example, a doctor can only prescribe a maximum of five refills, and a new prescription is required every 6 months.

Compared with other controlled substances, tramadol is at the safer end of the spectrum. Heroin, for example, is a Schedule I drug (high abuse potential and no acceptable medical use). OxyContin is a Schedule II drug (it also has high abuse potential, but has an accepted medical use). Classified as a Schedule IV drug, tramadol is considered useful as a pain reliever with a low potential for abuse.

Despite these concerns, tramadol is one of many common treatments recommended for osteoarthritis and other painful conditions. Several professional societies, including the American Academy of Orthopaedic Surgeons, include it in their guidelines as a recommended drug for osteoarthritis.

New research on tramadol

Researchers publishing in the medical journal JAMA examined the risk of death among nearly 90,000 people one year after filling a first prescription for tramadol or one of several other commonly recommended pain relievers, such as naproxen (Aleve, Naprosyn), diclofenac (Cataflam, Voltaren), or codeine. All participants were at least 50 years old and had osteoarthritis.

Those prescribed tramadol had a higher risk of death than those prescribed anti-inflammatory medications. For example:

• naproxen: 2.2% of the tramadol group died vs. 1.3% of the naproxen group
• diclofenac: 3.5% of the tramadol group died vs. 1.8% of the diclofenac group
• etoricoxib: 2.5% of the tramadol group died vs. 1.2% of the etoricoxib group.

Meanwhile, people treated with codeine had a similar risk of death to people treated with tramadol.

However, because of the study’s design, the researchers could not determine whether tramadol treatment actually caused the higher rates of death. In fact, the patients for whom tramadol is prescribed could make it look riskier than it truly is.

What is confounding?

Medical research studies may draw faulty conclusions for a number of reasons. Perhaps there were too few participants to find meaningful differences. Maybe the dose of the treatment was too high or too low. But a major source of error in studies is called confounding.

It means an unexpected or external factor — not the one actually being examined — has led to the observed results. For example, let’s say two groups are compared for the risk of heart attack and the group with the higher risk has a less healthy diet. One might conclude that dietary choices led to poorer heart health. But what if those with the unhealthy diet also smoked far more than the healthy eaters? The smoking could be the real culprit. It is a confounder that must be accounted for if the research is to have credibility.

How could confounding affect the study results?

With this new study of tramadol, confounding is a real concern. For example, for a person who has both kidney disease and arthritis, doctors may prescribe tramadol rather than naproxen because the latter may worsen kidney disease. Yet kidney disease could increase the risk of other health problems, including a higher rate of death, which could then be attributed to the tramadol. In other words, the very reason your doctor chose tramadol could make this medication appear riskier than it really is.

The authors of the study acknowledge this possibility and took measures to limit it. In fact, many studies try to avoid these sorts of errors, but they are impossible to avoid completely.

The bottom line

If you take tramadol, talk to your doctor about this study. While the higher rates of death among tramadol users is worrisome, it’s not clear that tramadol is the actual culprit. We’ll need more research to confirm — or refute — the findings. If tramadol does increase the risk of death, we want to understand why and what to do about it (for example, is it an easily avoidable risk, such as an interaction with other medications?). Further research can also help educate doctors and patients about all of the potential risks of tramadol treatment.

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My Health - Father’s Day: Tools for coping when celebration brings pain

With Father’s Day mere days away, we’re hearing more advertisements for outdoor grills and golf clubs, sailboats and fishing gear. As an infertility counselor, I am glad that Father’s Day is not welcomed with the gush of sentiment that envelops Mother’s Day. Still, a day dedicated to celebrating fatherhood can be difficult for any number of people.

Among them are men and women who lost their fathers when they were quite young, and those who have experienced rocky relationships with their dads. There are men who have regrets about their own role as fathers, and older gay men who missed out on fatherhood because they came of age when gay couples rarely had children together. Some single men long to be fathers on their own, but realize there is limited societal support for that choice. And there are married men, straight or gay, struggling to become fathers. Some heterosexual men feel the pain of watching their wives grieve anew with each failed pregnancy attempt. And some gay men grapple with the myriad challenges of wading through the adoption process, or assembling the funds and a team of professionals and helpers that can bring them a child through surrogacy.

How can you cope with Father’s Day?

How might you cope if you are, shall we say, not exactly in the mood for a Father’s Day barbecue? Although there can be no one-size-fits-all approach, here are a few strategies that might help.

• A must-go family gathering. Unlike Mother’s Day festivities, which frequently occur in restaurants, hotels, or country clubs, Father’s Day celebrations are more often in the backyard. If you must join in, this setting makes it easier to come and go and move about, avoiding difficult conversations such as the news that your younger brother who just got married last year is soon to be a father, or that your sister is expecting her fourth child. If the goal is being there to honor your father, remember that you can accomplish that without staying for hours and hours.
• An optional gathering. If friends are gathering, your attendance may be optional. If you are dealing with infertility or struggling to build your family, remember that you need not spend the day with a group of parents. Your friends will remain your friends whether or not you attend their Father’s Day cookout.

What alternatives might feel right?

• Volunteer. Homeless shelters, nursing homes, and facilities for veterans get lots of volunteers on Thanksgiving and Christmas, but far fewer on Father’s Day. These are places where you are likely to find men and women for whom Father’s Day brings pain. You may well find that the chance to brighten their day may lighten your own.
• Spend the day in nature. There is a reason that there are so many barbecues the third Sunday in June — and it’s not all because of fathers. Mid-June is a delightful time to be outside, enjoying warm weather and bonus hours of sunlight. This could be a wonderful day to go on a hike, paddle a canoe, or take a long bike ride. Not only does being away from the crowds let you escape Father’s Day rituals, it offers a chance to reflect on the blessings in your life.

June 16 — Father’s Day 2019 — is just a few days short of the longest day of the year. Whether you spend it alone or with friends, on a mountain top or in a kayak, I hope that the day will, in some way, reflect that light. Perhaps you will be comforted by memories of your father. Some of you may have a treasure trove of memories; others, a few that you hold dear. If you are hoping to be a father yourself one day, you may take time this year to imagine a future Father’s Day when you will be a dad. And remember, alongside you are countless others balancing hope, wishes, love, and loss on this and every Father’s Day.

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My Health - Brain health rests on heart health: Guidelines for lifestyle changes

Right now the world is experiencing an epidemic that is projected to get much, much worse. It’s an epidemic of dementia, affecting 50 million people and millions more of their caregivers — staggering numbers that are projected to triple by 2050.

The dementia crisis is such a massive worldwide issue that the World Health Organization (WHO) announced a strategic public health action plan, including compiling an organized database of quality dementia research and creating guidelines for the prevention of dementia. The guidelines have just been published, a 96-page document that is summarized here, as well as in this post.

Dementia is a progressive, heartbreaking 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 to, and greatly impacted by, the same diet and lifestyle factors.

Your diet and lifestyle can lower your risk of dementia

Several key protective health habits are highly recommended:

Regular physical activity — any activity, for at least 150 minutes per week, is number one on the list of evidence-based actions you can take. Exercise clearly 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.

Eating a plant-based diet is crucial. There is substantial research evidence showing that eating a diet high in fruits, vegetables, whole grains, healthy fats, and seafood is associated with a significantly lower risk of cognitive decline and dementia. This approach to eating is often referred to as the Mediterranean-style diet, but it can be adapted to any culture or cuisine.

The WHO also recommends avoiding toxic, inflammatory foods like processed grains (white flour, white rice), added sugar, sodium, and saturated fats like butter and fatty meat. It’s important to note that the WHO does not recommend taking any vitamins or supplements for brain health, because there is no solid evidence showing that these have any effect whatsoever. Just eat a healthy plant-based diet and avoid unhealthy foods as much as possible.

The WHO also issues strong recommendations to avoid or quit smoking and to minimize alcohol use, especially in those who already have cognitive concerns.

They mention additional lifestyle factors that have less evidence but may also help: getting enough good sleep, positive relationships, and social engagement have been shown to protect cognition.

What’s fascinating about these dementia prevention guidelines is how similar they are to those for heart disease prevention.

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 lead 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: obesity, high blood pressure, high cholesterol, and diabetes.

The evidence is substantial: studies show that people with these risk factors 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 brain blood flow can increase the risk for Alzheimer’s, and conversely, anything that increases blood flow can reduce the risk for Alzheimer’s.

What’s the take-home message?

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 minimum of 150 minutes per week of activity, a plant-based diet aiming for at least 5 servings of fruits and vegetables daily, avoiding toxic foods like processed grains, added sugars, sodium, and saturated fats, avoiding or quitting smoking, and curbing alcohol use as much as possible.

Selected resources:

WHO Dementia Prevention Guidelines Executive Summary

AHA/ACC Guideline on the Prevention of Cardiovascular Disease

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 Reports, March 2017.

Mediterranean diet, cognitive function, and dementia: A systematic review of the evidence. Advances in Nutrition, September 2016.

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My Health - Headaches: What to know, when to worry

Everyone gets the occasional when-will-this-day-end headache. These headaches may even follow a certain pattern. (Mine usually strike like clockwork if I miss my morning cup of French press coffee.)

But when is a headache cause for concern?

“Most bouts of regular headaches are not serious and can be treated on their own,” says Dr. Elizabeth Loder, chief of the division of headache in the department of neurology at Harvard-affiliated Brigham and Women’s Hospital. “However, being aware of the features of the different types of headaches can help you determine if your headaches are something more serious that requires medical attention.”

Headache know-how

There are three main types of headache: tension, migraine, and cluster. Here is a look at each one.

Tension. This is the most common type of headache. A typical attack produces a dull, squeezing pain on both sides of the head like it’s in a vise. The shoulders and neck can also ache. Episodes can last 30 minutes to seven days.

Although the cause of tension headaches is unknown, triggers include stress, fatigue, and lack of sleep.

The good news is that you can treat most tension headaches with over-the-counter (OTC) pain relievers, such as acetaminophen (Tylenol) or nonsteroidal anti-inflammatories, such as aspirin, naproxen (Aleve), or ibuprofen (Advil, Motrin). You could also try a warm shower, a nap, or a light snack.

Migraine. Migraines are more severe and can be quite debilitating. The pain often is centered on one side of the head, beginning around the eye and temple and spreading to the back of the head. Episodes can last from four to 72 hours.

According to Dr. Loder, one way to remember the features of a migraine is the acronym POUND:

P: pulsating pain
O: one-day duration of severe untreated attacks
U: unilateral (one-sided) pain
N: nausea and vomiting
D: disabling intensity.

Although migraines can strike without warning, they may be set off or worsened by specific triggers or aggravating factors, such as loud noises, a bright light, or strong smells. In some people, attacks are preceded by several hours of fatigue, depression, and irritability.

Almost a quarter of people with migraines often have an aura beforehand and experience halos, sparkles or flashing lights, and wavy lines. Numbness or tingling is also common. This often appears on one side of the body, usually in the face or hand.

If you catch a migraine early, you may be able to control it with an OTC pain reliever. If this doesn’t help, or if your migraines become more frequent or severe, ask your doctor about a stronger prescription drug. Common options include triptans, such as rizatriptan (Maxalt), sumatriptan (Imitrex), and zolmitriptan (Zomig). These are available as tablets, nasal sprays, or injections that patients can give to themselves. Triptans often provide complete relief within two hours. Other medicines — and even botulism injections — may help, too.

Cluster. Cluster headaches strike five times more often in men than in women. This type of headache gets its name because they come in clusters; for example, one to eight headaches a day over a one-to-three-month period that may reoccur every few years.

The pain is quite severe and always strikes one side of the head. The headache begins abruptly and lasts for 30 minutes to an hour, on average. Also, the eye on the painful side tends to become red and watery, the eyelid often droops, and the nose gets runny. Most people become restless and agitated during an attack, and nausea and sensitivity to light and sound is common.

Unfortunately, OTC drugs usually don’t offer much, if any, relief. High dose oxygen can be effective if taken during the onset of pain. Several medications can help shorten the duration of attacks. For example, sumatriptan can often provide quick relief, especially when given by injection, but a nasal or oral triptan also may help. And an injectable medicine called galcanezumab (Emgality), used for migraine prevention, is now FDA-approved to reduce episodes of cluster headaches.

Other types of headaches

Headaches also can be caused by other conditions or situations. These are often short-lived and easily treated. For example:

Sinus headaches. A sinus infection can cause pain over the forehead, around the nose and eyes, over the cheeks, or in the upper teeth. When the infection resolves, the pain disappears.

Brain freezes. Some people develop a sharp, sudden headache when they eat or drink something cold. The pain usually goes away within a few minutes. If this is a common problem, try to warm the cold food at the front of your mouth before swallowing.

Exercise headaches. Strenuous exercise can sometimes trigger a headache. Make sure you are well hydrated before and after exercise. Taking an OTC anti-inflammatory beforehand also may help.

When to worry about a headache

Most headaches respond to self-care, OTC pain relievers, or medication your doctor prescribes. For some headaches, though, it’s best to promptly seek medical advice. Warning signs include a headache that:

• is unusually severe or steadily worsens
• follows a blow to the head
• is accompanied by fever, stiff neck, confusion, decreased alertness or memory, or neurological symptoms such as visual disturbances, slurred speech, weakness, numbness, or seizures.

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My Health - The 6 don’ts of caring for your child’s teeth

Did you know that tooth decay is the most common chronic disease of childhood? And that 40% of children have tooth decay by kindergarten? This is a big deal, not only because of the pain and infection it can cause, but also because children with tooth decay are more likely to miss school and have poorer grades — and because tooth decay is linked to a higher risk of many health problems later in life, including heart disease and premature birth.

Tooth decay is simple to prevent, yet sadly, many families don’t take the steps that are needed.

1.   Don’t skip the fluoride. Fluoride is very helpful when it comes to preventing tooth decay. Too much fluoride isn’t good, as it can lead to fluorosis — but avoiding fluoride entirely is a big mistake. There is no need for “training” toothpaste. As soon as your child has teeth, you should use fluoride toothpaste. The trick is to only use a tiny bit. Before age 3, just a barely visible smear is plenty. Starting at 3, use a pea-sized amount.

2.  Don’t shirk the brushing. It can be busy in the morning when you are trying to get everyone out of the house — and it’s understandable to be so exhausted in the evening that just getting kids into bed becomes the goal. But regular brushing is key to preventing cavities. Ideally, brushing should happen after every meal, but twice a day is fine. Once a day is not fine.

3.  Don’t skip supervising the brushing. Independence is great in kids, but not when it comes to brushing teeth. To be really effective, each tooth needs to be brushed. Left to their own devices, most kids don’t brush all of their teeth (some of them barely brush any). So for kids younger than 6, rather than just handing them the toothbrush and then checking your phone, or sending them to the bathroom to brush on their own, parents need to be involved. Do it yourself until you are sure they are doing what they need to do.

4.  Don’t give kids sticky sweets. Sugar is bad for teeth, especially when it’s literally stuck to teeth. So stuff like toffee, caramel, gummy bears, and even dried fruit are not the best choices when it comes to snacks. Not that kids can never have them, but they should be limited, and ideally kids should brush soon after eating them.

5.  Don’t let kids carry around sippy cups or bottles of juice or milk. When kids are frequently sipping juice or milk, it ends up meaning that teeth are consistently bathed in sugar. Even 100% juice and unsweetened milk have sugar (the natural sugars of milk and juice, not sucrose), which can do the same damage to teeth. If kids are going to carry around a beverage, it should be water.

6.  Don’t avoid going to the dentist early or often enough. The American Dental Association and the American Academy of Pediatrics recommend that children see a dentist, and establish a dental “home,” by the age of a year. Once they get started, they should go every 6 months for a checkup, cleaning, and preventive care like sealants. Just like going to the pediatrician for regular checkups, going to the dentist for regular checkups is the best way to catch problems early and prevent them before they start.

For more information on keeping your child’s teeth healthy, visit the Children’s Oral Health page of the Centers for Disease Control and Prevention website.

Follow me on Twitter @drClaire

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My Health - When making summer plans for children, leave some time unplanned

The school year is ending, and it’s the time of year when families are planning what their children will do during summer vacation. For many families, these plans are crucial for childcare reasons, as parents need their children to be somewhere safe and supervised while they are at work. And of course, parents understandably want their children to use their vacation in ways that are productive and useful.

But here’s the thing: if you want your child’s vacation to be productive and useful, leave some of the vacation time unscheduled—or at least choose activities that have lots of embedded free time.

Keeping children busy has upsides, of course. It keeps them supervised. Depending on the activity, it may help them academically, help them learn a new skill or get them exercising. These are all important and good. But there are downsides to being fully scheduled and busy. Unscheduled time is important, crucial actually, for child development.

Benefits of unscheduled time

When children have unscheduled time, they learn to amuse themselves. Interestingly, this is a skill that children are losing—unless you count time on phones or other devices as amusing themselves, something that has all sorts of other downsides. The ability to come up with a game to play, or to create, or explore something, is something that has to be learned—and often grows out of boredom. Children need unstructured time to learn this skill. If you think that “amusing yourself” isn’t important, think of it in grownup terms: it is the ability to be at peace and happy without outside input, and the ability to create an idea or activity from scratch. These are skills that make all the difference in life.

Unscheduled time spent with others requires that children learn to negotiate and collaborate. When children are together in structured activities, much of that is already done for them—the roles and rules are decided already. The ability to work with others to create and decide roles and rules is a great way for children to learn skills that are crucial for workplace and life success.

All of this has to do with executive function, the “air traffic controller” skills that are part of everyday life in ways we don’t always appreciate. Those who master them are happier and more successful than those who don’t. It’s that simple.

As I said above, for working parents it’s not always easy to leave time unscheduled. But as you pick the places your child will spend his or her days, look for programs that have free or choice time built in—and have opportunities for creative collaboration.

Unscheduled time at home

And if your child does have some unplanned time at home, make sure they make the most of it. Limit time on devices to 2 hours or less each day. Make sure there are the tools for creativity and activity around the house—paper, paint, colored pencils, clay and other art materials (inexpensive stuff is fine), blocks and other building materials as well as balls and other equipment for active play (they can alter or make up games, all the better). Take trips to the library so that there are books. Take trips to parks for play or hikes. Have the kitchen available for cooking and baking (with supervision if kids are young). If they say that they are bored, resist the temptation to come up with an activity for them. Instead, remind them of everything around them, and leave it up to them to figure something out.

Sooner or later, they need to learn how to do this—and sooner is better than later.

Follow me on Twitter @drClaire

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My Health - Can an eye exam reveal Alzheimer’s risk?

Looking for clues about the health of your brain? You might want to pay a visit to your eye doctor. Research increasingly links common eye conditions — glaucoma, age-related macular degeneration, and diabetic retinopathy — to risk for Alzheimer’s and other forms of dementia.

What’s interesting about the study results, says Dr. Albert Hofman, chair of epidemiology at the Harvard T.H. Chan School of Public Health, is that cataracts, another common age-related eye condition, had no apparent connection to dementia risk. This gives scientists an important clue about the cause of dementia and Alzheimer’s disease, he says.

“My view, and one of the possible explanations that the authors present, is that these three eye diseases and Alzheimer’s and dementia have a joined etiology” — that is, a common causative factor. “All are linked to cardiovascular disease,” says Dr. Hofman.

How are eye conditions linked with cardiovascular disease?

• Glaucoma is a condition marked by increased pressure in the eye that can lead to vision loss. It has been linked to high blood pressure, diabetes, and poor blood circulation.
• Age-related macular degeneration involves breakdown of the macula, the part of the retina responsible for sharp central vision. It has also been linked to heart disease.
• Diabetic retinopathy occurs in people with diabetes when high levels of blood sugar damage blood vessels in the retina. There are strong links between diabetes and cardiovascular problems.

Cataracts — clouding of the lenses of the eyes — are more likely to develop as people age. However, they don’t appear to increase the risk of cardiovascular disease, Alzheimer’s disease, or other types of dementia.

Eyes on Alzheimer’s

The Adult Changes in Thought study, which began in 1994, included 5,400 dementia-free adults. Participants were followed until they decided to leave the study, died, or developed dementia. Research published in Alzheimer’s & Dementia in 2019 analyzed data drawn from the Adult Changes in Thought study. This time, the researchers focused on 3,800 of those participants, both with and without eye disease at the start of the study. Some 792 of them went on to develop dementia.

Study authors found that people with age-related macular degeneration were 20% more likely to develop dementia compared with people who did not have the eye disease. People with diabetic retinopathy were 44% more likely to develop dementia than those without. People in the study with a recent glaucoma diagnosis — but not participants with established disease — had a 44% higher rate of dementia. It’s not clear why there was a difference between people with new or existing disease.

Can eye exams be used to predict — and better still, prevent — Alzheimer’s?

While these findings show a link between three eye diseases and brain risks, one important question remains: what does this information mean for you? Can an eye exam tell you if you are destined to develop dementia in the future? More importantly, can it help you prevent it?

Someday the answer to those questions may be yes. For now, however, eye exams are valuable in detecting eye disease early so it can be treated — but they can’t yet yield much predictive information about your brain’s future health, says Dr. Hofman.

But there are lessons we can take from the study when it comes to avoiding Alzheimer’s disease. Today the only known way to prevent Alzheimer’s and other forms of dementia is to prevent cardiovascular disease.

“Doing all the things that you would do to prevent heart attack and stroke are likely beneficial to prevent Alzheimer’s disease,” says Dr. Hofman. This means treating high blood pressure and cholesterol, eating a healthy diet, getting enough sleep, and maintaining a regular exercise program.

If you have a family history of cardiovascular disease or a history of cardiovascular-related eye diseases, you may want to be even more aggressive in controlling your personal risk factors, says Dr. Hofman.

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My Health - Healthy meals: 3 easy steps to success

Healthy meals don’t just happen — you need to make them happen. Here are three easy steps to get you on your way.

Step 1: Make a plan

The first step is to plan your menu for the week. It doesn’t need to be elaborate, just jot down what you and your family would like to eat.

Then think about ways to make your choices healthier. Substitute chicken breast for steak and add more vegetables, for example. Can you streamline your cooking? Consider cooking a large batch of grains on the weekend and using them in more than one meal.

Step 2: Shop smart

You’ve already planned your menu. Once you make your shopping list, you’re on your way to choosing healthy foods. Sticking to your list will also save you time and money.

When you arrive at the supermarket, start shopping the perimeter of the store, which is where you’ll find fruits and vegetables, low-fat or non-fat milk, cheese, and yogurt, whole-grain breads, and fish, poultry, and lean cuts of meat. Use your shopping list to selectively navigate the rest of the aisles.

In addition to the items you need for your weekly menu, stocking your kitchen with the following key items will ensure that you have everything on hand to whip up fresh, nutritious, flavorful, and healthy meals.

For your fridge: fruits, vegetables, dark leafy greens, low-fat cheese, fresh salsa, plain yogurt, eggs, chicken, low-fat milk, pesto, light mayonnaise, hummus, lemons.

For your freezer: a variety of frozen vegetables (without sauce), poultry, fish, berries, whole-grain frozen waffles.

For your cupboard: brown rice, quinoa, oatmeal, whole-grain cereal, whole-grain tortillas, whole-wheat pasta, whole-grain bread, nuts and seeds, peanut butter, onions, sweet potatoes, garlic, canned beans (low sodium), sardines, tuna, salmon, low-sodium soup, canned tomatoes, low-sodium chicken and vegetable broth, tomato paste, olive oil, balsamic vinegar, mustard, herbs and spices.

Step 3: Put your plan into action

Now that you have a plan and the food you purchased readily available, it’s time to make it happen.

Breakfast

Eating breakfast can improve energy, mood, and performance at school or work. To create a well-balanced breakfast, include whole-grain carbohydrates, lean protein, and fruit. If you’re not a “breakfast person,” try starting with something small.

• Oatmeal with a small handful of nuts, cinnamon, and berries
• 100% whole-wheat bread, peanut butter, and a banana
• Breakfast sandwich: 100% whole-wheat English muffin, scrambled egg and low-fat cheese, with an orange
• Whole-grain crackers, low-fat cheese, and an apple.

Lunch

Lunch can be the hardest meal. It’s the busiest time of the day and it can be tempting to grab something fast and not-so-healthy. Packing a balanced lunch is not only important for health, but will also help you stay full and focused longer. A balanced lunch contains equal parts of lean protein, healthy carbohydrates, and vegetables.

• Homemade soup, such as minestrone, chicken vegetable, or lentil soup, with whole-wheat crackers
• Chili made with lots of vegetables and ground turkey
• Whole-wheat pasta salad with vegetables and chicken or tuna fish
• Whole-wheat English muffin pizza with vegetables and a small amount of low-fat cheese
• Vegetable quesadilla with whole-wheat tortilla, part skim mozzarella cheese, and vegetables
• Chicken or tuna sandwich on whole-grain bread with a side salad.

Dinner

Time can limit what gets to the dinner table. You might think it is faster to call for takeout or go to a nearby restaurant. The reality is that if you’ve planned and shopped wisely, it could be faster, healthier, and less expensive to prepare dinner at home. These dinner ideas can be ready in less than 20 minutes.

• Defrost shrimp, stir-fry with some vegetables, and serve over whole-wheat pasta.
• Grill fish or chicken breast, microwave a sweet potato, and add a salad.
• Pan-fry chicken in olive oil, then add a few vegetables such as onions, garlic, and mushrooms. Make a quick batch of a whole grain (quinoa, farro), or reheat grains that you made on the weekend.
• Put vegetables such as carrots, broccoli, onions, and cauliflower in a crockpot with chicken or beans, and chunks of winter squash or sweet potato. Set the timer before you leave for work.
• Sauté fresh or frozen vegetables with tofu or another healthy protein, flavor with your favorite low-sodium sauce, and serve with Instant brown rice.

Meal planning can be a challenge. But with a plan, a well-stocked kitchen, and a little time, healthy meals can be the norm rather than the exception.

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My Health - Cannabis is medicine — don’t make it taste good

Most of the clinical fiascos I’ve seen and heard about associated with cannabis consumption have involved the use of cannabis edibles, going back to the days when two bohemian college roommates visited Amsterdam, took two “space cakes,” waited 30 minutes, took two more, and spent the next 20 hours clinging to each other and hiding in the closet. I asked, “How was Amsterdam?” In unison, they replied, “We don’t know.”

I was surprised recently to be accused of “reefer madness” when I suggested, on Twitter, that cannabis shouldn’t be formulated into gummy bears or other succulent treats that a young child or a pet could gleefully over-consume. According to my logic, if cannabis is, or can be used as, a medicine, one should make it look and taste like a medicine. If we wouldn’t put ibuprofen into a candy, why would we put a psychoactive substance like THC into a chocolate bar? To me this is a no-brainer, but some people appear to take any limitation on their inherent right to consume medicine (or get stoned) by eating a gummy bear quite seriously.

Edibles have fueled the debate about cannabis safety

The topic of cannabis edibles is a flashpoint in the debate over how cannabis should be legalized and regulated, with arguments of personal freedom and responsibility clashing with concerns for public health. As with many things cannabis-related, the issue is highly politicized, and usually, when a new study comes out about some cannabis-related benefit or harm, such as levels of teenage usage, crime rates, medical uses, or driving statistics, there isn’t consensus on either the validity of the data or the implications of the data. It can be difficult to get a clear picture of the true benefits and dangers of cannabis.

Availability of edibles and emergency room visits

A recent study in the Annals of Internal Medicine discussed ED visits that were “deemed at least partially attributable to cannabis,” meaning that other conditions and factors could have been contributing to the admission. The study authors suggest that visits for cannabis edibles in the ED have been steadily rising in Colorado as a consequence of legalization of cannabis. Another explanation for the perceived increase in cannabis-related ED visits is that with legalization, patients are finally able to state the true reason they are in the ED without fear of getting in trouble with law enforcement or social services for using an illegal drug.

Personally, I believe the premise that ED visits are up for cannabis, in part because of the availability of edibles, and because of the many anecdotal stories I have heard through lifelong involvement with this issue. For example, an acquaintance, who is trying to be open-minded about a family member who uses medical cannabis, consumed that family member’s THC-infused medicinal chocolate bar which he found, unmarked, in the fridge, and ended up in the emergency department with a panic attack. This should never happen. By leaving a medicated but unmarked edible lying around, you put someone else’s well-being at risk. What if that person tried to drive? Then even someone else could have been harmed. The same goes for cannabis-infused barbecue sauce, pizza, honey, etc. I would suggest that these items are intrinsically too dangerous, in terms of accidental or incidental risk to others, to market and sell.

On social media, some people defend this type of risk, or the risk of exposure of a small child or a pet to some cannabis-infused treat, by saying, most commonly, “People should be responsible,” “A few irresponsible people shouldn’t ruin it for the rest of us,” or “Parents should just not leave it out around their kids.” Not to be cynical, but after practicing as a primary care doctor for 25 years, I can say with confidence: not all adults act like responsible adults. Also, even responsible adults can make mistakes. Any unmarked “spiked” consumable risks the well-being of anyone who is not aware of that fact.

Edibles are not for novice cannabis users

The main benefit of cannabis edibles is that they are long-acting — up to 12 hours — which can be helpful for chronic pain or chemotherapy patients. But the long-acting nature of edibles can also explain some of their menace: if you have consumed too high a dosage, you are stuck with it for a long time, and, if this is causing a panic attack, it can be extremely uncomfortable. It also can be difficult to gauge one’s dose correctly, as edibles can take from 30 to 200 minutes to kick in, and people often make the mistake of re-dosing too early, leading to an over-dosage and a miserable experience.

Edibles don’t always have the same effect every time

Edibles take effect more rapidly on an empty stomach, and their absorption depends on the amount of fat in your last meal. They aren’t always labeled accurately in dispensaries and, when cooked at home, the cannabis isn’t always evenly spread throughout the brownie batter. The effects of edibles are chemically different from that of smoked cannabis, because orally consumed cannabis passes more directly through the liver (versus the lungs) and the THC, which causes the high, is chemically converted to a different cannabinoid, called 11-hydroxy-THC, which has a different, and potentially stronger, psychoactive effect.

What if you’ve unknowingly consumed too much?

In clinic, with medical cannabis patients, I try to steer clear of problems with edibles altogether by advising all but the most experienced cannabis users to flat-out avoid them, and by reminding all patients to “start low and go slow.” If a medical or recreational cannabis user finds oneself in the unenviable situation of having consumed too large a dosage of a cannabis-containing edible, the best practice is to sit in a calm, quiet place, practice some mindfulness, hold the hand of a friend, drink plenty of water, try some CBD if you have it (which may antagonize the effect of the cannabis). Many people believe that consuming CBD helps negate the effects of THC, but this has not been definitively proven. Remind yourself that this will wear off, and you will be fine. This method almost always works. However, if you start to develop a full-blown panic attack, difficulty breathing, chest pain, or start having any unusual psychiatric symptoms, you must at that point consider having a friend take you to the emergency department.

If it can be used as a medicine, make it look like a pill

I believe there are a few sensible regulations that would reduce the problems caused by cannabis edibles: make them look and taste like medicine, in pill form, in pill bottles, with specific labeling that specifies exact dosages and with childproof packaging. This could go a long way toward helping us protect our pets and our kids, as well as those who find a benefit from cannabis and those around them. Sensible regulation of edibles may move us toward finding a larger patch of common ground on which to construct future cannabis policies.

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