My Health - Driving for teens with ADHD: What parents need to know

For all parents, it’s a scary time when their teen starts to drive. For parents of teens with ADHD, it can be — and should be — even scarier.

ADHD, or attention deficit hyperactivity disorder, is a condition that can cause problems with attention, impulsivity, and hyperactivity. These are not problems you want to have when you are driving.

What does research tell us about ADHD in teens and driving?

In a 2019 study published in Pediatrics, researchers looked at information about accidents, violations, and suspensions over the first four years of licensure for about 15,000 adolescent drivers. About 2,000 of these teens had ADHD. Here is what they found:

• The four-year crash rate for drivers with ADHD was 37% higher than for those without ADHD.
• The drivers with ADHD had a 62% higher rate of injury crashes, and a 109% higher rate of alcohol-related crashes.
• Teens with ADHD had a 36% rate of traffic violations, compared with 25% for those without.
• Teens with ADHD had a 27% rate of moving violations, compared with 19% for those without.
• 17 percent of teens with ADHD had their license suspended, compared with 10% of those who did not have ADHD.
• Teens with ADHD had a higher risk of speeding, not wearing seat belts, alcohol and/or drug use while driving, and using electronic equipment while driving.
• Teens with ADHD had a higher risk of accidents and other problems in the first month of driving.

Delaying driving to 18 rather than 17 didn’t make a difference. Additionally, delaying driving until 18 has a downside. At 18, graduated driving laws may not apply. These are laws designed to put some limitations on early drivers, such as not allowing them to drive with passengers, limiting the hours they can drive, and having stiff penalties for electronic device use.

The researchers also found in a previous study that there wasn’t a big difference in crash risk whether or not teens were being medicated for their ADHD. The best strategies for preventing accidents have to do with skills training — and with parents being involved in shared decision-making about when and how their teens drive.

Safe driving advice for parents of teens with ADHD

Here are some suggestions for parents of teens with ADHD when it comes to driving:

• Make sure they take a formal driver’s education class.
• Although medications didn’t seem to make a difference in the study, talk to your doctor about doing everything you can to maximize your teen’s treatment of ADHD before he or she starts driving. This may include medication, behavioral therapy, or something else.
• Before your teen gets a license, spend lots of time together in the car. Do many hours of driving together, working on skills and behaviors to keep them safe. Don’t let them take the driving test until you feel comfortable that they have learned those skills and behaviors.

Additionally, set rules about safe driving, and enforce them. This is crucial. These rules should cover things like:

• Number and type of passengers. Passengers increase crash risk. Some passengers are more distracting than others.
• Speed. Teen drivers must know and obey speed limits.
• Distraction. Any distraction that causes teens to glance away from the road for more than two seconds increases crash risk nearly four times — and distraction involving an electronic device increases it 5.5 times. Looking at phones is obviously a big distraction. So is looking out a side window, looking at a passenger, reaching for something that falls on the floor, or fiddling with a stereo system.
• Driving drowsy. Agree on rules to prevent this from happening.
• Any alcohol or substance use. There needs to be zero tolerance for this.

Parents might also want to consider using technology to help them. Many cars now come equipped with software that alerts drivers about risks or even starts braking before a collision. There are also apps that can help stop people from texting while they drive. Technology has limitations, but can sometimes help.

For more information about helping any teen drive safely, check out these tips from the American Academy of Pediatrics.

Follow me on Twitter @drClaire

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My Health - Simple ways to wake up your workout

Going to the gym regularly seems to be an exceptional act. Three 45-minute workouts are just a tick under the federal government’s recommendation of 150 weekly minutes of moderate activity. Yet according to the Centers for Disease Control and Prevention, more than three-quarters of United States adults don’t reach that threshold.

But let’s say you’ve established a fitness habit. The next challenge is what do with your time. Regardless of how solid your initial program is, eventually a sameness creeps in: the same exercises, same order, same weight — same routine overall. The body and mind respond by becoming bored. Is there a way to wake up your workout?

The easy antidote is to make a change. “In order to make something different happen, you need to challenge your body in a different way,” says Josie Gardiner, a personal trainer in the Boston area. You could hire a trainer to revamp your program. That isn’t a bad move, but it’s even simpler to slightly alter what you’re currently doing. Your time in the gym will be reinvigorated. And you’ll shift your mindset from just getting through your workout to believing, “I could do more than I thought,” Gardiner says.

Tweak your treadmill workout

By changing just one element, you can make your workout shorter — between 30 to 35 minutes — and more efficient. Choose among these options depending on how you feel.

Vary the speed. A fairly typical treadmill workout runs at a pace of 3.5 to 4 miles per hour for 45 minutes. Instead, interval train, Gardiner says. Research on healthy, young to middle-age adults shows that high-intensity interval training is better than endurance training at increasing VO₂ max, the amount of oxygen the body takes in and uses during exercise. A higher VO₂max indicates better conditioning and aerobic performance. Warm up at your normal starting speed for five minutes. Then start your interval cycle by increasing your speed by 1.0 miles per hour for one minute, then returning to your base rate for two minutes. Repeat this cycle six to eight times, ending with a five-minute cool down at a slower pace. This workout takes less than 35 minutes to complete.

Vary rest time. As you build your endurance, try cutting the rest time in each interval cycle to one minute. This shortens your workout even more and makes it harder.

Vary the incline. Warm up at your starting pace for five minutes, then increase the slope of the incline by one degree every minute with a goal of getting to 10. Once there, come back down by one degree every minute. End with a five-minute cool down. This is another way of changing the intensity, and it only takes 30 minutes.

Tweak your weight workout

Choose just one element to change at a time:

Play with pace. When using weights, vary the pace at which you lift the weights up and bring them back down to starting position. Count 2 seconds up, 2 seconds down; 3 up, 1 down; 1 up, 3 down, 4 up, 4 down. Your muscles will work and react differently.

Add weight. If the last few reps of your set feels easy, you aren’t working hard enough — you have to strain a little. If that’s not happening, choose a heavier weight so that you find it difficult to do the last few reps. Aim for the fewest additional pounds that your gym options allow. Most importantly, maintain good technique. “The minute you lose form, you’ve lost the exercise,” Gardiner says.

Change your hand position. The modifications will hit different parts of the muscle. With bicep curls, rotate your hands towards each other, with thumbs on top instead of pointing towards the walls, to make the exercise into a hammer curl. With a lat pulldown, you can either narrow or widen your grip on the bar. With a seated row, you can use different bars; a triangular one for a close grip, the lat pulldown bar for a wide one. With lateral dumbbell raises, rather than lifting to the sides, lift the weights straight out in front of you to shoulder height.

Focus on the feel. Regardless of what you do when lifting weights, the fundamental aspect to remember is that you’re targeting a specific muscle. It sounds overly obvious and basic, but concentrate on the muscle and feel it squeeze. “It puts your brain in the middle of muscle,” Gardiner says. It strengthens the mind-body connection. What’s more, a small study of college-age men suggests that focusing on the contraction can increase muscle size.

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My Health - Stress-eating: Five strategies to slow down

Weight gain has many underlying causes but one of the most common is something we all experience: stress. Whether it’s the, mild temporary kind caused by a traffic jam or major and chronic, triggered by a traumatic life event — stress is no friend to your waistline. It can set off physical and emotional changes that drive you to eat more, crave less nutritious, fattening comfort foods — and even gain weight much more easily.

Stress-eating and cortisol

“Stress drives up levels of a hormone called cortisol in the blood,” says Dr. Fatima Cody Stanford, an instructor in medicine at Harvard Medical School. Cortisol is a hormone produced by the adrenal gland that helps to regulate your metabolism. It also plays a role in blood sugar management and memory. When levels of cortisol rise, it can promote inflammation and may spur the body to start stockpiling fat around the midsection. “Stress might also disrupt sleep and drive people to seek out food when they wouldn’t normally — such as in the middle of the night,” says Dr. Stanford.

In earlier times this biological reaction to stress may have been beneficial, helping the body store up fuel for tough times ahead. But today, there’s typically no famine to outlast, no bear to outrun. Consequently, stress may just lead to unhealthy weight gain.

Feeling stressed?

Stress feels familiar to many of us. Yet some evidence suggests women are disproportionately affected by stress. A 2014 survey by the American Psychological Association (APA) found that women reported higher stress levels on average than men (5.2 out of 10 points for women, compared with 4.5 for men). Further, women were more likely than men to say that their stress levels were increasing (32% versus 25%).

Other factors matter, too. For example, the 2015 APA survey reports that average stress levels were highest among Hispanic adults versus all other races and ethnicities polled (5.9 vs 5.1 out of 10 points), and higher among people who identified as LGBT versus people who did not (6.0 vs 5.0 out of 10 points). Adults with disabilities reported extreme stress levels — 8, 9, or 10 on the 10-point scale — nearly twice as often as adults without disabilities.

Successfully managing stress may help control weight

While stress is an inevitable part of life for many people, the weight gain that can accompany it isn’t. Changing your response to stress and adopting strategies to reduce it can keep the numbers on your scale from moving in the wrong direction, says Dr. Stanford.

These five strategies may help:

Burn off tension. Exercise is a crucial component of stress management, because physical activity can actually reduce cortisol levels. But you will find excuses to avoid workouts if you dread them. Finding an activity you love — your “soulmate workout,” as Dr. Stanford calls it — can help you maintain the regular physical activity you need in order to dissolve daily stress. For some people it might be yoga, for others, high-intensity exercise — or a combination of the two.

Prioritize sleep. A lack of sleep can increase the amount of stress hormones circulating in your body. So ensuring you get enough restful slumber is crucial to managing stress effectively. “Avoid screen time at least an hour prior to bedtime,” says Dr. Stanford. This includes your smartphone. The blue light emitted by smartphones can interfere with sleep.

Change your outlook. The amount of stress you feel is based on circumstances and your perception of those circumstances. Two people may do the same job, yet only one perceives it as stressful. People also vary in their ability to manage stress, based on personality or early life experiences. Working to change the way you think about challenges can help reduce stress.

Plan ahead. If you are entering a high-stress period, prepare by setting up supports. “One woman I worked with gained weight at the same time each year around the anniversary of her child’s death,” says Dr. Stanford. If you’re getting ready for a stressful event or facing a work deadline, seek out additional support to help you through. This might include adjusting your schedule to add extra exercise, or making a healthy eating plan to help you resist the impulse to snack on unhealthy food.

Talk to your doctor. If you’re having problems coping with stress or controlling emotional eating, talk to your primary care physician. He or she may be able to refer you to a health coach, support services, or an obesity specialist. Medications might help some people, but these must be taken long-term or you may regain lost weight.

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My Health - How early can you — and should you — diagnose autism?

Autism is common. According to the most recent data from the Centers for Disease Control and Prevention (CDC), 1 out of every 59 children has been diagnosed with autism. That’s a marked rise from 2000, when only 1 in 150 children had been diagnosed with autism.

There is a lot we don’t know about autism, such as exactly what causes it or why it is becoming more common. But one thing we do know is that the earlier we start treating it, the better. Communication and social skills are built very early. We have our best chance of improving things if we work within that natural window. That’s why there has been a steady push toward making the diagnosis as early as possible.

It is not easy for parents to hear that their child has, or might have, autism. Even when there are worries about the child’s development, it is natural to hope that a child is just a late bloomer, or a bit quirky. And indeed, some children are late bloomers, or quirky, or have an entirely different problem with their development. So how early can you reliably diagnose autism?

What does research on autism tell us?

A recent study focused on this question. Researchers looked at more than 1,200 toddlers who had at least two developmental evaluations between 12 and 36 months. Less than 2% of the toddlers initially thought to have autism were subsequently thought to have normal development. And on the flip side, 24% initially thought to not have autism were then later diagnosed as having it. So while the picture is not always clear at first, once the diagnosis is made, it usually sticks.

At what age can the diagnosis be reliably made? At 12 to 13 months the “diagnostic stability” of the autism diagnosis — meaning the degree to which it was certain and stuck — was about 50%. This went up to 80% by 14 months, and 83% by 16 months. This makes sense if you think about the development of a toddler. At 12 months, they are just starting to say words, respond to commands, and interact with others. So a child who isn’t reliably doing those things would be cut some slack. But by 18 months, all those skills should be solidly in place, raising alarm bells about a child who doesn’t have them.

Which treatment strategies may help children with autism?

The main treatment for autism is called applied behavioral analysis (ABA). This is a behavioral program that breaks actions and behaviors down into small steps. It encourages positive behaviors and discourages negative behaviors. Other treatments include occupational therapy, sensory integration therapy, and strategies to improve communication, such as using pictures that children can point at to let caregivers know what they want.

Here’s the thing: ABA and the other treatments are helpful for children with developmental problems, no matter what their cause. There is no downside to doing them even if the child ultimately is found to have a different problem — or no problem at all. They are good for the child with autism, the child with a language disability, or a late bloomer. Yes, it’s hard for parents to hear a diagnosis of autism. But there is much reason for hope when it comes to autism, and we should never waste time when a child needs help.

The CDC’s Act Early campaign has a whole host of resources to help parents and caregivers know if a child is developing normally, or if there might be a problem. If you think there is a problem, ask for help. You have nothing to lose, and everything to gain.

Follow me on Twitter @drClaire

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My Health - When it comes to cholesterol levels, white meat may be no better than red meat — and plant-based protein beats both

A study published recently in the American Journal of Clinical Nutrition sparked interest when it reported that red and white meat have a similar effect on low-density lipoprotein (LDL, or “bad”) cholesterol, which is associated with increased heart disease risk. You may conclude, “Well, if chicken is just as bad for my cholesterol as red meat, I may as well order that hamburger.”

But let’s examine the study more closely before drawing any conclusions.

Red meat, white meat, or non-meat?

The study examined whether cholesterol levels differed after consuming diets high in red meat compared with diets with similar amounts of protein from white meat or non-meat sources (legumes, nuts, grains, and soy products). It also studied whether the results were affected by the amount of saturated fat in each of the diets.

One hundred and thirteen healthy men and women, ages 21 to 65, participated in the study. Each study participant was randomly assigned to either a high- or low-saturated fat diet. Then, for four weeks each, and in varying orders, they consumed protein from either red meat, white meat, or non-meat sources.

All of the foods consumed during the study were provided by the researchers (except for vegetables and fruits, to ensure freshness at the time of consumption). To reduce the chances that other factors that would affect cholesterol levels, participants were asked to maintain their baseline activity level and abstain from alcohol. They were also advised to maintain their weight during the study period, and their calories were adjusted if their weight shifted.

White meat has same effect as red meat on cholesterol levels

The study found that LDL cholesterol was significantly higher after consuming the red meat and white meat diets, compared with the non-meat diet. This result was found regardless of whether the diet was high or low in saturated fat, though the high-saturated fat diets had a larger harmful effect on LDL cholesterol levels than the low-saturated fat diets. High-density lipoprotein (HDL, or “good”) cholesterol was unaffected by the protein source.

Though striking, the study has a number of limitations. The size of the study, 113 participants, was small; the duration was short (only 16 weeks); and there was a relatively high participant dropout rate. The study also did not include processed meats such as sausage, cold cuts, or bacon, which are known to be particularly harmful for heart health, or grass-fed beef, which is often touted as a healthier red meat option.

Focus on plant-based protein

An important point that might be getting lost in the red meat versus white meat conversation is the beneficial effects of non-meat protein sources on cholesterol levels. As the study authors state, “The present findings are consistent with … earlier studies of primarily plant-based, lacto-ovo-vegetarian, or vegan dietary patterns reporting significantly lower total, LDL, and HDL cholesterol concentrations than diets including animal protein.”

The 2015–2020 Dietary Guidelines support healthy, plant-forward dietary patterns. Examples of plant-based diets include the Mediterranean diet and vegetarian diets.

This study looked at plant-based protein sources, and plant-based diets can provide all the necessary protein for optimal health. Here’s a look at the amount of protein contained in a variety of plant-based foods.

Protein content in plant-based foods
Food	Serving size	Protein (grams)	Calories
Lentils	1/2 cup	9	115
Black beans	1/2 cup	8	114
Chickpeas	1/2 cup	7	135
Kidney beans	1/2 cup	8	113
Black eyed peas	1/2 cup	7	112
Pinto beans	1/2 cup	7	117
Soybeans	1/2 cup	14	150
Tofu	1/2 cup	10	183
Nuts	1/2 cup	5–7	160–200
Peanut butter	2 tablespoons	8	190
Flaxseeds	3 tablespoons	5	150
Sesame seeds	3 tablespoons	5	156
Barley (uncooked)	1/4 cup	6	160
Bulgur (uncooked)	1/4 cup	4	120
Millet (uncooked)	1/4 cup	6	190
Quinoa (uncooked)	1/4 cup	6	160

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My Health - Talking to your doctor about your LGBTQ+ sex life

Generally speaking, discussing what happens in our bedrooms outside of the bedroom can be anxiety-provoking. Let’s try to make your doctor’s office an exception. Why is this important? People in the LGBTQ+ community contend not only with a full range of health needs, but also with environments that may lead to unique mental and physical health challenges. Whether or not you have come out in general, doing so with your doctor may prove critical in managing your health. Sexual experiences, with their impact on identity, varied emotional significance, and disease risk, are a keystone for helping your doctor understand how to personalize your healthcare.

Admittedly, talking about your intimate sexual experiences or your gender identity may feel uncomfortable. Many LGBTQ+ patients worry that their clinicians may not be knowledgeable about their needs, or that they’ll to have to educate them. Finding a LGBTQ+ adept doctor, preparing ahead of time for your next appointment, and courageously asking tough questions can give you and your health the best shot.

Finding a skilled clinician who is LGBTQ+ adept

Many large cities have healthcare institutions whose mission centers on care for LGBTQ+ peoples. However, these organizations may prove inaccessible to many for a variety of reasons. Regardless of your location, asking friends, family, or others to recommend a clinician may be a game changer. If your trans friend had a relatively painless experience visiting an area gynecologist, perhaps your Pap smear may go smoothly there as well. If your coworker has a psychiatrist who regularly asks him about his Grindr use, perhaps it may be easier to navigate your gay relationship questions with her.

Word of mouth is often an undervalued method of finding someone skilled and attentive to the needs of LGBTQ+ individuals. Online, many clinicians offer a short bio with their areas of expertise, and there are provider directories featuring trusted clinicians. Further, some doctors regularly write articles and give talks that may offer clues about desired knowledge. A simple Google search of your provider may yield a bounty.

Next, give your doctor or healthcare organization a call. Don’t be shy about requesting someone whose practice matches your specific needs. Your health information is protected, and generally, physicians hold your clinical privacy dear. Keep in mind that not all clinics will know or share whether or not your doctor is, for example, also a lesbian, but they may pair you with someone well suited to your request or point you in the right direction.

Preparing for your appointment

Let’s say you are nervous about coming out to your doctor. A little preparation may ease this burden. Here are some quick tips:

• Let them know you’re nervous at the start of the conversation.
• Be as bold as you can tolerate.
• Write down what you are excited about, nervous about, and/or curious about.
• Go in with a few goals and start with what’s most important.
• Maximize your comfort. If your partner is calming, bring them. If Beyoncé soothes what ails you, bring her along too.
• Lightly correct or update your clinician if they get something wrong.

Ask tough questions, give clear answers

As a psychiatrist who works with kids and adults, I often hear questions like, “I don’t know really how to say this, but I started experimenting with other guys. Does this mean I’m gay?” I may start by asking if you’ve enjoyed it. My colleagues in health care might begin with the same question.

Pleasurable experiences come in all sorts of constellations, and healthy exploration is part of being human. Additionally, clinicians need to assess and address your safety. Many LGBTQ+ people are at higher risk of intimate partner violence. We may ask about your use of condoms, how many partners you’ve had recently, your use of substances during sex, and how these experiences may shift how you see yourself. Give clear answers if possible, but don’t fret if you’re uncertain. Your doctor will not likely provide a label or pry unnecessarily. They may offer constructive information on the use of condoms, reasons to consider using PrEP (which can effectively prevent HIV), and places you can go for more guidance. Physicians enjoy giving personalized information so that you may make informed healthcare decisions.

There is no end to what is on people’s minds. Be bold. Will tucking reduce my sperm count? Maybe. Does binding my breasts come with risk? Likely. Was Shangela robbed of her RuPaul’s Drag Race: All Stars 3 crown? Utterly, but let’s get back to your cholesterol, shall we?

Remember that it is often impossible to squeeze everything into one appointment. Afterward, take time to catch your breath, reflect on what you’ve learned, and come up with more questions for next time. We’re here for that.

Follow me on Twitter@cecilwebstermd

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My Health - Rising temperatures? How to avoid heat-related illnesses and deaths

In Boston, we believe warmer is better. Our cravings for warmth are formed in the cold, dark winter nights when the prospect of summer seems impossibly remote. But with temperatures reaching 100°F in July, our winter dreams are becoming a nightmare. And it’s not just Boston. More than half of all Americans endured unsafe heat conditions during July, which was the hottest July ever recorded in US history, according to the Washington Post. Europe fared no better; sweltering temperatures broke records in more than a dozen countries in June (this was the hottest June ever in Europe) and July. Not surprisingly, heat-related illnesses and deaths of people at greater risk from high temperatures rose, too.

What is heat-related illness?

Our ability to cool off has limits. When the heat is too strong, our bodies overheat. When that happens, we can get headaches and muscle cramps, and vomit. Severe overheating, when body temperature reaches 104 or higher, can lead to heatstroke that can damage kidneys, brains, and muscles.

Even for people who are healthy, heat can be dangerous and cause heat-related illness. Outdoor workers, athletes — especially football players and young athletes — and women who are pregnant should be especially careful when it’s hot outside.

Who is at greater risk from high temperatures?

Heat can be a risk for those who are healthy, but it’s particularly risky for people who have existing health problems. It can even be lethal. Decades of research show that people die during heat waves, and that these deaths are notoccurring among people who were going to die soon anyway.

We all know someone who is at greater risk from too much heat. The elderly, particularly those with heart failure, kidney disease, and chronic lung disease, and the homeless are at high risk when temperatures soar. Less well known are the others who need to be vigilant when extreme heat hits, including parents of children with asthma and people with diabetes. Anyone taking medicines, such as diuretics, that can affect their body’s ability to sweat or hold onto water may also be more vulnerable.

How can you keep yourself and others safe during heat waves?

More than half the people in the US may have received some form of warning during our most recent heat wave. But research on these mass alerts shows they may not be as effective as we’d like. Many cities, including Boston, take a more targeted approach by offering services to communities at risk. You can keep yourself and others safe by taking these steps:

• Think about whether your health, or the health of your neighbors or loved ones, is at risk from heat. If so, make sure everyone — including you — understands how to stay safe during heat waves.
• Sign up for heat alerts. Many city or town governments have a website where you can sign up to receive text messages to alert you of dangerous heat conditions. Free services, such as iAlert, also can send you alerts. Be aware, though, that the alert may go out at temperatures above what is known to be risky for health.
• Find out where the cooling centers are in your city. Take advantage of these centers and tell others who might be at risk about them. During heat waves, many cities offer free transportation to these centers. Many cities have websites that can help you find the cooling center nearest you.
• Drink plenty of water during heat waves. Avoid too much caffeine and alcohol, which can promote dehydration.

What other steps can you take?

It’s right to focus our immediate actions on protecting people most at risk. But we also need to consider recent heat waves a sign of things to come. We know climate change has already led to more severe heat waves around the United States. Curbing carbon pollution by taking these actions and others can help prevent more frequent and dangerous heat waves.

We can make our cities greener. The difference in temperature between the hottest and coolest parts of cities can be 20°F or more, because of how much the urban landscape absorbs heat. Planting trees and other plants can make a big difference to reducing heat in cities. Green space doesn’t just keep us cool, it also keeps us healthy. Trees remove air pollutants that can further harm people who are at risk from heat. Vegetation prevents water runoff. In Boston, runoff from heavy rains this April led to pollution levels in the Charles River that forced cancellation of all summer swimming events. Climate change has increased heavy downpours in New England and around the country. Trees can help make our city more resilient to climate change.

We can work to reduce traffic congestion. This is a growing problem in cities all over the country. Use public transit whenever possible. Carpool. If you buy a car, remember that greater fuel efficiency reduces carbon pollution and other pollutants that damage lungs, hearts, and brains — and lowers monthly costs. Improvements to make public transit accessible, affordable, and reliable help everyone. Find out what’s going on in your community about transit, bike lanes, and pedestrian ways. Advocate by speaking out at community meetings and voting for improvements through local and state referendums.

We can conserve energy at home. If you are redoing your roof, consider getting a green roof, or at least choose light-colored roofing material. Many cities and states offer free home energy audits, plus incentives to improve a home’s insulation and replace old appliances with newer, more energy-efficient models.

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My Health - Why do you need a primary care physician?

Staying healthy is best done with expert help. We all need medical care at some point. And if chronic illness strikes, it requires the guidance of someone with the ability to make diagnoses and balance treatments that are often aimed at different organ systems.

Primary care physicians (PCPs) are generalists who see adult patients for common ailments including respiratory infections, headaches, back pain, and urinary infections. They also manage chronic conditions such as high blood pressure, diabetes, heart disease, obesity, anxiety, and depression. In addition, PCPs have expertise in managing multiple treatments, medications, and the interactions between them. They can address the entire person, taking into account their values, beliefs, and preferences.

The explosion of medical knowledge and treatment alternatives makes it important to have a generalist to interpret and advise on the best course of action. This often requires communication with specialists, who are usually expert in a specific condition or organ system, and coordination of care with patients and families.

Study reinforces benefits of primary care

A study published earlier this year in JAMA Internal Medicine examined the value of primary care. Researchers analyzed survey results from 49,286 US adults with a PCP and 21,133 US adults without a PCP.

They found that adults with primary care were significantly more likely to fill more prescriptions and to have a routine preventive visit in the past year. They were also significantly more likely to receive more high-value care such as cancer screenings, including colorectal cancer screening and mammography.

Choosing a PCP team

The best PCPs are great communicators who work in teams that keep the patient at the center of all diagnostic and treatment activities. A PCP team often comprises medical assistants, nurses, pharmacists, and social workers. At any given time, a patient will need support from the team member who is best qualified to find a solution to a specific problem. This approach extends the reach and efficiency of busy clinicians, and helps patients navigate a complicated health care system.

When choosing a PCP, it is important to consider your current health status and needs. Those with complicated needs or chronic medical illness would benefit most from a PCP team that can help with all aspects of health care. Looking for a practice that is a certified medical home is one way to find a good PCP team. Ask questions about the team and how it works.

If you are currently healthy and don’t have extensive medical needs, now is a great time to establish a relationship with a PCP who can get to know you, and help you meet your health care goals. They will also be there when you need them.

Preparing for your visits

Gathering previous medical records, medication lists, and insurance information is a good idea in planning for a first visit to your new PCP. Bringing a list of questions will help you make the most of the visit. The PCP will be better able to design a health care plan if they have a good sense of who you are and what your current needs are.

Additional visits may be required to address multiple symptoms, conditions, or concerns. Make sure your most pressing concerns are addressed, but also be ready to accept that additional visits or consultation with other members of the team may be needed.

Find out the best way to communicate with your PCP team between visits. Many practices have secure patient portals where non-urgent issues can be addressed by the appropriate team member, possibly reducing the need for a face-to-face visit.

PCPs can also help navigate transitions of care if you need to enter the health care system. Having guidance and support when leaving the hospital and going back home or to a rehabilitation facility can make a big difference in how well you regain previous levels of health and independence.

Most adults will need to enter the health care system at some point in their life. Having a PCP team that gets to know you as an individual in the context of your goals, values, and preferences will make it easier to get the care you need.

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My Health - Teens and confidentiality

When my primary care patients reach high school age, or sometimes before, I kick their parents out of the exam room.

I don’t do it right at the beginning of the visit. I meet with them both first, to see what the parents are worried about (teens don’t always tell me), and to get updated on what is going on with the family (teens don’t always know). Then I ask the parents to leave. I say that at their child’s age, I like to have some time alone with them.

I have a standard speech I give the teen. I say, “Anything you tell me is confidential, and your parent won’t be able to read the note I write. If you tell me anything I think your parents should know, we will talk about how to tell them. I won’t go behind your back.”

I can’t imagine doing it any other way. It’s what my teen patients need me to do.

Why does confidentiality matter?

In a study published this year in the Journal of Pediatrics, researchers asked youth ages 14 to 24 about their opinions and experiences with confidentiality in their health care. They found

• most had not had a conversation with their provider about confidentiality
• many thought all care should be confidential
• youth worry about privacy and future discrimination
• youth may lie about their risk behaviors or not seek health care when concerned about confidentiality.

It’s that last point that worries me the most. As anyone who has been a teen knows, there are things you don’t always feel comfortable discussing in front of a parent or guardian.

That might include things like sex or sexuality, meaning a teen could miss the opportunity to learn about or get birth control, get treatment for a sexually transmitted infection, discuss healthy relationships, or explore questions or feelings about sexuality.

It might include substance use, meaning a teen could miss the opportunity to get the advice they need to make safe and healthy decisions about substance use — or the help they need for a substance use disorder.

It might include mental health concerns such as depression or anxiety, meaning a teen could miss the opportunity to get the mental health help they need.

Sometimes there are physical concerns that a teen doesn’t want to talk about in front of a parent — because they think it is silly, or because they are embarrassed, or because they don’t want to worry their parents. They could miss the opportunity to get the treatment they need — or be reassured that they are fine.

This is not what we want for our teens.

Advice to parents about teen confidentiality

I understand that it can be hard for some parents to let their teen have confidential alone time with their health care provider. It’s normal to worry, and to not like the idea that they could keep secrets from you. It’s also normal to wonder if you can really trust the health care provider, or whether their values are the same as yours.

But besides the fact that what is most important is your child’s health and safety, the unavoidable truth is that teens grow into adults who need to learn to advocate for their own health and well-being. The best way to learn to do something is to practice it.

That’s why my advice to parents is to not just let their teen have confidential time with their health care provider, but to encourage it. If the doctor doesn’t ask you to leave the room, offer to do so — and make it clear that you don’t need to know what they talk about.

Follow me on Twitter @drClaire

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My Health - Impossible and Beyond: How healthy are these meatless burgers?

Plant-based burgers are not a novel concept. But new products designed to taste like meat are now being marketed to vegetarians and meat-eaters alike. Impossible Burger and Beyond Meat’s Beyond Burger are two such options. Eating these burgers is touted as a strategy to save the earth, casting meat as a prehistoric concept. Both brands also offer up their products as nutritious alternatives to animal protein.

But how do they stack up? It turns out the answer may depend on whether your priorities lie with your personal health or the health of the planet.

The good news: Meatless burgers are a good source of protein, vitamins, and minerals

The protein content of these newer plant-based burgers has been created to compete with beef and poultry gram for gram. Both the Impossible Burger and Beyond Burger have comparable amounts, the former deriving protein mainly from soy and the later from peas and mung beans.

Impossible Burger also adds vitamins and minerals found in animal proteins — like vitamin B₁₂ and zinc — in amounts equal to (and in some cases, greater than) both red meat and poultry. This is a plus for vegetarians, because these nutrients are typically harder to come by when relying solely on foods from the plant kingdom. Vitamin B₁₂, for instance, is found primarily in animal sources, and strict vegetarians and vegans must get their intake from fortified sources. What’s more, plant compounds such as phytic acid bind to minerals, which can increase requirements of zinc by 50% and may necessitate consuming about two times as much iron. For those who eat at least some animal protein, the vitamin and mineral fortification is less of a selling point.

This doesn’t mean a plant-focused diet is lacking in nutrients. Beans, for instance, are a good source of both zinc and iron. They are also an important protein resource. Black bean burgers are never going to be mistaken for hamburgers, but they are typically a solid choice when it comes to health.

The bad news: Meatless burgers are heavily processed and high in saturated fat

The same can’t necessarily be said of the aforementioned beef substitutes, which have been created to mimic what many people love about a burger — the red juicy center and meaty taste. Along with the ambition to replicate hamburgers comes a comparable amount of saturated fat. Since diets higher in saturated fat are associated with increased rates of both heart disease and premature death, they may not be the type to opt for if your ambitions are purely health-related. They are also a significant source of sodium, particularly for those on salt-restricted diets.

The following chart shows how the newer, meatless burgers stack up nutritionally against beef burgers, turkey burgers, and black bean burgers.

	Calories	Fat (g)	Sat fat (g)	Chol (mg)	Sodium (mg)	Carb (g)	Fiber (g)	Protein (g)
Impossible Burger (4 oz)	240	14	8	0	370	9	3	19
Beyond Burger (4 oz)	250	18	6	0	390	3	2	20
85% lean ground beef (4 oz)	240	17	6	80	80	0	0	21
Ground turkey (4 oz)	170	9	2	80	70	0	0	22
Black bean burger (Sunshine brand) (2.7 oz)	260	16	1.5	0	190	19	8	10

Even though legumes are sourced for protein in the branded meatless options, their health benefits are somewhat blunted by the high degree of processing involved. For instance, moderate amounts of whole soy foods, like edamame (soybeans), have been linked to reduced rates of cancer. This protection is often attributed to isoflavones, a subgroup of plant compounds called flavonoids thought to provide health benefits. Unfortunately, in the case of the Impossible Burger, one serving contains less than 8% of the isoflavones found in one serving of whole soy foods (one serving is roughly a quarter of a block of tofu or 1 cup of soymilk).

Poultry-based burger alternatives, such as turkey burgers, also do not contain significant amounts of protective plant compounds. On the other hand, they offer less saturated fat.

If a lower risk of diseases like cancer and heart disease is your ultimate goal, aim for the kind of veggie burgers that showcase their beans, grains, and seeds front and center. Choose legume-based varieties studded with seeds and whole grains, like brown rice and quinoa.

The bottom line: Meatless burgers are good for the planet, but not always good for our health

If you love the taste of a burger, but find the sustainability of raising cattle hard to stomach, beefless alternatives that mimic the real thing are worth a try. Producing the newer, plant-based burgers requires considerably less water and generates substantially less greenhouse gas emissions compared with traditional beef burgers. This is certainly an important consideration for the well-being of our planet, but they may not be the best option for the health of our bodies.

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My Health - I’m in pain, so why is my doctor suggesting a psychologist?

Pain makes us human. It is a bell, fine-tuned by evolution, that often rings in moments necessary for our survival. Because of pain, we can receive warnings that trigger the reflexes to escape potential danger.

But what happens when that bell continues to ring? How do we respond to a signal when it interferes with the other elements that make us human?

Pain that lasts longer than six months is considered chronic, and it may not go away. With chronic pain, the bell’s ongoing signal gets your nervous system wound up and increases its reactivity to incoming messages. This can be quite distressing and anxiety-provoking. Additionally, the feelings of frustration or sadness when pain doesn’t go away can make pain worse.

What’s the link between emotion and my perception of pain?

Pain, depression, and anxiety travel through similar pathways along your nervous system and share many of the same biological mechanisms. One of the areas in the brain that receives pain signals — specifically, the limbic region — shares many of the same messengers as the mood signals. We know from research studies using neuroimaging that the parts of the brain controlling emotion and sensory features of pain are altered in people with chronic pain.

The connection between pain and emotion can also be seen with certain classes of medications. For example, some medications used to treat pain can cause side effects like euphoria, and medications originally developed for psychiatric conditions can be effective treatments for certain types of pain.

The medical community has come to appreciate a direct correlation between improvement in one’s emotional well-being and their experience of pain (and vice versa). Chronic pain increases the risk of depression and anxiety, and depression and anxiety strongly predict the development of chronic pain. This association is seen in conditions like fibromyalgia and irritable bowel syndrome, where behavioral and psychological treatment strategies have shown benefit in reducing symptoms.

What can a psychologist help me address?

• Pain catastrophizing: This is when you magnify the negative effects of pain and focus on feelings of helplessness while ruminating about the presence of pain in your life. Negative thoughts and beliefs about pain often lead to worsened emotional and social functioning and a decreased response to medical interventions for pain.
• Fear of pain: Concern or worry about an injury drives avoidant or protective behaviors. The anticipation of an increased sensation of pain may limit you from engaging in physical activity or attending social outings. Pain-avoidant behaviors can lead to physical deconditioning and further decreased quality of life.
• Pain acceptance: This is a challenging, but highly effective technique focused on developing an accepting attitude towards the pain. It involves doing your best to nonjudgmentally acknowledge the presence of pain and minimize unhelpful thoughts and behaviors that won’t make pain better.
• Trauma: The link between prior trauma and chronic pain is becoming better understood. Psychological therapies can address ongoing physical and emotional stress responses linked to traumatic experiences.

What type of therapies help with chronic pain?

There are multiple psychotherapeutic treatment options commonly used to help people manage chronic pain. Practicing meditation and becoming as active as possible have been shown to be effective methods that can be done on your own. Mental health professionals who specialize in working with people in pain can guide you with additional evidence-based treatments:

• Cognitive behavioral therapy (CBT): talk therapy that helps to change your thoughts and behaviors related to pain and improve coping strategies. You can learn CBT techniques with a psychologist or as part of a therapeutic group, which may also provide a support network.
• Mindfulness-based stress reduction (MBSR): a form of mediation where you learn to nonjudgmentally become aware of your thoughts and feelings and accept pain and other uncomfortable sensations as neither positive nor negative.
• Hypnosis for pain (hypno-analgesia): a set of techniques intended to modify your thoughts, feelings and behaviors via subconscious suggestions aimed at altering your experience of pain. Hypno-analgesia differs from CBT, which is a conscious recognition of your emotions related to pain and a more self-directed, action-oriented approach.
• Biofeedback: a technique where your body functions such as heart rate, muscle tension, and skin temperature are monitored to make you aware of your involuntary responses to stress. During biofeedback sessions you learn a variety of ways to control your physical reactions to stress and anxiety.

Where can you find help to manage the emotional aspects of pain?

It is always recommended that you have a primary care physician coordinating your care, and you doctor may be able to provide you with a referral to a pain specialist or psychologist. It is worth finding out what mental health services your health insurance covers as you navigate this process.

Additional resources for finding specialists in your area:

American Chronic Pain Association

www.theacpa.org/

American Pain Society

www.americanpainsociety.org

Will my pain ever go away?

This question is surely at the top of every person’s mind if they are in pain. The difficulty in answering this stems from the variety and types of chronic pain syndromes, as well as individual variability. What has been shown to make a difference in people managing chronic pain is trying a variety of approaches, such as cognitive and behavioral techniques, staying active, practicing meditation, and working with your doctor to find effective medical and procedural interventions. The more of these interventions you try, the more likely you will find something that makes a positive impact.

The challenges of coping with a chronic pain condition cannot be understated. The negative emotions that come from it can be self-perpetuating, as one’s feelings of pain can lead to depression, and that very depression can lead to worsening pain. In coping with this cycle, the goal is to take whatever steps are possible to continue to lead a fulfilling life, including getting emotional and social support.

Our understanding of pain continues to evolve, and with it may come improved personalized treatments and better understanding of chronic pain’s influence on the body and mind.

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My Health - Do employee wellness programs actually work?

It seems like a question that’s not worth asking. If you offer employees wellness programs such as fitness centers, nutrition counselling, and stress reduction, and you charge little or nothing — or even offer financial incentives — surely it will improve the participants’ health. And surely the employer would see a return for investing in these programs, in improved worker productivity and decreased absenteeism.

What does the research say?

And yet that’s not what researchers reported in the April 2019 edition of JAMA. They analyzed data from nearly 160 worksites employing nearly 33,000 people. About 10% had wellness programs that addressed topics such as exercise, nutrition (including meetings with onsite registered dietitians), and stress. When comparing employees with and without a wellness program at work over 18 months, those who had a wellness program had significantly higher rates of self-reported exercise (70% vs. 62%) and weight management efforts (69% vs. 55%).

Despite these significant (though small) differences, those with a wellness program and those with no wellness program had similar

• self-reported health behaviors and outcomes (such as amount of regular exercise, sleep quality, food choice, and 24 others)
• results on 10 health measures (such as blood pressure, cholesterol, and body mass index)
• use of medical resources (including medical spending and medication expenses)
• absenteeism and job performance.

These results call into question whether the assumptions about wellness programs at work actually deliver on their promise.

Is this the end of employee wellness programs?

As noted by the authors of this study, this research will not be the last word on how effective employee health programs are. Reasons for this include:

• The results might have been different if the study had been performed at a different type of workplace, with different types of wellness programs and different types of workers.
• The worksites without a wellness program had relatively high rates of self-reported health behaviors. Workplaces with lower rates might benefit more from a wellness program.
• The study lasted only 18 months. A longer-term study might find more benefit for the wellness program.

So, while the assumption that wellness programs actually lead to improvements in the health of workers and lower absenteeism may be called into question, we need additional research before concluding that all of these programs are useless.

What’s an employee to do?

If your employer has more than 200 workers, there’s a good chance that you have a wellness program offered through your work: about 80% of larger companies have these programs. Even at smaller companies, more than half offer them. If you do have such a program where you work, take advantage of it! One study found that even with financial incentives, employee participation increased only modestly (from just under half with no financial incentive to 59% for a $100 reward and 63% for a $200 reward). Learn what they have to offer, participate with enthusiasm, and see if it improves your health, mood, work habits, or performance.

While this study suggests the impact may be small or nonexistent, some programs may be better than others, and some people (perhaps you!) may get more out of them than others.

If you don’t have a wellness program at work, design your own. Talk to your doctor about what you can do to improve your health. Perhaps your focus should be on exercise if you’re currently inactive. Or maybe your diet, sleep, or mood could be better. Your doctor may refer you to a physical therapist or trainer, dietitian, or psychotherapist who can help in ways similar to workplace wellness programs.

What’s next?

I think we’ll see more research looking at the effectiveness of employee wellness programs. Hopefully, this will include studies with older or younger workers, and different types of programs that encourage participation in different ways (such as financial rewards or a break on health insurance premiums). You can bet employers will take note of this study — after all, workplace wellness programs are part of an $8 billion industry that is likely to lose steam if there is truly little return on this hefty investment for employees or employers.

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My Health - Popular drugs used for treating enlarged prostates associated with high-grade prostate cancer

If a man has an enlarged prostate, there’s a good chance he’ll be treated with a type of drug called a 5-alpha reductase inhibitor (5-ARI). These drugs shrink the gland to improve urinary flow, and the approved forms used for treating enlarged prostates come in two varieties: Proscar (finasteride) and Avodart (dutasteride).

However, a side effect of 5-ARI inhibitor treatment is that it suppresses blood levels of prostate-specific antigen (PSA) by about 50%. Doctors measure PSA during prostate cancer screening, and if a man on 5-ARI therapy winds up with results that are artificially low, then he might be falsely reassured that he doesn’t need any additional prostate cancer testing.

A new study with just over 80,000 prostate cancer patients highlights this risk. Men in the study who developed prostate cancer while taking a 5-ARI inhibitor had significant delays in diagnosis compared to nonusers. And because those cancers were discovered at more advanced stages, the men’s outcomes were also comparatively worse. The study was led by Dr. Brent S. Rose, assistant professor in the department of radiation medicine and applied sciences at the University of California, San Diego School of Medicine.

PSA tests raise red flags for cancer when the measured values are 4 nanograms per milliliter (ng/mL) or higher in blood. As a general rule, doctors can double the measured PSA result in men taking a 5-ARI inhibitor to account for the 50% reduction in actual blood levels. So if a man’s test reads 3.5 ng/mL, then the doctor can interpret the value as 7 ng/mL, which would ordinarily trigger a prostate imaging test or a biopsy to look for cancer in the gland.

What the researchers did

Dr. Rose and his colleagues speculated that this doubling occurs infrequently in the general medical community. To investigate, they looked at 80,750 prostate cancer cases documented in the Veterans Affairs database between 2001 and 2015. They focused specifically on differences between men who either were or were not taking 5-ARIs when they were diagnosed with prostate cancer. The men on 5-ARI inhibitors had been taking the drugs for a median of 4.8 years before the prostate cancer was detected.

What they found

According to the study findings, men on 5-ARI inhibitors fared worse in all respects: the time to diagnosis triggered by PSA readings among men using 5-ARI inhibitors was 3.6 years, compared to 1.4 years for nonusers, and there were also statistically higher numbers of high-grade tumors, a higher frequency of cancer in the lymph nodes, and metastatic tumors spreading in the body among men who were taking 5-ARI inhibitors. Lastly, the prostate cancer-specific death rate at 12 years was 13% among 5-ARI inhibitor users, compared to 8% among nonusers and men taking other treatments for enlarged prostates that don’t affect PSA.

Dr. Rose and his colleagues emphasize that the findings don’t mean 5-ARI inhibitors are inherently unsafe, or that PSA screening is ineffective in men who take these treatments. Indeed, other studies have shown no impact on survival for men on 5-ARI inhibitor therapy — and fewer cancer deaths among them compared to nonusers — “but these studies also required strict adjustment of PSA level,” to account for how the drugs suppress PSA levels, the authors wrote.

The authors also admit that they don’t know how many doctors do or do not adjust for PSA suppression among men who take 5-ARI inhibitors. But the new results, they claim, suggest that such adjustments aren’t routinely performed, and that there is a continued need to raise awareness of 5-ARI–induced suppression of PSA, in addition to clear guidelines on how to manage it.

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, said the findings are disturbing. According to Garnick, 5-ARIs have been extensively studied, and an FDA review panel associated the drugs with an increased risk of higher-grade prostate cancer compared to placebo. “The current study underscores that same finding,” he said. “And whether it is due to a diagnostic delay resulting from lower PSA levels or whether these drugs are affecting the biological behavior of the cancer itself should be a source of continued investigations. In the meantime, these drugs do have good efficacy in controlling the symptoms of an enlarged prostate, and a frank discussion needs to be undertaken with the patient and physician before the prescription is filled.”

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My Health - Is there a role for surgery in treating Hashimoto’s thyroiditis?

Autoimmune disease occurs when the body’s immune system attacks its own tissues, mistakenly sensing them as foreign. When the body attacks thyroid gland tissue, it is known as Hashimoto’s thyroiditis, named after Japanese physician Dr. Haruko Hashimoto, who first described the illness in 1912. The condition is also called chronic lymphocytic thyroiditis or autoimmune thyroiditis.

Hashimoto’s thyroiditis is the most common cause of hypothyroidism in most of the world. It is also the most common autoimmune disease known to man. It affects males and females as well as the young and the old. But it is most common in women, is more likely to occur with age, and is more prevalent in those with a family history of thyroid disease or other autoimmune disease.

Hashimoto’s thyroiditis and hypothyroidism

The thyroid gland is part of the endocrine system. It regulates a wide range of vital body functions, influencing the rate at which every cell, tissue, and organ in your body — from your muscles, bones, and skin to your digestive tract, brain, and heart — functions. It does this primarily by secreting hormones that control how fast and efficiently cells convert nutrients into energy — a chemical activity known as metabolism.

Your doctor may suspect Hashimoto’s thyroiditis if you have low thyroid hormone levels, an enlarged thyroid gland (goiter), or, in some cases, repeated miscarriages without explanation. The diagnosis is usually confirmed with blood tests looking for specific antibodies to the thyroid.

Over time, Hashimoto’s thyroiditis can cause damage to the thyroid gland that results in hypothyroidism (insufficient thyroid hormone to meet the body’s needs). Hypothyroidism can cause a range of symptoms related to a slowed metabolism. Symptoms include fatigue, cold intolerance, loss of appetite, weight gain, depression, dry skin, hair loss, constipation, heavier menstrual periods, and high cholesterol.

Hypothyroidism isn’t the only complication associated with Hashimoto’s thyroiditis. In some, the condition can cause a goiter. The larger the goiter, the more likely it is to be visible. A goiter, particularly a large one, may also cause symptoms such as difficulty swallowing. When this occurs, surgery may be necessary to remove all or part of the goiter.

Standard treatment of Hashimoto’s thyroiditis

Once diagnosed, Hashimoto’s thyroiditis is typically treated with observation alone. In the event that hypothyroidism develops (even mild cases in the event of pregnancy), it is treated with thyroid medication (synthetic thyroid hormone).

Study explores a possible role for surgery

In 2019, a well-designed, provocative study done in Norway’s Telemark Hospital compared the benefits of thyroidectomy (removal of the thyroid) in patients with Hashimoto’s thyroiditis to thyroid medication alone.

Study participants were between 18 and 79 years old, had thyroid antibody levels that were at least 10 or more times greater than the upper limit of normal, and were being treated with thyroid medication. Despite having normal thyroid hormone levels (likely due to taking thyroid medication), study participants reported symptoms that interfered with measures of their quality of life including fatigue, the ability to function physically and socially, vitality, emotional and mental health, and bodily pain.

Of the 147 enrollees who completed the 18-month study, 73 underwent surgery. Those who did not have surgery continued to be treated with medication alone.

The results in those who had surgery were striking. Antibody levels fell to nearly normal. Quality of life improved. Fatigue improved to the point that it was comparable to the normal Norwegian population.

Cautious optimism, but more research is needed

This study raises the possibility of a role for surgery for patients with Hashimoto’s thyroiditis who continue to feel poorly despite optimal treatment with thyroid hormone.

However, the study, while well done, is a relatively small one. We need longer-term follow up and confirmation with additional studies done on diverse populations.

It’s also important to consider that thyroid surgery in patients with advanced Hashimoto’s thyroiditis is difficult. Rates of complications, including injury to the laryngeal nerve (which controls voice) and the parathyroid glands (which maintain normal blood calcium levels), are increased. What’s more, once the thyroid is removed, the body will no longer be able to make thyroid hormone, and the patient will have to take thyroid medication for the rest of their lives.

Thus, until further confirmatory studies are done, surgery for patients with Hashimoto’s thyroiditis should only be considered when thyroid enlargement is causing symptoms such as difficulty swallowing.

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My Health - Keeping children safe around cosmetics

When we think about household products that need to be kept out of the reach of small children, we usually think about medications and cleaning products. We don’t usually think about cosmetics. But a study published in the journal Clinical Pediatrics shows that we need to think about cosmetics too.

How many childhood injuries are due to cosmetics?

Researchers used the National Electronic Injury Surveillance System to look at data about children younger than 5 who were treated in US emergency departments for cosmetics-related injuries between 2002 and 2016.

They found that in that time period, almost 65,000 children went to the emergency department because of a cosmetics-related injury. That’s a little more than 4,000 every year. About 60% of children injured were younger than 2, and 40% were ages 2 to 4. The vast majority suffered minor injuries. Only 6.4% (about 1 in 15) needed to be hospitalized. Not surprisingly, children younger than 2 were most likely to be hospitalized. There were no fatalities.

Which cosmetics are often involved?

When looking at the injuries, the researchers found:

• 28% were from nail care products
• 27% from hair care products (including things like hair dye, or chemicals used for straightening or permanent waves)
• 25% from skin care products (including sunscreen)
• 13% were from fragrances.

Almost all — 99% — of the injuries occurred at home.

The injuries were most often poisonings or chemical burns. Here are the products that were the biggest offenders:

• nail polish remover (contains acetone, which can be poisonous)
• fragrance (the most common cause of eye injuries)
• hair relaxer and permanent wave solutions (the most common cause of hospitalization).

The authors point out that cosmetics are often “colorful, visually appealing, easy to open and use.” They also often smell good, even like food. Obviously, with curious toddlers and preschoolers, this is a recipe for disaster. Add that to the fact that children see their parents using them all the time — and love to imitate what their parents do.

How can parents and caregivers prevent injuries from cosmetics?

So, what can parents and caregivers do?

• Keep cosmetic products out of reach. This is the simplest and most important thing to do. Think of them the same way you’d think of medications or cleaning fluids, and keep them either up high or in a secured container.
• Make thoughtful purchases. Only buy the cosmetic products you really need and use — and if possible, avoid buying products that might be particularly appealing and interesting to toddlers (or that look like food, as many do).
• Throw out any cosmetic products you aren’t using. Keep your supply as lean as possible.
• Have the Poison Control Center phone number handy: 800-222-1222. They have a database that has information on literally anything your child might get into. Have the product with you when you call.
• If your child gets anything in his or her eyes, flush the eyes immediately with lots of cold water while you are calling for help.

While you should always call in an emergency, the Poison Control Center also has a website that can give you information on whether something is poisonous — and what to do.

Follow me on Twitter @drClaire

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My Health - Want a sharp mind, strong memory? Ramp up activities

We all want to keep our minds sharp and our memories strong as we get older. So, what can we do right now to prevent cognitive decline in later years? Engaging in regular aerobic exercise for at least 30 minutes a day, five days a week, probably has the biggest effect on people of many ages (see here and here). Convincing evidence also suggests that a Mediterranean-style diet of fish, olive oil, avocados, fruits, vegetables, nuts, beans, and whole grains is beneficial. But what about social and mental activities — do they help at all?

Social activities, a positive attitude, and learning new things

Previous research convincingly demonstrates that older people who engage in social activities, have a positive mental attitude, and work to learn new things maintain their cognitive abilities longer than those who are socially isolated, have a negative attitude, and do not try to learn new things. However, several questions remain. When is the ideal time to do these activities: in middle age or later in life? Does it help to do multiple activities, or is a single activity as good as several? And what about other common mental activities, such as reading books and playing games — do they help too?

Mentally stimulating activities: More is better

A recently published study from researchers at the Mayo Clinic followed 2,000 cognitively normal men and women age 70 or older for about five years. Participants filled out surveys regarding their engagement in five common mentally stimulating pursuits –– social activities, reading books, playing games, making crafts, and using a computer –– in midlife (between ages 50 and 65) and in late life (ages 70 and above). The researchers also performed face-to-face evaluations every 15 months. These evaluations included a neurologic interview and exam, detailed history of their abilities at home and in the community, and neuropsychological testing for memory, language, visuospatial skills, attention, and executive function.

When the study ended, the researchers looked at whether participants remained cognitively normal or developed mild cognitive impairment (MCI). MCI is diagnosed when a concern about a person’s thinking and memory is confirmed by testing that shows impairment on one or more tests of thinking and memory. However, day-to-day functioning is essentially normal, and the person is not demented.

The study yielded several important findings

• Engaging in two, three, four, or five mentally stimulating activities in late life correlated with a lower risk for developing MCI. A trend suggests a greater number of activities is linked to a greater reduction in risk.
• Three activities — computer use, social activities, and games — had benefits when pursued in both midlife and late life. However, crafts were beneficial only in late life.
• Reading books showed no benefit — a dismaying finding to me as both an author and an avid reader.

The bottom line

If we want to keep our minds sharp and our memories strong, the evidence suggests that there is much we can do today. We can engage in regular aerobic exercise. We can eat a Mediterranean-style diet. We can work to learn new things and keep a positive mental attitude. And lastly, with a nod to this new research, we can pursue social activities, play games, and use computers from midlife onward, and engage in crafts in late life. Books, on the other hand, should be read whenever we are seeking knowledge, wisdom, enlightenment, or enjoyment.

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My Health - Kratom: Fear-worthy foliage or beneficial botanical?

Depending on what you read, kratom is a dangerous, addictive drug with no medical utility and severe side effects, including overdose and death, or it is an accessible pathway out of undertreated chronic pain and opiate withdrawal. How can the US Drug Enforcement Agency (DEA), media professionals, and millions of regular kratom users have such divergent views of the same plant?

What is kratom?

Kratom (Mitragyna speciosa) is a tropical tree from the coffee family native to Southeast Asia, with properties that range from stimulant-like, energizing and uplifting, to opiate-like, causing drowsiness and euphoria. Kratom has dozens of active components, which makes it difficult to characterize as one particular type of drug such as “stimulant” or “opiate.” The two main chemicals, mitragynine and 7-hydroxymitragynine, have strong activity at the main opioid receptor, the “mu” receptor, which is the same one stimulated by heroin and oxycodone. Kratom is commonly consumed orally, with added sweetener to overcome its harsh bitterness, made into tea or swallowed as a pill. Side effects can include agitation, tachycardia, drowsiness, vomiting, and confusion. There can also be grave side effects such as seizures, as well as respiratory and cardiac arrest.

Kratom can be found in gas stations and paraphernalia shops in most parts of the US, except in the handful of states and cities that have banned it. Many people purchase kratom over the Internet, where it is sold “for soap-making and aromatherapy” to avoid the fact that in 2014 the FDA made it illegal to import or manufacture kratom as a dietary supplement.

What are some of the problems with kratom?

There is little to no control or reliable information on the growth, processing, packaging, or labeling of the kratom sold in the US, which adds to the already considerable uncertainty of its health risks. In 2018 the FDA instituted a mandatory recall over concerns about Salmonella contamination of kratom-containing products. The DEA has recently placed kratom on its Drugs and Chemicals of Concern list, but has not yet labeled it as a controlled substance.

Kratom can be addictive due to its opiate-like qualities, and a small minority of users end up requiring addiction treatment. The CDC claims that between 2016 and 2017, there were 91 deaths due to kratom, but this claim should be greeted with skepticism, as all but seven of these casualties had other drugs in their system at the time of death, making it impossible to uniquely implicate kratom.

Why do people use kratom?

The DEA maintains that kratom has no medical uses or benefits, but in Asia kratom has been used for hundreds of years to treat cough, diarrhea, opiate withdrawal, and chronic pain, and to boost energy and sexual desire. More recently, in the US there has been an uptick in the use of kratom by people who are self-treating chronic pain and acute withdrawal from opiates and seeking alternatives to prescription medications. Despite a vocal community of supporters, and numerous anecdotal testimonials of effectiveness, these treatment practices using kratom have not been rigorously studied as either safe or effective.

A patient wishing to use kratom for pain or to mitigate withdrawal symptoms would encounter several problems, not all of which have to do with the intrinsic properties of kratom itself.

• First of all, the DEA is threatening to make it a Schedule 1 controlled substance, in the same category as heroin or methamphetamine, which would make it difficult to access, and would likely make the supply as a whole even more dangerous. Generally, it’s not a good idea to use something for pain or addiction which is about to become less available and less safe.
• Secondly, the complete lack of oversight or quality control in the production and sale of kratom makes its use potentially dangerous.
• Thirdly, kratom has not been well studied for any of the uses its proponents claim, though as the saying goes, “absence of evidence of benefit isn’t evidence of absence of benefit.”
• A final problem is that kratom doesn’t show up on drug screens, and one can argue that the wider adaptation of another potentially addictive opiate-like substance in the midst of an opiate epidemic is the last thing we need.

Is there a sensible path forward with kratom?

I’m not sure that anyone has the answer to this question. At bare minimum, safety could be improved with:

• Regulation: it would be safer if people knew the exact dosages they were consuming and that it was free of contamination.
• Education: educated consumers, who know the dangers and potential benefits, are far less vulnerable to misleading claims.
• Research: if it does have benefits for either addiction or chronic pain, we should know, and it is critical that we better define the risks of using kratom, so that people are more accurately informed.

If all of the above could somehow be accomplished, by scientists and public health specialists, without overdue distortion from corporate interests, antidrug ideology, and romanticism by kratom enthusiasts, we could then have enough clarity to answer the question: is kratom harmful or helpful?

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My Health - Are antibacterial products with triclosan fueling bacterial resistance?

When it comes to keeping clean, there could such a thing as too clean. I’ve posted before about how often people shower and whether showering daily might have a downside. It’s not just my opinion. Over five years ago, the FDA raised alarms about antibacterial soap and whether it might lead to more resistant bacteria. At the time, most liquid soaps and about a third of bar soaps contained triclosan, a powerful antibacterial drug that’s also found in mouthwash, makeup, toothpaste, cutting boards, and even mattress pads. For decades, these products have been marketed as cleaner or more hygienic, to exploit our aversion toward (or obsession about) germs and their potential to cause disease.

In 2013, the FDA told makers of antibacterial soaps to prove that their products are more effective than regular soap and water at preventing disease, or else take them off the market. Because no such proof ever came, the FDA proposed banning triclosan from liquid soaps in 2016. This year, the FDA announced the final rule on this ban, which will take full effect in April 2020.

New concerns about antibacterial products

A new study suggests that concerns about triclosan’s impact on bacterial resistance to antibiotics are well-founded. Researchers exposed bacteria to triclosan before administering antibiotics to find out whether bacterial resistance to antibiotics would increase. It did — dramatically. One in 10 bacteria exposed to triclosan managed to survive antibiotics versus one in a million bacteria that weren’t exposed to triclosan.

This may seem odd, since triclosan is specifically intended to kill bacteria. But there are two problems to consider when people try to eradicate bacteria. Most treatments — including triclosan — are not 100% effective. Some bacteria may survive regardless of how much you clean. And bacteria are very good at finding ways to resist antibiotics. In the fight against bacteria, it’s often true that what doesn’t kill them makes them stronger: the bacteria that survive may have a mutation that helped them do so. Those bacteria can then replicate into a resistant population of germs that don’t respond to antibiotics.

Now what?

Triclosan is banned from soap, but still allowed in other consumer products. We need to learn much more about the benefits — if any — as well as the risks and unintended consequences of using triclosan and other antibacterial agents.

Has the impulse to eradicate germs in our environment gone too far? In recent years, knowledge about the microbiome — the organisms that live within and around us — has exploded. And we’ve learned that in some situations, more bacteria (or the right mix of different types of bacteria) might actually be healthier than less bacteria.

An increasingly popular, although unproven, “hygiene hypothesis” suggests that the rising incidence of allergies, asthma, and perhaps other diseases is due, at least in part, to our efforts to keep our environments germ-free. The idea is that the less exposure we have to germs as our immune systems are developing, the more inappropriate or exaggerated our immune reactions may become.

What else is in hand sanitizers?

Alcohol is the major germ-killer in hand sanitizers now that triclosan has been removed. But there are also conditioners (since alcohol is quite drying to the skin), fragrances, and bitter additives (to discourage anyone from drinking the stuff). Similar additives are found in many cosmetics and other consumer products and are not known to be harmful.

Additionally, some hand sanitizers contain chemicals that turn them into a gel, so you can conveniently squirt a dab into your palm without making a mess or needing to get to a sink. After pushing a shopping cart that hundreds of people touched before you, a dollop of hand sanitizer is a convenient way to quickly and effectively clean your hands.

The bottom line: You should reallywash your hands

The FDA and other experts are now recommending we stick with alcohol-based hand sanitizers or soap and water, rather than more powerful antibacterial agents. But remember: when you wash your hands, really wash your hands! Cover all surfaces well and wash for 20 seconds or more. In one study of a public restroom, nearly 95% of people did not wash their hands long enough to be effective after using the restroom. This includes about 10% who did not wash at all. (Yes, researchers planted themselves inconspicuously near sinks to tally how often, how long, and whether people washed their hands to complete the study.)

The bottom line? Take the time to wash your hands well, especially when you’re touching surfaces many others have touched, or if you’re sick or around others who may be sick.

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