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Thursday, January 17, 2019

Going Mediterranean to prevent heart disease

Medical myths die hard. Maybe that’s because there’s no agreement on whether a common belief is indeed a myth.

For example, there’s the longstanding belief that weather affects arthritis pain. Many of my patients notice a clear connection; some are so convinced of the link, they believe they can predict the weather better than the TV meteorologists. And maybe that’s true.

But that’s not what the science says. A recent study finds no connection between rainy weather and symptoms of back or joint pain. This conclusion was based on a staggering amount of data: more than 11 million medical visits occurring on more than two million rainy days and nine million dry days. Not only was there no clear pattern linking rainy days and more aches and pains, but there were slightly more visits on dry days.

Still not convinced? That’s understandable. Maybe it’s not rain or shine that matters — maybe it’s barometric pressure, changes in weather, or humidity that matters most. Or maybe the study missed some key information, such as when symptoms began or got worse — after all, it can take days or even weeks after symptoms begin to see a doctor.
What does past research say about weather and arthritis pain?

The question of whether there’s a link between weather and aches and pains has been studied extensively. While a definitive answer is nearly impossible to provide — because it’s hard to “prove a negative” (prove that something doesn’t exist) — researchers have been unable to make a strong case for a strong connection.

For example, a 2014 study in Australia found no link between back pain and rain, temperature, humidity, or air pressure. This study collected data regarding features of the weather at the time of first symptoms, and compared it to the weather a week and a month before. But, an earlier study found that among 200 patients followed for three months, knee pain increased modestly when temperature fell or barometric pressure rose.
Does research matter when you have personal experience?

That’s a fair question. And it’s something I’ve even heard in TV commercials about headache medicines: “I don’t care about the research. I just know what works for me.” But it’s worth remembering that humans have a remarkable tendency to remember when two things occur or change together (such as wet, gloomy weather and joint pain), but remember less when things do not occur together. That rainy day when you felt no better or worse is unlikely to be so notable that you remember it. If you rely solely on memory rather than on more rigorous, data-based evidence, it’s easy to conclude a link exists where, in fact, none does.
There is a mountain of high-quality research supporting a Mediterranean-style diet as the best diet for our cardiovascular health. But what does this diet actually look like, why does it work, and how can we adopt it into our real lives?
What is a Mediterranean diet?

The Mediterranean diet is not a fad. It is a centuries-old approach to meals, traditional to the countries bordering on the Mediterranean Sea. The bulk of the diet consists of colorful fruits and vegetables, plus whole grains, legumes, nuts and seeds, fish and seafood, with olive oil and perhaps a glass of red wine. There is no butter, no refined grains (like white bread, pasta, and rice), and very little red or processed meat (like bacon). There is also an emphasis on sitting down and enjoying a meal among family and friends, as well as avoiding snacking, and getting plenty of activity. It’s not just about the food: it’s a way of being.
What’s a Mediterranean-style diet?

The food part is similar to most other healthful diet approaches in that it’s plant-based. And the recipes do not have to be Italian or Greek, which is why I refer to it as a Mediterranean-style diet. Every meal should have vegetables and fruits as the base. Any grains should be whole grain, like quinoa, brown rice, corn, farro, or whole wheat. Legumes are an excellent source of plant protein, things like lentils, garbanzo, kidney, cannellini, or black beans. Nuts and seeds have protein and healthy fats, and olive oil provides even more healthy fat. Including fish and seafood is traditional, but not required. I advise people not to stress about dairy, poultry, and eggs; these are okay in small amounts. A glass of wine a day may be beneficial, but not for everyone, and there is no reason for non-drinkers to take it up.
Why does this way of eating produce such impressive health benefits?

In a recent study published in JAMA Network Open, researchers looked at data from over 25,000 women over 45 (with an average age of 55) and with no history of heart disease.

Using the baseline dietary questionnaire, a Mediterranean diet “score” was calculated. Basically, there was one point given for each of these nine main components: higher than average intake of fruits, vegetables, whole grains, legumes, nuts, fish, and healthy fats; healthy level of alcohol intake; and lower than average intake of red and processed meats. Participants were divided into groups based on low, medium, and high Mediterranean diet consumption (scores of 0–3, 4–5, and 6–9).

After 12 years average follow-up time, 1,030 participants had some kind of serious cardiovascular issue (including heart attack, angina with stent placement, peripheral vascular disease requiring intervention, or stroke). The women in the medium and high Mediterranean diet groups had significantly lower risk (23% and 28% lower, respectively).

Higher Mediterranean diet scores were also associated with lower body mass index and blood pressure, as well as more optimal lab data like lower inflammatory markers (high-sensitivity CRP), lower diabetes risk (insulin resistance), and a better lipid profile (higher HDL). These findings suggest the pathways through which the diet benefits the body: by decreasing inflammation and promoting healthy blood cholesterol and sugar levels.
How to “go Mediterranean”

Adopting the Mediterranean diet in our busy, high-tech world may seem daunting. But there are tips and tricks to change your eating habits and reduce your risk of heart disease.

My book, Healthy Habits for Your Heart, teaches you the basics of behavior change, as well as step-by-step methods to make these changes happen in your real life. Chapter 5, “Eat For Your Life: Nutrition Habits” takes you through the science-backed recommendations for adopting a heart-healthy, plant-based Mediterranean-style diet. One suggestion is:
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Friday, January 4, 2019

Preterm birth and heart disease risk for mom

When I’m dragging and feeling tired during the occasional low-energy day, my go-to elixir is an extra cup (or two or three) of black French press coffee. It gives my body and brain a needed jolt, but it may not help where I need it the most: my cells.
The cellular basis of being tired

What we call “energy” is actually a molecule called adenosine triphosphate (ATP), produced by tiny cellular structures called mitochondria. ATP’s job is to store energy and then deliver that energy to cells in other parts of the body. However, as you grow older, your body has fewer mitochondria. “If you feel you don’t have enough energy, it can be because your body has problems producing enough ATP and thus providing cells with enough energy,” says Dr. Anthony Komaroff, professor of medicine at Harvard Medical School. You may not be able to overcome all aspects of age-related energy loss, but there are ways to help your body produce more ATP and replenish dwindling energy levels. The most common strategies revolve around three basic concepts: diet, exercise, and sleep.

Diet. Boost your ATP with fatty acids and protein from lean meats like chicken and turkey, fatty fish like salmon and tuna, and nuts. While eating large amounts can feed your body more material for ATP, it also increases your risk for weight gain, which can lower energy levels. “The excess pounds mean your body has to work harder to move, so you use up more ATP,” says Dr. Komaroff. When lack of energy is an issue, it’s better to eat small meals and snacks every few hours than three large meals a day, according to Dr. Komaroff. “Your brain has very few energy reserves of its own and needs a steady supply of nutrients,” he says. “Also, large meals cause insulin levels to spike, which then drops your blood sugar rapidly, causing the sensation of fatigue.”

Drink enough water. If your body is short on fluids, one of the first signs is a feeling of fatigue. Although individual needs vary, the Institute of Medicine recommends men should aim for about 15 cups (3.7 liters) of fluids per day, and women about 12 cups (2.7 liters). Besides water and beverages like coffee, tea, and juices, you can also get your fluids from liquid-heavy fruits and vegetables that are up to 90% water, such as cucumbers, zucchini, squash, strawberries, citrus fruit, and melons.

Get plenty of sleep. Research suggests that healthy sleep can increase ATP levels. ATP levels surge in the initial hours of sleep, especially in key brain regions that are active during waking hours. Talk with your doctor if you have problems sleeping through the night.

Stick to an exercise routine. Exercise can boost energy levels by raising energy-promoting neurotransmitters in the brain, such as dopamine, norepinephrine, and serotonin, which is why you feel so good after a workout. Exercise also makes muscles stronger and more efficient, so they need less energy, and therefore conserve ATP. It doesn’t really matter what kind of exercise you do, but consistency is key. Some research has suggested that as little as 20 minutes of low-to-moderate aerobic activity, three days a week, can help sedentary people feel more energized.
When being tired warrants a visit to your doctor

You should see your doctor if you experience a prolonged bout of low energy, as it can be an early warning of a serious illness. “Unusual fatigue is often the first major red flag that something is wrong,” says Dr. Komaroff. Lack of energy is a typical symptom for most major diseases, like heart disease, many types of cancer, autoimmune diseases such as lupus and multiple sclerosis, and anemia (too few red blood cells). Fatigue also is a common sign of depression and anxiety. And fatigue is a side effect of some medications.
If you delivered a baby early, you may want to pay closer attention to your heart health. A study published in the journal Hypertension shows that a history of preterm birth (defined as a birth before the 37th week of pregnancy) may bring health risks for not only for baby, but for mom, too.

The study found that women who delivered a baby preterm were more likely to experience rising blood pressures later, compared to women who delivered closer to term. If they had this pattern, they were also more likely to show signs of coronary artery disease, which is associated with an increased risk of heart attack and stroke.

Because of the unique demands that pregnancy places on a woman’s body, it may serve as a stress test for a woman’s heart, says Dr. JoAnn E. Manson, the Michael and Lee Bell Professor of Women’s Health at Harvard Medical School. Pregnancy-related conditions (for example, gestational diabetes and pre-eclampsia) are known to raise a woman’s risk of developing cardiovascular disease. Preterm birth should now join that list, says Dr. Manson.

“I think this study adds to the mounting evidence that preterm birth is yet another complication of pregnancy that indicates a higher risk of cardiovascular disease in the mother,” she says.
The association between early birth and heart disease risk

The study looked at data from more than 1,000 mothers in several major US cities. Researchers divided the women into three categories — “low stable,” “moderate,” and “moderate increasing” — based on how their systolic blood pressure (the first number in a reading) changed over time. Women who had what was defined as “moderate increasing” blood pressure were 19% more likely to have delivered a baby early than women with “low stable” blood pressure. In addition, more than 38% of the “moderate increasing” group developed coronary artery calcifications (a marker for higher risk of future heart attack), seen on CT heart scans, compared with 12.2% of the “low stable” group. Women who had both a preterm delivery and “moderate increasing” blood pressure had more than double the risk of developing arterial calcifications, compared with women who delivered at term and had a lower blood pressure pattern.

The associations researchers found were stronger in women who experienced high blood pressure conditions during pregnancy, but were also found in women who did not. Interestingly, women who had a “moderate increasing” blood pressure pattern but delivered a full-term baby didn’t seem to have excess risk for artery calcifications.

But not all preterm births bring the same potential heart risks. The study authors found that a preterm birth alone wasn’t enough to raise risk. That happened only when women had both a preterm birth and a pattern of increasing blood pressure in the years that followed. This may be the case because there are other factors that can result in a preterm birth, such as carrying twins or other multiples, or having a physical problem with the cervix, says Dr. Manson. For women with such conditions, a preterm delivery would not be expected to reflect higher cardiovascular risks, says Dr. Manson.
If you gave birth early, pay attention to all heart disease risk factors

Having a preterm birth or other pregnancy-related complications doesn’t mean you are doomed to develop cardiovascular disease. Steps you can take to reduce your risk include the following:

    Discuss your pregnancy history with your doctor. Your doctor should be aware that you delivered preterm and should also know about any other pregnancy-related complications you had, such as gestational diabetes or pre-eclampsia — and should understand that it may raise your risk for future heart disease.
    Track your blood pressure. “Your blood pressure should be monitored closely, at least once a year, and preferably more often,” says Dr. Manson. Self-monitoring using a blood pressure machine monthly at home might also help you spot troubling trends early. Blood pressure should ideally remain below 120/80 mm Hg. If it rises above that level, discuss it with your doctor.
    Maintain a healthy diet and lifestyle. It’s been said a million times before, but eating a well-balanced diet rich in fruits, vegetables, and whole grains can help head off cardiovascular disease. Avoid excess sodium, red meat, and heavily processed foods whenever possible. And of course, don’t smoke, and make time to squeeze in regular exercise.
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Understanding and improving core strength

It may not seem possible to be able to write your way to better health. But as a doctor, a public health practitioner, and a poet myself, I know what the scientific data have to say about this: when people write about what’s in their hearts and minds, they feel better and get healthier. And it isn’t just that they’re getting their troubles off their chests.

Writing provides a rewarding means of exploring and expressing feelings. It allows you to make sense of yourself and the world you are experiencing. Having a deeper understanding of how you think and feel — that self-knowledge — provides you with a stronger connection to yourself. It’s that connection that often allows you to move past negative emotions (like guilt and shame) and instead access positive ones (like optimism or empathy), fostering a sense of connection to others in addition to oneself.
Making connections is key

It’s remarkable that the sense of connection to others that one can feel when writing expressively can occur even when people are not engaged directly. Think of being at a movie or concert and experiencing something dramatic or uplifting. Just knowing that everyone else at the theater is sharing an experience can make you feel connected to them, even if you never talk about it. Expressive writing can have the same connecting effect, as you write about things that you recognize others may also be experiencing, even if those experiences differ. And if you share your writing, you can enhance your connection to someone else even more. That benefit is energizing, life-enhancing, and even lifesaving in a world where loneliness — and the ill health it can lead to — has become an epidemic.

Maybe it’s time to pay greater attention to expressive writing as one important way to enhance a sense of connection to others. Social connection is crucial to human development, health, and survival, but current research suggests that social connection is largely ignored as a health determinant. We ignore that relationship at our peril, since emerging medical research indicates that a lack of social connections can have a profound influence on risk for mortality, and is associated with up to a 30% risk for early death — as lethal as smoking 15 cigarettes a day. Social isolation and loneliness can have additional long-term effects on your health including impaired immune function and increased inflammation, promoting arthritis, type 2 diabetes, cancer, and heart disease.
How expressive writing battles loneliness

Picking up a pen can be a powerful intervention against loneliness. I am a strong believer in writing as a way for people who are feeling lonely and isolated to define, shape, and exchange their personal stories. Expressive writing, especially when shared, helps foster social connections. It can reduce the burden of loneliness among the many groups who are most at risk, including older adults, caregivers, those with major illnesses, those with disabilities, veterans, young adults, minority communities of all sorts, and immigrants and refugees.

Writing helps us to operate in the past, present, and future all at once. When you put pen to paper you are operating in the present moment, even while your brain is actively making sense of the recalled past, choosing and shaping words and lines. But the brain also is operating in the future, as it pictures a person reading the very words you are actively writing. When expressing themselves in writing, people are actually creating an artifact — a symbol of some of their thoughts and feelings. People often can write what they find difficult to speak, and so they explore deeper truths. This process of expression through the written word can build trust and bonds with others in unthreatening ways, forging a path toward a more aware and connected life.

When people tell their personal stories through writing, whether in letters to friends or family, or in journals for themselves, or in online blog posts, or in conventionally published work, they often discover a means of organizing and understanding their own thoughts and experiences. Writing helps demystify the unknown and reduce fears, especially when we share those written concerns with others.
Write for your health

As a poet, I’ve personally experienced the benefits of expressive writing. The skills it sharpens; the experience of sharing ideas, feelings, and perceptions on a page; the sensations of intellectual stimulus and emotional relief — all are life enhancing. I’d like more people to discover that expressive writing can contribute to well-being, just as exercise and healthful eating do.

I’ve documented some of the research being done in the area of healing and the arts. After reviewing more than 100 studies, we concluded that creative expression improves health by lowering depression and stress while boosting healthy emotions. So pick up a pen, and start to write creatively. For the mind and the body, writing is a strong prescription for good health.
The rate of type 2 diabetes is increasing around the world. Type 2 diabetes is a major cause of vision loss and blindness, kidney failure requiring dialysis, heart attacks, strokes, amputations, infections and even early death. Over 80% of people with prediabetes (that is, high blood sugars with the high risk for developing full-blown diabetes) don’t know it. Heck, one in four people who have full-blown diabetes don’t know they have it! Research suggests that a healthy lifestyle can prevent diabetes from occurring in the first place and even reverse its progress.
Can a healthy diet and lifestyle prevent diabetes?

The Diabetes Prevention Program (DPP), a large, long-term study, asked the question: we know an unhealthy diet and lifestyle can cause type 2 diabetes, but can adopting a healthy diet and lifestyle prevent it? This answer is yes: the vast majority of prediabetes and type 2 diabetes can be prevented through diet and lifestyle changes, and this has been proven by 20 years of medical research.

Researchers from the DPP took people at risk for type 2 diabetes and gave them a 24-week diet and lifestyle intervention, a medication (metformin), or placebo (a fake pill), to see if anything could lower their risk for developing diabetes. The very comprehensive diet and lifestyle intervention had the goal of changing participants’ daily habits, and included: 16 classes teaching basic nutrition and behavioral strategies for weight loss and physical activity; lifestyle coaches with frequent contact with participants; supervised physical activity sessions; and good clinical support for reinforcing an individualized plan.

Perhaps not surprisingly, the diet and lifestyle intervention was incredibly effective. After three years, the diet and lifestyle group had a 58% lower risk of developing diabetes than the placebo group. Participants aged 60 and older had an even better response, with a whopping 71% lower risk of developing diabetes. The diet and lifestyle effect lasted: even after 10 years, those folks had a 34% lower risk of developing diabetes compared to placebo. Men, women, and all racial and ethnic groups had similar results (and almost half of participants represented racial and ethnic minorities). These results are not surprising to me or to other doctors, because we have all seen patients with prediabetes or diabetes get their sugars down with diet, exercise, and weight loss alone.

Meanwhile, the medication group had a 31% lower risk of diabetes after three years, and an 18% lower risk after 10 years, which is also significant. It’s perfectly all right to use medications along with diet and lifestyle changes, because each boosts the effect of the other. Studies looking at the combination of medication (metformin) with diet and lifestyle changes have shown an even stronger result.
Dietary recommendations to prevent diabetes (and even reverse it)

    Decrease intake of added sugars and processed foods, including refined grains like white flour and white rice. This especially includes sugary drinks, not only sodas but also juices. The best drinks are water, seltzer, and tea or coffee without sugar.
    Swap out refined grains for whole grains. Whole grains are actually real grains that haven’t been stripped of nutrients in processing. Foods made from 100% whole grain (like whole wheat) are okay, but intact whole grains (like farro, quinoa, corn, oatmeal, and brown rice) are even better. Swapping out grains for starchy veggies (like potatoes) is also okay, as long as these veggies aren’t in the form of french fries!
    Increase fiber intake. High-fiber foods include most vegetables and fruits. Legumes are also high in fiber and healthy plant protein. Legumes include lentils, beans, chickpeas, peas, edamame, and soy. People who eat a lot of high-fiber foods tend to eat fewer calories, weigh less, and have a lower risk of diabetes.
    Increase fruits and vegetables intake. At least half of our food intake every day should be non-starchy fruits and vegetables, the more colorful the better. Cruciferous vegetables like broccoli, cauliflower, and Brussels sprouts, and high-fiber fruits like berries of all kinds, are especially healthy. All fruits and vegetables are associated with living a significantly longer and healthier life!
    Eat less meat, and avoid processed red meat. Many studies have shown us that certain meats are incredibly risky for us. People who eat processed red meat are far more likely to develop diabetes: one serving a day (which is two slices of bacon, two slices of deli meat, or one hot dog) is associated with over a 50% higher risk of developing type 2 diabetes. Eating even a small portion of red meat daily (red meat includes beef, lamb, and pork), like a palm-sized piece of steak, is associated with a 20% increased risk of type 2 diabetes. This may be because of the iron in red meats, and the chemicals in processed meats. As a matter of fact, the less meat you eat, the lower your risk of diabetes. People who don’t eat red meat at all, but do eat chicken, eggs, dairy, and fish, can significantly lower their risk of developing type 2 diabetes, by about 30%; those who eat only fish, 50%; those who eat only eggs and dairy, 60%; those who are vegan, 80%.
    Eat healthier fats. Fat is not necessarily bad for you. What kind of fat you’re eating really does matter. Saturated fats, particularly from meats, are associated with an increased risk of diabetes and heart disease. Plant oils, such as extra-virgin olive oil and canola oil, carry less risk. Omega-3 fats, like in walnuts, flax seeds, and some fish, are actually quite good for you.

Diet and lifestyle changes that can help prevent diabetes

Diet and lifestyle changes are so effective for diabetes prevention that as of April 2018, insurance companies are now covering these programs for people at risk. The CDC’s Diabetes Prevention Program, used in many clinics, is a free tool to help you learn and stick with the healthy diet, physical activity, and stress management techniques that reduce your risk of diabetes.

One helpful tool is the Harvard School of Public Health Nutrition Source Healthy Eating Plate, which shows you what your daily food intake should look like: half fruits and vegetables, about a quarter whole grains, and a quarter healthy proteins (plant protein is ideal here), with some healthy fats and no-sugar-added beverages. The Harvard Health Blog also offers many articles with recipes and cooking videos to help you create a healthier, diabetes-free lifestyle. When most people think about core strength, they think about an abdominal six-pack. While it looks good, this toned outer layer of abdominal musculature is not the same as a strong core.
What is the “core” and why is core strength so important?

The core is a group of muscles that stabilizes and controls the pelvis and spine (and therefore influences the legs and upper body). Core strength is less about power and more about the subtleties of being able to maintain the body in ideal postures — to unload the joints and promote ease of movement. For the average person, this helps them maintain the ability to get on and off the floor to play with their children or grandchildren, stand up from a chair, sit comfortably at a desk, or vacuum and rake without pain. For athletes, it promotes more efficient movement, therefore preventing injury and improving performance. Having a strong or stable core can often prevent overuse injuries, and can help boost resiliency and ease of rehab from acute injury. The core also includes the pelvic floor musculature, and maintaining core stability can help treat and prevent certain types of incontinence.
The problem with a weak core

As we age, we develop degenerative changes, very often in the spine. The structures of the bones and cartilage are subject to wear and tear. Very often, we are able to completely control and eliminate symptoms with the appropriate core exercises. Having strong and stable postural muscles helps suspend the bones and other structures, allowing them to move better. Scoliosis, a curving or rotation of the spine, can also often be controlled with the correct postural exercises. Having an imbalanced core can lead to problems up and down the body. Knee pain is often caused by insufficient pelvic stabilization. Some runners develop neck and back pain when running because the “shock absorbers” in their core could use some work.
Finding the right core strengthening program for you

A good core program relies less on mindless repetition of exercise and focuses more on awareness. People with good core strength learn to identify and activate the muscles needed to accomplish the task. Learning to activate the core requires concentration, and leads to being more in tune with the body.

There is no one method of core strengthening that works for everyone. Some people do well with classes (though it can be easy do the repetitions without truly understanding the targeted muscle groups). Others use Pilates or yoga to discover where their core is. Physical therapists are excellent resources, as they can provide one-on-one instruction and find a method that works for any person with any background at any ability level. It sometimes takes patience for people to “find” their core, but once they do, it can be engaged and activated during any activity — including walking, driving, and sitting. While building the core starts with awareness and control, athletes can further challenge their stability with more complex movements that can be guided by athletic trainers and other fitness specialists.
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Orthorexia: The extreme quest for a healthy diet

One of the best parts of being a geriatrician (a specialist caring for older adults) is to meet individuals who are aging successfully, taking care of themselves, and taking their health seriously. Well-informed individuals usually like to know if their chronic health conditions are well controlled or not.

With improved public education, it is now common knowledge that uncontrolled diabetes leads to damage to the major organs of the body, such as the heart, kidneys, eyes, nerves, blood vessels, and brain. So, it is important to ask how tightly blood glucose (also called blood sugar) should be controlled to decrease the risk of harm to these organs.
Blood sugar: too high, too low, or just right?

To answer this question, first let’s discuss how diabetes is different than other chronic health conditions. For example, a doctor can tell you that your cholesterol levels need to be below a certain number to lower the risk of heart disease. Diabetes is different. Diabetes is a unique condition in which both high and low glucose levels are harmful to the body.

Diabetes control is measured as A1c, which reflects average blood sugar levels over the past two to three months. High glucose levels (A1c levels greater than 7% or 7.5%) over a long period can cause damage to the major organs of the body. However, medications and insulin that are used to lower glucose levels can overshoot and lead to glucose levels that are too low. Low glucose levels (known as hypoglycemia) can result in symptoms such as rapid heartbeat, excessive sweating, feeling dizzy, difficulty thinking, falling, or even passing out.

So, both high and low glucose levels are harmful. Thus, diabetes management requires balancing the risk of high and low glucose levels, and requires constant assessment to see which of these glucose levels is more likely to harm an individual patient.
Different blood sugar goals over a lifetime

The next consideration in answering the question about tight glucose control is to understand why younger and older adults need different goals. In younger individuals, longer life expectancy means a higher risk of developing complications over many decades of life. Younger adults typically recover from hypoglycemic episodes without severe consequences.

On the other hand, people in their 80s or 90s may not have several decades of life expectancy, and so the concern about developing long-term complications due to high glucose levels is decreased. However, hypoglycemia in these individuals may lead to immediate consequences such as falls, fractures, loss of independence, and subsequently a decline in quality of life. In addition, tighter control of diabetes frequently requires complicated treatment regimens, such as multiple insulin injections at different times of the day or a variety of glucose lowering pills. This further increases the risk of hypoglycemia, as well as stress, to both older patients and their caregivers at home.
Identifying the “why” of blood sugar control

Thus, when considering goals for blood glucose in older adults, it is important to ask why we are managing diabetes. As the reason to tightly control diabetes is to prevent complications in the future, tighter control of diabetes could be a goal in an older adults who are in good health and have few risk factors for hypoglycemia. Hypoglycemia risk factors include previous history of severe hypoglycemia that required hospital or emergency department visits, memory problems, physical frailty, vision problems, and severe medical conditions such as heart, lung, or kidney diseases.

In older individuals with multiple risk factors for hypoglycemia, the goal should not be tight control. Instead, the goal should be the best control that can be achieved without putting the individual at risk for hypoglycemia.

Lastly, it is important to remember that health status is not always stable as we get older, and the need or the ability to keep tight glucose control may change over time in older adults. Goals for all chronic disease, not just blood sugar control, need to be individualized to adapt to the changing circumstances associated with aging.
The pursuit for the healthiest diet continues. Just as I was finishing writing this blog post, a new study came out suggesting that both low-carb and high-carb diets may shorten lifespan. In the 1980s and ‘90s, we were following the low-fat trend. These days, the ketogenic diet and the very-low-carb diet are all the rage. And if you think there is controversy about the right amount of carbohydrates, fats, and proteins you should eat, the conversation can get downright ugly if we start talking about specific items like gluten. Research continues to look for insight into the best diet for humans. But the relentless focus on diet and health may lead some people to obsessively seek a perfect “utopian” diet, a condition called orthorexia.
The difference between healthy eating and orthorexia

Orthorexia, although not yet recognized as a disease, is the obsessive fixation on healthy food and healthy eating. People with orthorexia are often on a stringent diet and may have anxiety about how much they eat, how certain foods are prepared, and where those foods came from. This behavior has hints of obsessive-compulsive disorder and anorexia nervosa. Some people feel very guilty if they do not follow the rigid plans they originally designed to have a healthy diet. Their lives are too focused on healthy eating, and they hardly ever have dinner with friends. They prefer starvation to eating “impure” foods. The result is social isolation and hours spent preoccupied and anxious about what to eat. It is important to note that people who choose to eat a specific diet for religious or environmental reasons, or to protect animal welfare and agricultural sustainability, are not considered to have orthorexia.
Cultural shifts about healthy eating

Growing up in the ‘80s, I hardly knew anyone who had dietary restrictions. Today it is very common to know people who strictly avoid certain foods. There are several theories to explain this new phenomenon: exposure to more toxins and chemical products in our foods; the advent of genetically modified organisms; the modern, more hygienic way of living (which is also blamed for the rise of allergies, asthma, and autoimmune diseases). But others think it may be partially related to the increased recognition and awareness of healthier habits and the significant influence of social media, blogs, health magazines, and clinicians who pontificate ideas of what is right and wrong in the nutritional world. All these factors, added to the avalanche of contradictory studies published almost daily about what we should eat, create the perfect storm for those who may have anxiety about health and avoiding illness.
When the quest for a healthy diet leans toward orthorexia

For those who have documented medical reasons to do so (for example, food allergies or celiac disease), a restricted diet is essential and sometimes lifesaving. But if you do not have much reason to support a restricted diet, and a rigid eating pattern negatively impacts your life and relationships with friends and family, consider looking for medical help, ideally a mental health clinician with whom you can talk about your concerns and underlying fears. Relaxation training, behavior modification strategies, and medications may also help with obsessive and compulsive thoughts. Try to avoid reading blogs and books from people who have radical opinions regarding specific food items. The information era has brought great advancement in publicizing tips about a healthy lifestyle, but the broadcast of extreme views may not be so healthy. Of course, eating a lot of sugar, flour, and red meat every day, all day, will not help you live a long and healthy life, but it doesn’t mean you can never touch them.

Most of the population will never need to avoid specific foods. If you suspect you might have a problem with a specific food item, before you make a final decision about eliminating it, first consult with your doctor. The aspiration to eat a healthy diet is not a problem in itself, but when these thoughts are excessive it may undermine the original goal. Food is one of the great pleasures in life; it is connection, it is culture, it is something to cherish. We should avoid going overboard toward notoriously unhealthy items, but we should be able to eat the most comprehensive diet possible. For most of us, eating nutritionally dense whole foods, mostly vegetarian and non-processed, rarely causes problems.
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Thursday, January 3, 2019

Alcohol and your health: Is none better than a little?

I was called to your room in the middle of an overnight shift. There you were, breathing quickly, neck veins bulging and oxygen levels hovering despite the mask on your face. I placed my stethoscope on your back and listened to the cacophony of air struggling to make its way through your worsening pneumonia.
“We’re going to place a tube down your throat to help you breathe,” I told you.
Your eyes were pleading, scared. “We’ll put you to sleep. It’ll help you breathe more comfortably. Okay?”
You nodded. You had already told the doctors who cared for you during the day that if your breathing worsened, you would agree to intubation to allow more time to treat your pneumonia. So I called for the anesthesiologists. Minutes later, you were sedated and intubated, silenced — maybe forever.
I thought about you recently, when I read a poignant Perspective in JAMA Internal Medicine: “Saving a Death When We Cannot Save a Life in the Intensive Care Unit.” In this piece, critical care doctor Michael Wilson relates the story of a woman in the ICU who was electively intubated for a procedure and then died, without ever having had the opportunity for her loved ones to say goodbye.
Fueled by his feelings of regret over this and similar cases, Wilson argues for a different approach to intubation, which he likens to the talk a parent has with a child who is going off to war. Of course, these parents hope their children will come back safely, but they are given the chance to say what they want to say — knowing the conversation might be their last. Wilson suggests that we might build a similar pause into our protocols before intubation, lest we unwittingly deprive our patients of the opportunity for a final exchange with their loved ones. “Stealing the opportunity for meaningful last words is precisely the kind of avoidable complication that ought to be visible to us in the ICU,” Wilson writes. “My intubation checklist now includes this step.” In doing so, Wilson suggests that we might be able to “save a death” even if we are ultimately unable to save a life.
Reading this piece, I’m left with the image of Wilson’s patients — both the one who never had the chance to say goodbye, and another woman he describes who was given the chance to say “I love you” to her husband — and also of my own patients. It is too easy, in the heat of the moment, to forget that this patient before us is a person. How many times have I decided on intubation, ordered the appropriate medications, prepared for complications, but not taken pause to allow my patient to talk to a loved one?
I only took care of you for the night, as the physician on call. Though I remember your face, I do not remember your name and I don’t know what happened to you. Maybe the breathing tube came out in a day or two, and you were able to talk to your family once again. Or maybe it did not. Maybe your pneumonia worsened and you died, there in our ICU. It has been months since that night, and I can’t know. But I do wish, now, that I had paused and given you that chance. Well, it seems as though not even a week can go by without more data on aspirin! I recently reviewed the ARRIVE trial and the implications for primary prevention — that is, trying to prevent heart attacks and strokes in otherwise healthy people. Since then, yet another large clinical trial — the ASPREE study — has come out questioning the use of aspirin in primary prevention. Three articles pertaining to this trial were published in the prestigious New England Journal of Medicine, which is an unusual degree of coverage for one trial and highlights its immediate relevance to clinical practice.
Aspirin still strongly indicated for secondary prevention

Nothing about any of the new aspirin data, including ASPREE, pertains to secondary prevention, which refers to use of aspirin in patients with established cardiovascular disease. Examples include a prior heart attack or certain types of stroke, previous stents or bypass surgery, and symptomatic angina or peripheral artery disease. In general, in patients with a history of these conditions, the benefits of aspirin in reducing cardiovascular problems outweigh the risks. Chief among these is a very small risk of bleeding in the brain, and a small risk of life-threatening bleeding from the stomach.
ASPREE study suggests no benefit from aspirin in primary prevention

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

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

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

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

However, there are likely select healthy patients who have a very high risk of heart attack based on current smoking, family history of premature heart attacks, or very elevated cholesterol with intolerance to statins, for example, who might benefit. Therefore, the decision to start aspirin should involve a detailed discussion with your physician as part of an overall strategy to reduce cardiovascular risk. If you are already taking aspirin for primary prevention, it would be a good idea to meet with your physician and see if you might be better off stopping. Surprisingly, one of the most controversial areas in preventive medicine is whether or not people without known cardiovascular disease should take a daily aspirin for primary prevention. That is, should you take aspirin to reduce the risk of heart attack, unstable angina, stroke, transient ischemic attack, or death from cardiovascular causes? You would think that we would know the answer by now for a medicine as commonly used as aspirin.
Aspirin has unquestioned benefit for secondary prevention

Before considering the impact of aspirin in people without cardiovascular disease, it is first important to clarify uses for aspirin that are not up for debate. In people who have had a heart attack or certain types of stroke, the use of aspirin to prevent a second event — potentially a fatal one — is firmly established. These uses of aspirin are called secondary prevention. Similarly, in people who have had stents or bypass surgery, lifelong daily aspirin is typically warranted. While there is a very small risk that aspirin can cause bleeding in the brain, and a small risk it can cause life-threatening bleeding such as from the stomach, in general the risks are worth it in the setting of secondary prevention.
ARRIVE study suggests no benefit from aspirin in primary prevention

Primary prevention refers to trying to prevent the first event, such as heart attack or stroke (or dying from these causes). In this setting, the actual risks of a cardiovascular event are much lower, though the bleeding risks persist. Therefore, the margin of potential benefit is much more narrow.

Recently in Munich, at the European Society of Cardiology conference — now the world’s largest cardiology meeting — important results pertaining to aspirin in primary prevention arrived in the form of the ARRIVE trial. This clinical trial randomized over 12,000 patients to either 100 milligrams (mg) of coated aspirin daily or to a placebo (a blank). Overall, after an average of five years of following these patients, the trial did not show a significant benefit for aspirin, though there was a significant increase in gastrointestinal bleeding. There were no significant differences in the rates of deaths, heart attacks, or strokes.

Digging a bit more deeply into the results, the enrolled patients ended up being at much lower cardiovascular risk than the researchers had intended. Thus, it is possible that in a higher-risk population with a greater rate of cardiovascular events, aspirin may have been useful. Furthermore, many patients stopped taking their aspirin, diluting the potential to see a benefit. In patients who actually took their assigned aspirin, there was in fact a significant reduction in the rates of heart attack. However, these types of “on treatment” analyses should be viewed cautiously, as it would of course exclude patients who had bleeding complications or other side effects that may have led to aspirin discontinuation.

Aspirin is not currently labeled for use in primary prevention. In fact, based on trials prior to ARRIVE, the US FDA did not feel the data were robust enough to give aspirin this indication for use. It seems unlikely that they will change that opinion on the basis of ARRIVE.

One notable group excluded from ARRIVE was people with diabetes. A separate randomized trial called ASCEND was presented at the European Society of Cardiology conference. This study did find a significant reduction in adverse cardiovascular outcomes with daily aspirin in people with diabetes, though there was also a similar magnitude of increased major bleeding. Still, many people would rather be hospitalized for bleeding and get a transfusion versus being hospitalized for a heart attack that causes permanent damage to the heart. Others may not see much difference between the two types of events and may prefer not to take an additional medication.
Should you take a daily aspirin?

So, where does this leave the average person who is worried about a heart attack and wants to do everything they can to reduce that risk? Again, for people with cardiovascular disease — secondary prevention — nothing about ARRIVE pertains to you. For otherwise healthy people at elevated risk for heart disease or stroke, make sure not to smoke, maintain a healthy weight and diet, and control elevated blood pressure and cholesterol with medications if needed. If you have diabetes, make sure that is controlled with diet and medications if diet alone is insufficient.

The decision to start daily aspirin in otherwise healthy people is quite complex, with potential benefits and actual risks that on average are rather similar. Serious bleeding may occur. Online risk calculators (such as www.cvriskcalculator.com) might be somewhat useful in more objectively calculating the degree of cardiovascular risk. However, in the absence of diabetes, most otherwise healthy people should probably not be taking a daily aspirin to prevent heart attacks.

In the future, if randomized evidence supports it, imaging tests that gauge the degree of silent atherosclerosis (plaque buildup in the arteries that is not causing symptoms) may help decide if a patient should be reclassified from primary to secondary prevention. Other analyses from the large ASPREE trial are ongoing, should report soon, and may further tip the scales. For now, healthy people without atherosclerosis should not just take aspirin on their own without consulting their doctor first.
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Conflict of interest in medicine

Just the idea of packing a lunch elicits a stress response in so many of us. Maybe we’re packing lunch for our kids, maybe it’s for us, but the pressure is on to create a simple yet satisfying, healthy yet hearty, easily transportable meal. This seemingly impossible task is daunting to many people. So much easier to rely on the school cafeteria, lunch trucks, and takeout, right?

Wrong! Let us consider the short- and long-term effects of poor choices at lunchtime. Yes, the school cafeteria may offer some healthy-ish options. I can count on my kids not to choose any of them. Likewise our workplace food trucks and fast food/delivery services: it’s a dietetic disaster out there, folks, and not packing a lunch is akin to heading out to the battlefield in a bathing suit.

My kids would eat mostly carbs, fats, and sugars, if given the chance, and their trays would be piled with pizza, pasta, burgers, hot dogs and fries, chips, juice, and dessert. The downtown lunch scene features pretty much the same choices. Almost all options include refined grains and added sugars, foods with a high glycemic index and load. These will cause a spike in blood sugar, which triggers a surge in insulin. The insulin grabs all that sugar and brings it to the fat cells to be stored away, causing a nice late-afternoon blood sugar crash.

Studies show that people who eat meals prepared at home, including brown-bag lunches, tend to consume significantly more fruits and vegetables and have a lower body mass index than those who do not. If we pack a lunch, we can make better choices: a meal higher in fiber, protein, complex carbohydrates, and healthy fats has a lower glycemic index and load, and will keep our blood sugar steady — no crash! So in the short term, we can be productive through the afternoons. A little planning goes a long way: in the long term, studies show that a healthier diet is associated with improved cognition through the elder years.
How to build a healthy lunch

There’s a basic formula to follow: Primarily plants (actual fruits and vegetables) and protein (like legumes, lentils, tofu, seafood, chicken), with some complex carbohydrates (think: whole grains) and healthy fats (think: nuts and nut butters, seeds and seed butters, avocado, healthy oils).

If the bulk of the meal is plants, like actual fruits and vegetables, you’ll get plenty of fiber. Protein and healthy fats are satisfying. If you include whole grains, you’ll get complex carbohydrates. All of these are absorbed slowly, preventing that blood sugar spike and crash (and also inhibiting fat formation).

But what do these healthy options look like? Below are some simple lunches that follow the basic formula, and that our family actually eats.

Everyone loves dipping and stacking their food, not just kids — this is why those prepackaged boxes of processed food sell so well. So we make our own healthy versions of these with things that can be simply thrown into a “bento box”-style container, without requiring much prep. Here are a number of suggestions that are easy, inexpensive, require slicing at most, and travel well:

Build-Your-Own Gourmet Pizza: Sliced cherry tomatoes; mozzarella cheese; fresh basil; marinara sauce; mini whole-wheat pita breads or pizza dough rounds; orange sections.

Nacho Lunch Muncher: Strips of bell peppers; pinto beans; slices of cheddar cheese; whole-grain chips; low-sodium salsa; sliced peaches.

Breakfast-As-Lunch Box: Sliced strawberries and fresh raspberries, blackberries, and/or blueberries; healthy yogurt; sliced almonds or unsalted sunflower seeds; low-sugar granola or toasted oats cereal.

Hummus Dipper: Carrot sticks and bell pepper strips; container of hummus; whole-grain crackers; unsalted pistachios; apple slices tossed with cinnamon.

Deconstructed Tuna Sandwiches: Cucumber slices; container of tuna salad (tuna, lemon juice, touch of mayo); whole-grain bread squares or crackers; cantaloupe chunks.

Nut Butter Dips and Mini-Wraps: Apple and banana slices (spritz with lemon juice to prevent browning); small container of almond, cashew, peanut, or sunflower seed butter; raisins; whole-wheat wrap cut into fourths. On the surface, your own brain may be your furthest consideration when you are trying to improve your relationships. Yet it is the very place that processes where you perceive, understand, remember, evaluate, desire, and respond to people.

The somewhat bizarre fact of life is that the people who are in our lives are not simply who they actually are. They are some interesting mix of who they are and what we make of them in our brains. If we understand the ways in which relationships impact our brains, we can likely change our brains to alter the ways in which we interact with others too.
Transference

Transference is a psychological phenomenon in which conversational or relational partners activate earlier memories. As a result, we may unconsciously repeat conflicts from the past that have nothing to do with the current relationship.

For instance, you may be having an off day and may be a little short with a colleague. The colleague may snap at you in a way that is out of proportion to your actual interaction, since your manner may remind them of a conflictual and bossy relationship earlier in their lives. These kinds of knee-jerk responses occur in the brain due to the brain’s propensity to make non-conscious predictions based on early life experiences. They may be unwarranted, but we are usually not aware of them.

What you can do: To prevent this kind of situation, introduce new self-reflections, and possibly even points of discussion when you find yourself engaged in a conflict. Ask yourself, “Am I responding to this person, or am I mixing them up with someone from the past?” This can also make for an interesting discussion when you are trying to resolve a conflict.
Emotional contagion

Our emotions can be easily transferred to another person without us even knowing about this. This can also happen through large-scale social networks without in-person interactions or nonverbal cues.

Interact with a disgruntled group online, and you are likely to feel disgruntled as well. On the other hand, interacting with a positive group will probably make you feel more positive. Often, our negative emotions such as anger are transferred more easily than positive ones. It’s meant to be to our evolutionary advantage to be able to pick up emotions that quickly, but sometimes it can interfere with relationship dynamics. The culprits responsible for this contagion in the brain are called mirror neurons. They are specialized to automatically pick up the emotions of others.

What you can do: When you are interacting online, ensure that you know that whatever content you are consuming is likely to impact your mood. Be judicious about this depending on what you want to feel.

In interactions with friends, colleagues, or romantic partners, be aware that their negative emotions could throw you into a negative state, even if you do not actually feel negative. Many a fearful dating partner has turned off the other person automatically because they somehow start to feel afraid as well.

Be aware when your partner or colleague “makes” you angry. You may not actually be angry with them, but instead, mistaking their anger for yours when your brain reflects their feeling states.
Cognitive empathy

When you are trying to negotiate with someone, you may think it helpful to reflect their emotions, but this emotional empathy could backfire. In most instances, it’s far more effective to use cognitive empathy instead. When you use cognitive empathy, the other person becomes less defensive and feels heard too. While there is some overlap, cognitive empathy activates a mentalizing network in the brain, which differs from the emotional mirroring mechanisms of emotional empathy.

What you can do: When trying to resolve a conflict, try using cognitive empathy rather than emotional empathy to resolve the conflict. This means that you reflect on what they are saying, and then neutrally paraphrase what they are saying or intending. Paraphrasing can actually decrease their anger and reactivity. It’s a form of cognitive empathy, indicating that you are able to walk in their shoes.

Changing your own brain’s automatic reactions can help you navigate relationships more effectively. By knowing when to examine and explore transference, emotional empathy, and cognitive empathy in different situations, relationships have the potential to deepen too. For many people receiving care in a hospital or emergency room, one of the most common occurrences (and biggest fears) is getting an IV, the intravenous catheter that allows fluids and medications to flow into a vein in your arm or hand.

A trained health professional puts in an IV by sticking a needle that’s inside a thin tube (catheter) through the skin into a vein. Once inside the vein, the needle is removed. The catheter is left in the vein and taped down to keep it from moving or falling out. While IV lines are typically painless, the initial needle stick can be quite painful, especially for those who are a “difficult stick” (when the needle misses the vein, requiring multiple attempts).

IVs can be medically needed when the digestive system isn’t working well, to receive more fluids than you’re able to drink, to receive blood transfusions, to get medication that can’t be taken by mouth, and for a host of other treatments. In cases of massive bleeding, overwhelming infection, or dangerously low blood pressure, IV treatments can dramatically increase the chances of survival.
Drip bars: IVs on demand

And this brings us to a relatively new trend: the option to receive IV fluids even when it’s not considered medically necessary or specifically recommended by a doctor. In many places throughout the US, you can request IV fluids and you’ll get them. A nurse or physician’s assistant will place an IV catheter in your arm and you’ll receive IV fluids right at home, in your office, or at your hotel room. There’s even a mobile “tour bus” experience that administers the mobile IV hydration service. Some services offering IV hydration include a “special blend of vitamins and electrolytes,” and, depending on a person’s symptoms (and budget), an anti-nausea drug, a pain medication, heartburn remedies, and other medications may be provided as well.

And no, it’s not covered by your health insurance — more on the cost in a moment.
Why would anyone do this?

When I first heard about this, that’s the question I asked. Why, indeed? People may seek out IV fluids on demand for:

    hangovers
    dehydration from the flu or “overexertion”
    food poisoning
    jet lag
    getting an “instant healthy glow” for skin and hair

Many of the early adopters of this new service have been celebrities (and others who can afford it) including Kate Upton, Kim Kardashian, Simon Cowell, and Rihanna. Or so I’ve read.
Are IV fluids effective or necessary for these things?

Some people who get the flu (especially the very young and very old) need IV fluids, but they’re generally quite sick and belong in a medical facility. Most people who have exercised a lot, have a hangover, jet lag, or the flu can drink the fluids they need. While I’m no beauty expert, I doubt that IV fluids will improve the appearance of a person who is well-nourished and well-hydrated to start with.

And it’s worth emphasizing that the conditions for which the IVs-on-demand are offered are not conditions caused by dehydration or reversed by hydration. For example, jet lag is not due to dehydration. And while oral fluids are generally recommended for hangover symptoms (among other remedies), dehydration is not the only cause of hangover symptoms.

Finally, there’s a reasonable alternative to IV fluids: drinking fluids. If you’re able to drink fluids, that’s the best way to get them. If you’re too sick to drink and need rehydration, you should get care at a medical facility.
Is it worth going to a drip bar?

I’ll admit I’m skeptical. (Could you tell?) It’s not just that I’m a slow adopter (which is true) or that I’m dubious of costly treatments promoted by anecdotes on fancy websites (which I am). What bothers me is the lack of evidence for an invasive treatment. Yes, an intravenous treatment of fluid is somewhat invasive. The injection site can become infected, and a vein can become inflamed or blocked with a clot (a condition called superficial thrombophlebitis). While these complications are uncommon, even a small risk isn’t worth taking if the treatment is not necessary or helpful.

I can see how the idea of IV fluids at home might seem like a good idea. We hear all the time about how important it is to drink enough and to remain “well-hydrated.” It’s common to see people carrying water bottles wherever they go; many of them are working hard to drink eight glasses of water a day, though whether this is really necessary is questionable.

And then there’s the power of the stories people tell (especially celebrities) describing how great they felt after getting IV fluid infusions. If you have a friend who says they feel much better if they get IV fluids to treat (or prevent) a hangover, who am I to say they’re wrong? The same can be said for those who believe they look better after getting IV fluids as part of getting dolled up for a night on the town.
What about the cost?

While the benefits of IV fluids on demand are unproven and the medical risks are low (but real), the financial costs are clear. For example, one company offers infusions for $199 to $399. The higher cost is for fluids with various vitamins and/or electrolytes and other medications. Keep in mind that the fluids and other therapies offered can be readily obtained in other ways (drinking fluids, taking generic vitamins, and other over-the-counter medications) for only a few bucks.
The bottom line on drip bars

In recent years, more and more options have become available to get medical tests or care without actually having a specific medical reason and without the input of your doctor. MRIs, ultrasounds and CT scans, recreational oxygen treatment, and genetic testing are among the growing list of options that were once impossible to get without a doctor’s order. While patient empowerment is generally a good thing, IV fluids on demand may not be the best example. Some of these services are much more about making money for those providing the service than delivering a product that’s good for your health. Recent news reports described an “ethical lapse” by a prominent New York City cancer specialist. In research published in prominent medical journals, he failed to disclose millions of dollars in payments he had received from drug and healthcare companies that were related to his research. Why is this such a big deal? Disclosing any potential conflict of interest is considered essential for the integrity of medical research. The thinking is that other researchers, doctors, patients, regulators, investors — everyone! — has a right to know if the researcher might be biased, and that measures have been taken to minimize the possibility of bias.
Is it an advertisement or research?

One way to think about the importance of full disclosure regarding medical research is to ask: is the information I’m reading or hearing about coming from a paid spokesperson? If so, it may be the equivalent of an advertisement. Or, is it from a researcher without a financial stake in the results? The answer matters. While the information may be valid either way, the way it’s delivered, how alternative explanations for the results are considered, and the skepticism (or enthusiasm) surrounding the findings can vary a lot depending on whether the source has a vested interest in a study’s results.

One of my favorite examples of how bias can affect how medical information is delivered is the way pain relievers (such as ibuprofen or naproxen) are described in ads. There are more than 20 of them available, and for most conditions their effectiveness is about the same. And that’s exactly how a researcher with no financial ties to the makers of these drugs might describe them: in clinical trials, they are equally effective. But a company’s television ad might claim that “nothing’s proven stronger for your headaches” than their medication. Factually, both ways of presenting the information are true. But knowing the source of the information and whether it might be biased can make a big difference in how you interpret that information.
Why you should care about conflict of interest in medicine

Medical schools, hospital systems, and other institutions that employ doctors generally require disclosure of outside income. But do their patients want to know? Would it matter to you if your doctor accepted gifts, meals, or cash payments from drug companies?

There’s been enough concern about the answers to these questions that the federal government set up a website to post information about payments doctors receive from drug companies, medical device makers, and others. Perhaps you’ve heard of it. It’s called OpenPayments,* a disclosure program mandated by the Sunshine Act that posts these financial relationships online for public viewing. It’s been up and running for several years. But the impact of this program is not clear; many of my patients have never heard of it, and most people have never looked up their own doctors on the site.

*In the interest of full disclosure, my name appears in Open Payments: However, it’s for consulting with the Institute for Healthcare Improvement, an independent healthcare organization. They provided grants to encourage shared decision making and understanding of treatment options for patients with rheumatoid arthritis. A pharmaceutical company sponsored the program but has no role in promoting any particular medication.
Other ethical issues your doctor might face

Even if your doctor doesn’t accept payments from pharmaceutical companies, he or she may have to consider other ethical questions, such as:

    Is it acceptable to own his or her own testing equipment? While it may be more convenient for patients, studies show that when a practice performs (and charges for) its own lab or imaging tests (such as a scanner for osteoporosis screening), more tests tend to be ordered.
    Should he or she meet with representatives from pharmaceutical companies who are promoting their latest drugs? Some physicians get updates regarding new medications from drug reps (along with gifts of minor value, such as pens or lunch), but this may lead to higher rates of prescribing newer, higher priced drugs when older, cheaper options would be just as good.
    Should your doctor attend medical meetings where drug companies sponsor the speaker (complete with dinner in a fancy restaurant)? Again, the information presented may be accurate but biased.
    Is it reasonable for doctors to receive payments to enroll patients in a study sponsored by a drug company? This is a common practice, and it’s likely that the financial arrangement is not always disclosed to the patient.

And these are just a few of the many ethical dilemmas that many doctors face.
What do you think?

Many doctors I know are insulted by the suggestion that they “can be bought” by a charismatic drug rep bearing gifts. But a number of studies show these practices work. Large pharmaceutical companies spend millions on doctors to market, educate, and perform clinical trials. They would not invest so much money if it didn’t work.

Does any of this concern you? Do you think the case of the NYC doctor is unusual and that most doctors navigate the ethical minefields of modern medicine successfully? Let me know!
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Healthy, wholesome easy lunches

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

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

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

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

As for CBD, you can expect claims of health benefits to multiply as it morphs from a component of an illicit drug to a financial opportunity in the growing “wellness” food and beverage industry. But I’ll still be looking for more studies confirming its safety and health benefits before I’ll buy anything containing CBD. Today is National Depression Screening Day. If you are experiencing symptoms of depression, you should know that there are effective treatments and help is available.

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

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

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

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

As they answered these questions, the researchers documented whether the connections between different brain regions were affected.
What did we learn about people who are depressed?

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

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

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

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

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

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

So, being aware that your brain distorts your self-impression in the first step in this therapy. Once you understand this, you can learn how to switch your attention to positive goals so that you can feel better about yourself again. There has been lots of attention on concussions in youth, especially from sports, over the past few years. It’s good that we are paying more attention to concussions. As the stories of prior National Football League players show us, concussions can lead to lifelong problems.

The problem for doctors, parents, and coaches has been that while we want to do the right thing when a child gets a concussion, we haven’t known what that right thing is. So it’s great news that the Centers for Disease Control and Prevention (CDC) has reviewed all the research and made recommendations to help guide us as we care for children with concussions.

The recommendations reflect the fact that every child who has a concussion is different. Every injury is different, obviously, but it’s more than that. Some children are more likely to have trouble, such as those who have had prior concussions or have learning problems, mental health problems, or neurological problems. Interestingly, children whose families are stressed for reasons such as poverty can take a longer time to recover from concussions. And there is a bit of a wild card factor too: sometimes children unexpectedly take a long time to recover — or, conversely, recover very quickly.
Overview of new concussion care recommendations

    Most children with concussions don’t need CT or MRI scans. If there was a severe injury or the child is having severe or unusual symptoms, then it’s worth doing to be sure there isn’t internal bleeding, a fracture, or some other injury. Most of the time with concussions, there is nothing to see — and it’s not worth the risk or expense involved in these studies.
    Use the right tool to make the diagnosis. There are some symptoms we associate with concussion, like bad headache, dizziness, loss of memory of the accident. But because it isn’t always clear, it’s helpful to use a checklist or questionnaire that is “validated,” meaning that it’s been shown to accurately pick out those with a concussion from those who simply have a bad clunk to the head and not a concussion. The CDC lists some tools that are recommended.
    When a child has a concussion, assess for risk factors for a prolonged recovery. As I said above, some children take longer to get better — and while we can never predict for sure, it’s important to think about that at the time of the injury. This can help doctors…
    Provide education for parents and caregivers about concussions and what to expect. Most people with concussions get completely better within one to three months. It’s important that patients, families, and coaches know what all the symptoms are after a concussion — and know not only what’s normal, but also what is a sign of a problem. For example, trouble sleeping, dizziness, and moodiness can be normal, but if any of those symptoms are getting worse, it’s important to call the doctor.
    Help children return gradually to normal activities after a concussion. Rest — of not just the body but the mind too — is important for the first two to three days after a concussion, but after that it’s important to start getting back to normal. When people rest completely for longer than that, it actually takes them longer to get better!

Getting back to normal after a concussion

Gradual is the key word for returning to exercise and school — and this is where families, doctors, schools, and coaches need to work together. The basic idea is to start slow and see how the child does. If they do okay, they can do a bit more schoolwork or exercise. If they don’t do okay, meaning they have more symptoms, that’s where the education comes in — they should do less and go more slowly. The process of getting back to normal life can take a few days, or a few months. It has to be tailored to each child and each situation, which is why collaboration is so important. It’s also really important not to rush the process, especially when it comes to returning to a sport where concussions are common, such as football, hockey, or soccer. If a child gets another concussion while they are still recovering, it will take them much longer to get better and put them at risk of permanent disabilities. I am now 11 years into recovery from my battle with opiate addiction, and I have always been fascinated with two related questions: is there truly such a thing as an “addictive personality,” and do people substitute addictions?
The myth of the addictive personality

The recently deceased writer and television personality Anthony Bourdain was criticized by some for recreationally using alcohol and cannabis, in what was seemingly a very controlled and responsible manner, decades after he quit heroin and cocaine. Was this a valid criticism? Can a person who was addicted to drugs or alcohol in their teens safely have a glass of wine with dinner in their middle age?

It depends on which model of addiction and recovery you subscribe to. If you are a traditionalist who believes that addictions last a lifetime, that people readily substitute addictions, and that people have ingrained “addictive personalities,” the answer is: absolutely not. This would be playing with fire.

During my 90 days in rehab, it was forcefully impressed upon me that addictions are routinely substituted, and that if one is ever addicted to any substance, then lifelong abstinence from all potentially addictive substances is one’s only hope of salvation. This seemed to make sense, as a person would have the same lifelong predispositions to an addiction: genetic makeup, childhood traumas, diagnoses of anxiety or depression — all of which could plausibly set them up to become addicted to, say, alcohol, once they have put in the hard work to get their heroin addiction under control. In medical terms, the concern is that different addictions can have a common final pathway in the mesolimbic dopamine system (the reward system of our brain), so it is logical that the body might try to find a second pathway to satisfy these hungry neurotransmitters if the first one is blocked, a “cross-addiction.”

I learned early in my own recovery how critical it is to apply logic and evidence to the field of addiction, and that just because things make sense, and because we have thought about them in a certain way for an extended period of time, that doesn’t mean that they are necessarily true. While in rehab, I was actually told a lot of other things that turned out to have no basis in scientific evidence. For example, I was told on a daily basis that “a drug is a drug is a drug.” This mentality doesn’t allow for there being a difference between, for example, the powerful opiate fentanyl, which kills thousands of people every year, and buprenorphene (Suboxone) which is a widely-accepted treatment for opioid use disorder.

I have come to believe that an uncompromising “abstinence-only” model is a holdover from the very beginnings of the recovery movement, almost 100 years ago, and our understanding has greatly evolved since then. The concepts of addiction and recovery that made sense in 1935, when Alcoholics Anonymous was founded, and which have been carried on by tradition, might not still hold true in the modern age of neurochemistry and functional MRIs. That said, mutual help groups today do have a place in some people’s recovery and they can encourage the work of changing and maintaining change.
Recovery may improve resiliency to new addictions

It seems as if no one definitively knows the answer about whether people substitute addictions. According to the National Institute on Drug Abuse in response to a request for comment from the website Tonic: “A previous substance use disorder is a risk factor for future development of substance use disorder (SUD),” but “It is also possible that someone who once had an SUD but doesn’t currently have one has a balance of risk and protective genetic and environmental factors that could allow for alcohol consumption without developing an AUD [alcohol use disorder].”

One study published in JAMA in 2014 showed that, “As compared with those who do not recover from an SUD, people who recover have less than half the risk of developing a new SUD. Contrary to clinical lore, achieving remission does not typically lead to drug substitution, but rather is associated with a lower risk of new SUD onset.”

The authors of this study suggest that factors such as “coping strategies, skills, and motivation of individuals who recover from an SUD may protect them from the onset of a new SUD.” In other words, by making the life-affirming transition from addicted to recovered, we gain a recovery “toolbox” that helps us navigate life’s challenges and stresses in a much healthier way. We learn to connect with people, push our egos aside, and to ask for help if we need it. Thus, when faced with stressful situations that formerly would trigger us to drink or drug, we might respond by exercising or calling a friend, rather than using a substance. As such, we substitute addictions with healthier activities that perform the function that the drink or drug used to, albeit in a much more fulfilling way.

This issue is also, partly, a question of semantics, and of how narrowly or widely we define addictions. Many hold that an addiction can be to either a substance or a process: gambling, eating, video game playing, Internet use, sex, work, religion, exercise, or compulsive spending. Lots of people gain weight when they quit smoking. Is that a case of substituting an addiction? I like to joke that, in my observations, the only reliable outcome from a stay at rehab was a nicotine addiction, because many people, in an attempt to cope with the trauma and dislocation of being sent away to rehab, pick up cigarettes.
People grow and change

Personally, I am skeptical that many people substitute addictions. In my experience, people who are addicted tend to have a particular affinity for a particular class of drug, not for all drugs and alcohol. This is probably based on some combination of their neurochemistry and their psychological makeup. I was addicted to opiates, but didn’t have difficulties with substances in other classes. I have seen this to mostly be the case with thousands of my brothers and sisters in recovery who I have had the honor to interact with. People continue to add to their coping skills toolbox throughout life, so the unhappy 18-year-old who is struggling is not the well-adjusted 50-year-old who has worked through many of their problems, or who has improved their life circumstances. Vulnerabilities can improve over time. People aren’t static, which is what reminds us to never give up hope when dealing with an addicted loved one, no matter how dire the circumstances appear to be.
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