Could white-coat hypertension harm your heart?

For most people, going to the doctor is usually a bit nerve-racking. But for some, the stress of a medical appointment triggers a temporary rise in blood pressure. If that’s the case for you — and if your blood pressure is normal at home and in other nonmedical settings — you may have what’s known as white-coat hypertension. Now, a large study suggests that people with this condition face a greater threat of heart disease than people whose blood pressure readings are always normal.

According to current guidelines from the American College of Cardiology and the American Heart Association, normal blood pressure is defined as less than 120/80. High blood pressure is 130/80 and higher.

“If your blood pressure goes up under the relatively nonthreatening situation of seeing a doctor, then what might happen if you’re cut off on the highway, or experience a challenging family or work circumstance?” says Dr. Randall Zusman, a cardiologist at Harvard-affiliated Massachusetts General Hospital.

Everyone’s blood pressure fluctuates constantly throughout the day. But people with white-coat hypertension may experience more frequent and higher spikes. About one in five people has the condition, which doctors typically don’t treat with medication.

The white-coat effect

For the study, researchers pooled findings from 27 studies involving more than 64,000 people in the United States, Europe, and Asia. Compared with people whose blood pressure was normal both at the doctor’s office and at home, people with untreated white-coat hypertension had a 36% higher risk of heart attack, stroke, and other heart-related events. They were also twice as likely to die from heart disease.

However, people taking blood pressure medication whose blood pressure still rose at the doctor’s office (a phenomenon known as the white-coat effect) did not have a higher risk of heart disease. The study was published June 10 in Annals of Internal Medicine.

According to Dr. Zusman, the findings lend further support for treating people with white-coat hypertension. Research suggests that the condition nearly always progresses to sustained high blood pressure.

What you can do

Treatment doesn’t necessarily mean taking blood pressure medication, however. “Losing weight, exercising, limiting salt, and not smoking are all associated with better blood pressure control. I certainly encourage people to do all those things, whether they have intermittent or sustained high blood pressure,” says Dr. Zusman.

Sometimes, even determined efforts to make these changes aren’t sufficient. If lifestyle changes aimed at controlling hypertension can’t bring your blood pressure down to a normal range, there are many safe, effective medications that can help.

Dr. Zusman advises all of his patients to use a home blood pressure monitor to make sure their treatment is working. “I also have them bring their device in and watch them take their blood pressure to make sure they’re using the monitor correctly,” he says. Doctors often suggest checking your blood pressure once or twice a day for a week or so right after starting or changing medications. After that, two to three times a week at different times of the day is a good idea, says Dr. Zusman.

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Will a purpose-driven life help you live longer?

Do you get joy out of volunteering, helping out with your grandkids, or learning new skills in that class you’ve been taking?

If you said yes, it could help you live longer. As it turns out, being inspired by things in your life doesn’t just help your emotional well-being — it may keep you healthier.

A 2019 JAMA Network Open study found that among a group of nearly 7,000 adults over age 50, those who scored highest on a scale that measured “life purpose” were less likely to die during the four-year study period. They were also less likely to die during the same period from heart, circulatory, or blood conditions, compared with those who scored lower.

“There have been a number of studies suggesting that a higher sense of purpose in life is associated with reduced risk of early death,” says Eric S. Kim, PhD, a research scientist in the department of social and behavioral sciences at the Harvard T.H. Chan School of Public Health. “However, this study showed for the first time that sense of purpose in life is associated with specific causes of death, and that’s an interesting advancement of knowledge.”

Defining a purposeful life

So, what exactly is life purpose? Life purpose is defined differently by different people. But in general it indicates that you have an aim in life and goals. This purpose, the study authors said, helps make it more likely that you will engage in behaviors that are good for your health. Some studies have simply asked people what gives them a sense of purpose in life, says Kim. People listed such factors as

• family and relationships
• community
• helping others
• learning new skills
• taking part in leisure activities or hobbies.

“I define it as the extent to which people experience their lives as being directed and motivated by valued life goals,” says Kim.

In this study, having more life purpose was associated with a lower rate of death during the study period overall, from cardiovascular disease and blood conditions, and also from digestive conditions.

However, stronger life purpose didn’t appear to insulate study participants from all health conditions. Researchers did not find an effect on death rates from cancer, tumors, or conditions that affected the respiratory tract. It’s also important to note that the study didn’t prove that having a life purpose resulted in the lower death rates seen in the study.

“This was a well-done observational study. But there are limitations from studies with this kind of design, as they can’t pinpoint causality,” says Kim.

How does life purpose keep you healthy?

There are a few theoretical reasons why having a life purpose might help improve your health. “We’re currently working on a review article about this topic and we found literature suggesting that purpose in life works through three main pathways,” says Kim.

These include the following:

• It makes you more likely to protect your health. For example, you might eat healthier, sleep better, exercise more, or increase your use of preventive health services.
• It could reduce stress. “There’s some evidence from lab studies and studies that track people over time that suggests that people with a higher sense of purpose in life are less perturbed by various stressors, and also recover more quickly when they are more stressed out,” says Kim.
• It could reduce inflammation. Researchers have linked inflammation in the body to cardiovascular disease and other health conditions. Stress is known to prompt inflammation in the body, so reducing stress might help to reduce inflammation.

Ultimately, activities that provide life purpose may be prompted by an overarching outlook in which life itself is greatly valued, says Kim. “One caveat is that there are important studies that show no association between a sense of purpose in life and some of these factors, so this is still an active field of research.”

Lacking purpose? Strategies to help

If you feel like you are lacking purpose, seeking out new opportunities may help. Look for activities and roles that will provide a compelling reason to get up every morning. Some research has found that volunteering is a valuable option for many people.

But if you’re feeling stuck, don’t be afraid to reach out for help.

“There’s some evidence to suggest that specialized cognitive behavioral therapy can improve a sense of purpose in life, as well as meaning in life, which is a conceptually close cousin,” says Kim.

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A clue to a cure for Alzheimer’s disease

Are you worried about Alzheimer’s disease? Does one of your parents or siblings have the disease? If so, your risks are between two and four times that of the general public. What about people without a family history of the disease? Unfortunately, everyone is at risk for it. By age 85, half of you reading this article today will have developed Alzheimer’s disease, with or without a family history.

Sounds pretty scary, doesn’t it?

I’m writing today to give you some good news. A new study from the lab of Harvard researcher Yakeel Quiroz, PhD, has suggested a new target for drugs that might have the potential to slow down or even stop Alzheimer’s disease in its tracks.

A family with early-onset disease — and one exception

Dr. Quiroz, her longtime colleague Dr. Francisco Lopera, and first author Dr. Joseph Arboleda-Velasquez have been studying a large family in Colombia, South America, some of whom have a mutation in the presenilin 1 gene that causes early-onset Alzheimer’s disease. Over 1,000 people in this family are affected by the mutation. Among these family members, early symptoms of Alzheimer’s, such as memory loss and word-finding difficulties, almost always develop around age 44, and dementia follows at around age 49. Sometimes individuals may develop these symptoms or dementia one, two, or even three years later. But not 10 or 20 years later — and certainly not 30 years later. Yet one individual — a woman in her 70s with this genetic mutation — is only now starting to show symptoms.

The study, reported in the November 2019 issue of Nature Medicine, is a case report and extensive analysis of this one woman.

The APOE gene can modify your risk of Alzheimer’s

Many people have read or heard about variations in the APOE gene as a risk factor for Alzheimer’s. Interestingly, in their inquiry into why this woman with a mutation for early-onset Alzheimer’s had not yet developed dementia, the researchers found that she had an additional mutation in her APOE gene.

APOE has been linked to ordinary, late-onset Alzheimer’s disease and comes in three common forms. Most people, about 70% to 75%, have APOE3. About 15% to 20% of people have an APOE4 gene, and about 5% to 10% of people have an APOE2 gene.

• If you have one APOE4 gene, your risk of developing Alzheimer’s disease is three to four times more likely than if you only have APOE3 genes.
• If you have one APOE2 gene, your risk of developing Alzheimer’s disease is somewhat less than if you only have APOE3 genes.

This woman’s mutation of her APOE gene is an unusual variant called APOE3Christchurch (APOE3ch), named after the New Zealand city where it was first discovered. Even more unusual is the fact that she had two versions of this mutation, meaning that both her father and her mother gave it to her. The researchers wondered if this APOE3ch mutation could be the cause of her resistance to Alzheimer’s disease.

Resistance to tau

Another piece of the puzzle relates to an abnormal protein called tau. Tau is associated with the destruction of brain cells in Alzheimer’s disease. Tau is thought to accumulate in the brain after amyloid protein — the pathologic hallmark of Alzheimer’s disease — forms plaques. Although her brain was full of abnormal amyloid plaques — even more so than most people with full-blown Alzheimer’s dementia — she had relatively little tau.

Now the question was, could the APOE3ch mutation be related to the small amounts of tau protein? Although the answer is far from settled, the researchers did uncover some clues through laboratory experiments. Their findings suggest that the APOE3ch mutation may reduce the uptake of tau in brain cells. In addition, they were able to produce similar beneficial results using a special protein they created in the laboratory to try to mimic the effects of the APOE3ch mutation.

Where we are now

In brief, these Harvard researchers have a viable hypothesis to explain why this woman has been highly resistant to developing Alzheimer’s disease dementia. Moreover, their work suggests a possible path to a treatment that could be beneficial for all forms of Alzheimer’s disease.

We are still years away from a human treatment. The next step will be to try to treat laboratory models of Alzheimer’s disease in rodents, and then clinical trials in people with the disease after that. But in my view, this paper has provided the scientific community with a clue that may lead us to an eventual cure for Alzheimer’s disease.

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Living with Crohn’s disease: Recognizing and managing flares

Crohn’s disease is an inflammatory condition that can affect any part of the gastrointestinal tract. Together with ulcerative colitis, Crohn’s is one of the two main types of inflammatory bowel disease (IBD). Crohn’s affects approximately 500,000 Americans and is a chronic, lifelong condition that typically alternates between periods of relatively stable or absent symptoms (remission) and periods of symptom flare-ups that can last for days, weeks, or even months.

The goal of treatment is to induce remission and then to maximize the chance that patients stay in remission. However, almost everyone with Crohn’s disease will experience a flare-up at some point. If you have Crohn’s disease, it is important to understand what you can do to reduce the risk of a flare, to recognize symptoms of a flare, and to manage flares when they do happen.

Tracking symptoms helps recognize Crohn’s disease flares early

Flare-ups can be triggered by a variety of factors including changes in diet, new medications, infections and antibiotics, stress, and changes in the underlying disease itself. In some cases a specific trigger can be identified, but in many cases the trigger remains unknown.

Symptoms of Crohn’s disease can vary widely. Some people primarily have abdominal pain and diarrhea, while others may have lack of appetite, nausea, or abdominal distension, and still others may have less specific symptoms such as fatigue, joint pain, mouth ulcers, or eye symptoms.

The key is to have a good sense of your baseline symptoms at remission, and how your Crohn’s disease manifests when it is more active. A number of smartphone apps, including Oshi: IBD tracker and myColitis, can help patients better monitor their condition, prompting you to track things like bowel movements, symptoms, and medications. The Crohn’s & Colitis Foundation has developed an easy-to-use symptom tracker. These types of records can help you provide your gastroenterologist with a more complete picture of your disease activity between office visits.

Contact your doctor at the first sign of a flare

You should contact your doctor if you think you are experiencing a flare so he or she can test to see if the flare is due to an infection, or determine if any new medications or exposures, such as recent antibiotics, might have triggered the flare. In the absence of infection or another reversible cause of the flare, your gastroenterologist may recommend a treatment course of corticosteroids, either topical (applied to the lower colon through enemas or suppositories) or systemic (body-wide).

Symptom flares can also indicate a change in your body’s response to your current treatment. For example, each year a portion of patients who take either immunomodulator or biologic medications such as infliximab (Remicade) or adalimumab (Humira) stop responding to their medication. Sometimes a major symptom flare can signify that these medications are no longer working. Your doctor can perform tests to confirm if this is the case and, if necessary, switch you to a different medication.

Dietary and lifestyle changes can help manage Crohn’s disease flares

There are a number of additional measures you can take to help manage flares when they do occur.

Avoid NSAIDs. Nonsteroidal anti-inflammatory medications (NSAIDs) like ibuprofen (Advil) or naproxen (Aleve) can impair the ability of the GI tract to protect and heal itself, and can precipitate a flare. If you are having pain, take acetaminophen (Tylenol) instead of NSAIDs.

Quit smoking. Smoking is a strong risk factor for developing Crohn’s disease and can also set off a disease flare. Quitting smoking is strongly associated with fewer flares, decreased medication requirements, and reduced risk of surgery.

Reduce stress. Although stress does not directly cause Crohn’s disease, it does strongly impact IBD symptoms. Many people with Crohn’s disease find the regular use of stress management and stress reduction techniques to be helpful. These can include meditation, deep breathing, biofeedback, yoga, and cognitive behavioral therapy.

Simplify your diet. There is no specific diet that prevents or cures Crohn’s disease, but you may identify specific foods that tend to worsen your symptoms. Keeping a food journal can help you make these connections. There are also several general principles that help most patients feel better when they are experiencing a flare:

• Eliminate dairy.
• Avoid greasy and fried food.
• Limit foods that are high in fiber, such as raw vegetables and whole grains.
• Avoid foods that tend to cause gas (beans, cruciferous vegetables).
• Limit your diet to well-cooked vegetables.

Minimize caffeine and alcohol. They may make symptoms worse during a flare.

The bottom line

Most people with Crohn’s disease will experience a flare at some point, even if they take their maintenance medications as directed. Carefully monitoring and tracking symptoms every day will help you recognize a flare-up when it begins. Let your gastroenterologist know about a flare-up and to be sure to follow recommendations for medications and tests. Dietary and lifestyle modifications can also help manage flare-ups when they do occur.

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Yes, you can avoid weight gain over the holidays!

The holidays are a time when family and friends gather to enjoy each other’s company — and eat! Indulgent meals, bountiful buffets, cookie swaps, holiday parties… it’s no surprise that maintaining a healthy weight can present even more challenges during the holidays than throughout the rest of the year. Each year, on average, we tend to gain a small amount of weight (about one pound per year). According to some research, most of that weight is gained over the holiday season.

Study suggests you can control holiday weight gain

Does that mean we are destined to see a bigger number when we step on the scale in January? Or can we keep the end-of-year weight gain at bay?

A study published in The BMJ sought to find out. Researchers examined the effectiveness of a brief (four to eight week) behavioral intervention to prevent weight gain over the Christmas holiday period. The researchers randomized 272 adults into one of two groups. The intervention group was given a behavioral intervention intended to increase their restraint of food and beverage consumption. The intervention involved three components: encouraging participants to regularly weigh themselves and record their weight; providing specific weight-management strategies; and providing information on how much physical activity would be needed to burn off the calories consumed in typical holiday foods and drinks. The control group received information on healthy living.

Results showed that the intervention group lost an average of 0.3 pounds, while the control group gained 0.8 pounds. This may not seem like much, but research shows that weight gains are not fully lost in the months following the holidays. Although the yearly gain is small, it can add up to an increase of 10 pounds over 10 years.

10 top tips for weight management

Study participants in the intervention group were encouraged to follow these 10 tips to help prevent weight gain:

• Keep to your meal routine. Try to eat at roughly the same times each day.
• Go reduced-fat. Choose low-fat foods when possible.
• Walk off the weight. Aim for 10,000 steps each day.
• Pack a healthy snack. Choose fresh fruit or low-calorie yogurt instead of chocolate or chips.
• Look at the labels. Check food labels for fat and sugar content.
• Caution with your portions. Don’t heap food on your plate, and think twice before having second helpings.
• Up on your feet. Stand up for 10 minutes every hour.
• Think about your drinks. Choose water or calorie-free drinks, and limit alcohol.
• Focus on your food. Slow down, and don’t eat in front of the TV or on the go.
• Don’t forget your 5-a-day. Eat at least five servings of fruits and vegetables each day.

How much activity would it take to burn off this eggnog?

Physical activity — or at least understanding how much physical activity it would take to burn off calories, and possibly considering that information when making choices about what to eat — also played a role in preventing weight gain. In the study, the researchers provided the intervention group with a chart that showed the approximate amount of activity it would take to burn the calories found in a given amount of festive foods. For example, it would take approximately 12 minutes of walking or six minutes of running to burn off the calories in five pigs in a blanket, and it would take approximately eight minutes of walking or four minutes of running to burn off the calories in 5 tablespoons of gravy.

More strategies to prevent holiday weight gain

Here are a few more tips to help you keep your weight in check without foregoing your holiday traditions.

• Mark all of the holiday events you’ll be attending on your calendar so that you’ll remember to plan ahead. If the meal is not at your home, eat lighter the day of the event to balance the extra calories you may consume at the party. If the event is in the evening, have a healthy breakfast and satisfying lunch, with a light snack before the event to avoid overindulging later.
• If you are the host and struggle with tasting while cooking, try chewing sugar-free gum while preparing the meal, or have a small snack before you start cooking. Serve plenty of raw vegetables and yogurt-based dips to start the event and fresh fruit to finish. After the meal, send leftovers home with friends and family.
• The workplace can be hazardous around the holidays; holiday lunches and office parties can make it difficult for even the most health-conscious employee to make smart choices. If the team is going out for a special holiday lunch, choose lower-calorie items and go light on dinner that evening. Move holiday cookies and candies to a high-traffic area to spread the goodies around.
• Start new traditions that don’t revolve around food. For example, attend a holiday concert or show, or take a drive or walk to see holiday lights. Catch up with a friend over a yoga or Zumba class instead of meeting for a peppermint mocha latte.

Preventing weight gain over the holidays can be a challenge. But it is possible!

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Darolutamide approved for nonmetastatic castration-resistant prostate cancer

Sometimes after finishing prostate cancer treatment, men get an unwelcome surprise: their prostate-specific antigen (PSA) levels creep higher, suggesting tumors too small to be seen lurk somewhere in the body. This leads to several options. Doctors can continue to monitor a man’s condition with imaging scans. Or, given the anxiety associated with rising PSA, they might try to lower the levels with chemically “castrating” drugs that inhibit testosterone, a hormone that makes prostate tumors grow faster.

Following that treatment, called androgen deprivation therapy (ADT), PSA generally declines and may become undetectable. But what if PSA climbs further despite ADT’s inhibiting effects on testosterone? This condition is called nonmetastatic, castration-resistant prostate cancer (nmCRPC). It’s called “nonmetastatic” because cancer hasn’t spread in a way that’s detectable with imaging technology. And it’s called “castration-resistant” because PSA isn’t responding to the chemically castrating effects of ADT on testosterone production. The condition is asymptomatic, but a third of the men who have nmCRPC develop metastases within two years.

New choices

Until recently, doctors had few options for treating nmCRPC, and there weren’t any clear guidelines. The typical strategy was to hold off until it was obvious a tumor was spreading as demonstrated by a positive bone scan or CT scan, and then give drugs approved for metastatic prostate cancer.

However, three drugs have recently won FDA approval for the condition. Apalutamide (Erleada) was approved in February 2018, enzalutamide (Xtandi) in July 2018, and the latest — darolutamide (Nubeqa) — was approved in August 2019.

Like apalutamide and enzalutamide, darolutamide is an anti-androgen, meaning it prevents testosterone from binding to its receptor in cells.

Keeping metastases at bay

All three drugs lengthen the time it takes for visible metastases to appear on imaging scans in men who have nmCRPC. This measure — called metastasis-free survival (MFS) — is a new endpoint for clinical research in prostate cancer. During the clinical trial leading to darolutamide’s approval, MFS lasted a median of 40.4 months among men who got the drug (taken orally in tablet form twice a day), compared to 18.4 months among men in a control group who were treated with placebo. Darolutamide also delayed pain progression, the time to chemotherapy, and preliminary evidence suggests it might extend overall survival, which refers to how long men actually live with prostate cancer before dying of the disease. Confirming overall survival improvements, however, will require years of additional follow-up.

Anti-androgens have side effects, so experts say they should be used cautiously, particularly with elderly men who have no cancer symptoms. Though it was generally well-tolerated, darolutamide, for instance, had side effects including fatigue (16%), pain in extremities (6%), and rash (3%). There may be some differences in other side effects among the three drugs. But according to Dr. Marc Garnick, Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org, further follow-up is needed.

Dr. Garnick said clinical studies in this area raise important questions: One, he said, relates to the timing of ADT when PSA levels initially increase after surgery or radiation. “This is a very disconcerting finding,” Dr. Garnick acknowledged. “But men should also be informed they can potentially live for a significant period of time after PSA rises — years to decades — without any treatment.” Similarly, the decision to undertake anti-androgen therapy in nmCRPC treatment hinges on criteria such as how fast the PSA levels rise, Dr. Garnick said, or how aggressive a man’s cancer appeared in the initial biopsy. “Longer follow-up will be needed to assess the impact of treating nmCRPC, both in terms of safety and overall survival,” Dr. Garnick said.

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Harvard Health Ad Watch: A fibromyalgia treatment (“But you look so good!”)

It’s something I’ve heard countless times from patients with fibromyalgia. They’re telling a friend or family member about their condition and the response is, “But you don’t look sick” or “But you look so well.” Sometimes, the reaction is more of an eye roll or some other response that reflects skepticism that the problem is even “real.”

Those are issues addressed head-on in a TV ad for Lyrica (pregabalin), a treatment for fibromyalgia. “To most people, I look like most people,” a woman says. “But on the inside I feel chronic, widespread pain.” After clarifying that the pain is real, this direct-to-consumer drug advertisement moves on to say one of the current theories about the origin of pain in fibromyalgia is that it’s “thought to be caused by overactive nerves.”

The mood of the ad is somber at first. Sad music serves as backdrop to a woman who is clearly suffering as a man — perhaps her husband? — plays in the park with two adorable kids. That all changes when she talks about taking Lyrica. Then the music soars and the voiceover tells us that “Lyrica is believed to calm these nerves.” The now-smiling woman looks into the camera and pronounces, “I’m glad my doctor prescribed Lyrica.” The scene brightens and she’s smiling as she goes about setting up for a neighborhood block party. The voiceover informs us that, “For some, Lyrica delivers effective relief for fibromyalgia pain and improves function.”

Then comes the litany of side effects that might accompany treatment. More on those shortly.

The good

The ad gets a number of things right, including:

• the fact that the condition may be “invisible” to others
• the notion that the cause of fibromyalgia is unknown, but experts believe it may be due to “overactive nerves”
• the character in the ad who has fibromyalgia is a woman — in fact, the condition is up to six times more common in women than men
• mentioning the risks (and not just benefits) of a medication is important. The most common, and many rare, potential side effects are described. Keep in mind, though, that including a description of side effects or referring consumers to more information is required by the FDA, as I noted in my initial blog on direct-to-consumer ads describing pros, cons, and words to consider very carefully).

What’s missing

Some important information is missing from this ad, including:

• The limited effectiveness of the drug. Note the language in the ad: Lyrica works well “for some.” You might wonder just how many “some” is! A recent analysis of past studies found that only about 10% of treated study subjects reported excellent results, and only about 40% reported very good or excellent results. Lyrica was only modestly better than a placebo pill. Another analysis found that among prior studies, only 20% to 25% of study subjects experienced “at least 50% pain intensity reduction” within two to three months of treatment.
• The ad only mentions one treatment option: medication. But that’s not the only option. In fact, nondrug options, such as regular exercise and improved sleep, are considered vital for the successful treatment of fibromyalgia.
• No comparison to other medications. A number of other medications are approved and prescribed for fibromyalgia, yet there’s no mention of how Lyrica measures up to these other medications prescribed. According to a recent review, Lyrica seems to be no better (or worse) than other approved medications, including milnacipran (Savella) and duloxetine (Cymbalta).
• As with nearly all drug ads, the price of the drug is not mentioned. In November, the price of Lyrica was about $12 per 75-mg capsule, according to Drugs.com. The recommended starting dose is 75 mg twice daily, which adds up to around $24/day or more than $760/month. Often, higher doses are needed, which pushes the price even higher. Of course, medication costs are a moving target, because health insurance coverage, copayments, deductibles, drug company coupons, and other factors may affect the price you pay.

The risks of treatment

The list of side effects in this commercial is so long that many (or perhaps most) viewers will tune out. While common side effects include dizziness, sleepiness, weight gain, or swelling of the extremities, “severe allergic reactions” and “suicidal thoughts or actions” are the first ones mentioned. These risks are listed against a visually interesting and wonderfully distracting backdrop — in this ad, it’s giant bubbles and puppies. Yes, bubbles and puppies! Maybe providing a distraction from the list of things that could go wrong if you take Lyrica is not a coincidence. In fact, most drug ads do this.

The bottom line

Ads for drugs are not meant to be thorough or balanced. Their intent is to increase sales of their drug. Drug makers often talk about the importance of these ads to educate the public about treatment options. But the obvious (and understandable) bias toward the drug being advertised — Lyrica, in this case — makes the quality of the education suspect. That’s why I’m opposed to direct advertising to consumers for medications and medical procedures, and that’s probably a reason most countries don’t allow it.

Yes, fibromyalgia is a real and troublesome condition that’s invisible to others. But medication treatment, such as Lyrica, is only one part of standard treatment. And it’s not always effective. Want more complete and balanced information about fibromyalgia? Talk to your doctor or consult unbiased sources that aren’t trying to sell you anything. A pharmaceutical advertisement may not be your best bet.

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A look at the effects of nail polish on nail health and safety

In recent years, the nail polish industry has been transformed by the development of longer-lasting polish techniques. As dermatologists, we are often asked about the effects of these various products on nails. Here we review the main types of polish, and consider the pros and cons of each with an eye toward nail health and safety.

Traditional nail polish

Classic nail polish is painted onto the nail plate, usually in multiple coats, and then air-dried. Conventional nail polish is a polymer dissolved in a solvent. During the drying process, the solvent evaporates, and the polymer hardens. “Hybrid” polish is similar; it is applied and removed the same way as regular polish, but is intended to be longer-lasting.

Pros:

• Quickly and easily removed with an acetone-based nail polish remover. Because acetone can be harsh, drying, and damaging, less contact time may mean less damage to the nail plate, skin, and cuticles.

Cons:

• Some colors, especially darker colors, can cause nonpermanent discoloration of the nails.

The verdict: Dermatologist approved. We do recommend taking intermittent breaks from polish, and keeping nails and cuticles well-moisturized between manicures. Always remove polish before an appointment with your dermatologist so he or she can examine your nails.

“Non-toxic” nail polish

When it comes to cosmetics, the term “non-toxic” can be difficult to decipher. With regard to nail polish, a commonly used term is “five-free.” Five-free refers to polishes that do not contain five specific ingredients: formaldehyde, toluene, dibutyl phthalate, formaldehyde resin, and camphor. There are also brands that market themselves as being free of more substances, such as 7-free or 10-free.

Formaldehyde is a preservative that has been recognized by the National Cancer Institute as a potential cancer-causing substance. It is also among the most common substances that cause allergic contact dermatitis. Formaldehyde resin, dibutyl phthalate, and toluene can also cause allergic contact dermatitis. Camphor is an oil that has been long used as a topical remedy for various conditions, but can be toxic if consumed by mouth.

Studies have shown that chemicals in nail polish can be absorbed into the body. But the exact amount of absorption, and whether it is enough to have negative health effects, are not well established. In general, the question of whether “natural” cosmetic products are safer and healthier still remains, as discussed in an editorial published in JAMA Dermatology.

Pros:

• easy removal process akin to regular polish
• contains fewer chemicals that can cause contact dermatitis; may be a good option for those with sensitive skin.

Cons:

• There is no strong research data regarding whether the chemicals excluded from non-toxic polishes have harmful health effects at the concentrations present in traditional nail polish.

The verdict: This may be a good alternative to conventional polish for those wishing to avoid those particular chemicals, although the health benefits are uncertain.

Gel polish

Gel polish is painted on and then “cured” under a lamp, which dries and hardens the polish almost instantly. Curing of nail polish means photopolymerization, which is a process during which a liquid absorbs energy from UV or visible light and undergoes cross-linking to become a solid. Most curing lamps emit ultraviolet A light, which is a known cause of cellular damage and aging and increases risk of skin cancer. There are some alternative lamps available that emit LED light; however, they may still emit some UV light.

Pros:

• longer lasting

Cons:

• exposure to UV light
• Removal process of gel polish can be destructive to nails. Removal involves soaking in acetone, and aggressive buffing, scraping, and peeling of polish, which can injure the nail plate.
• Wearing gel polish for long periods may result in severe brittleness and dryness of the nails.

The verdict: Gel polish is unlikely to have long-term negative effects on nail health if used sporadically or for special occasions. Remind your nail technician to avoid aggressive buffing (always avoid electric buffing), and not to scrape the nail plate forcefully. Never peel or pick off gel polish; doing so may peel off layers of the nail plate along with the polish, resulting in brittleness. Apply sunscreen 20 minutes prior to the UV treatment, or wear fingerless gloves while under the lamp.

Powder dip polish

This manicure entails application of a bonding polish (composed of a resin that is often made up of chemicals used in superglue) that serves as an adhesive for the polish. Next, a finely milled acrylic powder is applied, either by dipping the nail into the powder or brushing it onto the nail. Finally, an activator is applied. This is a liquid containing chemicals that induce polymerization of the resin-containing bonding polish, leaving a hard shell.

Pros:

• No drying lamp needed, therefore no UV exposure.

Cons:

• Sanitation is the major potential issue here. Communal jars of powder may be used for multiple people, which could become a reservoir for bacteria, fungi, and viruses.
• Harsh removal process similar to that of gel, often with use of an electric file, can damage the nail plate and cuticle.

The verdict: Unless a salon is transferring the powder into smaller, individual containers for each client, or using a clean brush to apply the powder, we recommend avoiding this type of manicure.

Follow us on Twitter @KristinaLiuMD and @JanelleNassim

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Suffering from “chemo brain”? There’s hope and many things you can do

Some of the most common symptoms experienced by cancer patients are memory problems, difficulties with multitasking, and reduced attention and concentration. Historically, cancer patients with these symptoms were often diagnosed with depression. Research over the past decade has revealed that many cancer patients experience such symptoms as a consequence of specific damage to the brain caused by either their tumor or their treatment.

While radiation to the brain has long been linked to causing cognitive difficulties, the effects of chemotherapy on brain structure and function have only recently been discovered. We now know that the majority of patients treated for cancer, including breast, lung, colon, and many other cancer types, experience difficulties with memory, multitasking, cognitive processing speed, attention, and concentration as a consequence of their treatment. The good news is that such symptoms may slowly improve over time in most patients.

There are treatment strategies to help patients recover more quickly

If you or someone you care for is having problems with memory or thinking following cancer treatment, it is important to undergo a comprehensive medical evaluation to rule out other conditions that can mimic certain side effects from chemotherapy. For example, endocrine disorders (such as thyroid abnormalities), vitamin deficiencies, sleep deprivation, or depression should all be ruled out (or treated), as these conditions can cause changes in memory and slowed thinking.

Extensive research over the past decade has identified how chemotherapy targets brain structure and function as an unwanted side effect of cancer therapy. Those efforts have also started to shed light on the mechanisms that enhance brain regeneration and expedite recovery from brain injury, previously thought to be impossible. While various therapeutic interventions currently remain in clinical testing, there are a number of lifestyle actions that have been found to be effective.

• Regular physical exercise. Cardiovascular exercise is one of the strongest drivers of brain repair after injury, stimulating the growth of new neurons, facilitating connections between brain cells, and enhancing overall cognitive resilience.
• Sufficient restorative sleep. Chronic sleep deprivation damages brain cells, prevents brain regeneration, causes daytime fatigue, and reduces cognitive function. Poor sleep also impairs the basic mechanism that eliminates toxic waste in the brain — a process that primarily happens during sleep. Simple behavioral changes to improve sleep hygiene include avoiding neurostimulants prior to bedtime (coffee, chocolate, beverages with high sugar content, etc.), and minimizing exposure to electronic devices in your bedroom. Meditation and various relaxation techniques can also be helpful to improve sleep.
• Good nutrition. A diet rich in antioxidants can be helpful in minimizing cancer therapy-related damage to brain cells and unwanted cognitive side effects from cancer therapy. Therefore, enriching your diet with fruits and vegetables, along with weight loss (if you are overweight or obese), are highly recommended strategies. While a natural supply of antioxidants and vitamins from food is best, some people who are unable to maintain a well-balanced diet may benefit from multivitamin supplementation.
• Engaging in positive and stress-reducing activities. Brain plasticity and nervous system regeneration can be enhanced when all senses are activated, particularly through activities that lead to new experiences and sensations (“environmental enrichment”). Engaging in new activities, learning a novel skill, or traveling can be of tremendous value. In addition, many patients find that engaging in spiritual practices can have a positive effect on healing.

Certain medications may enhance brain function and minimize cognitive symptoms

Medications such as neurostimulants and anti-aging drugs may be used in conjunction with lifestyle interventions to improve memory and cognition after cancer treatments. Speak with your doctor about these options.

New research suggests there may be a connection between the immune system, the bone marrow, and the brain, highlighting new avenues for future pharmacological and biological therapies that may enhance brain function after injury and delay the process of brain aging.

Cancer survivorship programs at many hospitals may offer help

A thorough neurological evaluation can be helpful in identifying areas of brain functioning that can be improved with specialized neurocognitive rehabilitation programs. Many patients benefit from this type of rehab as part of their cancer treatment.

Collectively, while symptoms of brain dysfunction are common in cancer patients, there are several interventions that can be considered to help with recovery and enhance healing. Research in this area remains in its infancy, but the curtain has been lifted. There are promising pharmacological and nonpharmacological therapeutic interventions on the horizon, and there are many lifestyle changes you can start today.

Resources

Neural correlates of chemotherapy-related cognitive impairment. Cortex, May 2014.

Assessment and management of cognitive changes in patients with cancer. Cancer, June 15, 2019.

Pharmacologic management of cognitive impairment induced by cancer therapy. Lancet Oncology, February 2019.

Sleep drives metabolite clearance from the adult brain. Science, October 18, 2013.

Bone marrow drives central nervous system regeneration after radiation injury. The Journal of Clinical Investigation, June 1, 2018.

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Benefits of incorporating more aerobic activity into stroke rehabilitation

After a stroke, the main goal is to get back home and be as independent as possible. To achieve that goal, most stroke rehabilitation centers focus on helping people to regain lost function, such as the inability to use a hand, to speak, to swallow, or to walk. A great deal of effort is put into functional recovery so that the patient can go home safely and adequately perform activities of daily living (ADLs). There is little effort put into aerobic exercise and conditioning in most stroke rehabilitation programs.

A recent systematic review and meta-analysis published in the Journal of the American Heart Association (JAHA) found that stroke survivors benefit from aerobic programs similar to those found in cardiac rehabilitation programs. These findings may prompt a closer look at how stroke rehab programs are designed.

Aerobic exercise can help achieve goals of stroke rehabilitation

Exercise has many known benefits for the body and mind. These include lowering blood pressure and resting heart rate; raising HDL (good) cholesterol levels; lowering triglycerides; increasing the body’s ability to break down clots; improving insulin sensitivity, which helps with diabetes prevention and control; increasing muscle mass; increasing metabolism; improving mood; and lowering anxiety. Many of these benefits can also help prevent another stroke.

Another priority for most stroke survivors is the ability to walk or move around. However, research demonstrates that stroke survivors spend almost 80% of their days sitting or lying down. In doing so, they accumulate less than 50% of steps compared to what their healthy counterparts accumulate.

Sedentary behavior leads to deconditioning, reduced aerobic capacity, and lower energy levels. It also contributes to higher triglyceride levels, a risk factor for stroke. Empowering stroke survivors to be upright and mobile during the day could help prevent another stroke.

Stroke rehab programs can take a cue from cardiac rehab

Stroke survivors are usually discharged from a hospital or rehab facility with an exercise program to continue at home. The program typically focuses on functional exercises that help them perform their ADLs independently. Sometimes home physical therapy and occupational therapy are provided for a few weeks, but there is little focus, if any, on increasing aerobic capacity with a walking program.

Patients who have suffered a heart attack are often enrolled in an outpatient cardiac rehab program, which focuses on increasing aerobic capacity. There is no equivalent, aerobic activity-based outpatient program for stroke survivors. The JAHA systematic review and meta-analysis suggests that perhaps there should be.

Researchers examined 19 studies that looked at the use of aerobic training programs for stroke survivors. The aerobic training programs were mostly walking (47%), some stationary cycling (21%), some mixed modality (21%), and a few recumbent stepping (11%). The amount of exercise was comparable to the amount and intensity of that offered in most cardiac rehab centers for survivors of heart attacks. The researchers found that programs providing two to three exercise sessions a week, for 30 to 90 minutes per session for eight to 18 weeks, resulted in significant improvements in aerobic capacity and the distance the stroke survivor could walk in six minutes (the six-minute walk test).

More research is needed, but in the near future it may be that stroke survivors join heart attack survivors at cardiac rehabilitation facilities.

Incorporate more aerobic activity into stroke recovery, with or without a formal program

Until aerobic training becomes part of routine discharge planning for stroke survivors, they can speak to their physicians about starting a walking program. The goal would be to work your way up to two to three sessions a week for 30 minutes or longer per session.

Local YMCA programs may have treadmills available, as well as personal trainers, if needed, for supervision. If a stroke survivor is discharged with home physical therapy, they can discuss a walking program with their therapist. Having an exercise buddy — a family member, a friend, or a fellow stroke survivor — helps with motivation and consistency. For stroke survivors who are not walking independently, swimming or pool exercises may be beneficial.

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Why are women using CBD products — and do they work?

Cannabidiol (CBD) oil and other products containing CBD are being touted as a natural, organic remedy for a wide range of women’s health concerns. Sellers of these products make many claims: CBD has calming effects on sleep, mood, and anxiety; eases hot flashes and improves bone density by balancing hormonal changes of menopause; and has anti-inflammatory properties that clear skin, cure acne, and calm rosacea. It’s promoted for PMS symptoms like bloating and mood swings. And CBD-infused lubricants claim to boost arousal and enjoyment of sex. So, how much of this is true?

First, what is CBD?

CBD is a major ingredient in cannabis plants (like hemp and marijuana). It comes in different strengths and forms, often as CBD oil, but also in pills and powders. It can be absorbed through the skin, ingested, or inhaled. (Vaping it, however, may not be safe, as this blog post and web page from the CDC explain.)

Unlike marijuana, pure CBD products don’t make you feel high. A different ingredient in marijuana called THC makes people feel high.

Does CBD have proven benefits?

So far, there’s not much evidence on the medical benefits of CBD, partly because laws on marijuana made it difficult to study. Until we learn more, it’s wise to keep in mind that few high-quality studies have been done.

• In 2018 the FDA approved a drug derived from CBD to treat rare forms of childhood epilepsy. This medication was shown in randomized clinical trials to reduce the frequency of seizures (see here and here).
• A few studies have found CBD may improve anxiety, but the studies were small and of poor quality (see here and here).
• Some laboratory research on human cells suggests CBD may have anti-inflammatory effects on oil-secreting glands in the skin. This might have implications for acne and other inflammatory skin disorders, but further research is needed to confirm this. And while CBD in skin products is unlikely to harm you, most dermatologists agree that there are more effective and better-studied medications and treatments for acne and inflammatory skin disorders.

Other potential benefits of CBD aren’t clear. No high-quality research shows that CBD improves sex drive, decreases pain, treats depression or mood disorders, decreases PMS symptoms like bloating and cramps, or relieves symptoms of menopause like hot flashes. This may change as more studies are done, but for now, the jury is out.

Are CBD products safe?

The short answer is this: pure CBD seems to be safe for most people. However, we don’t have rigorous studies and long-term data to prove whether or not a wide range of CBD products are safe for everyone. For example, there is no evidence to suggest that CBD is safe during pregnancy or breastfeeding, or for people who are immunocompromised.

Because CBD products aren’t regulated by the FDA in the way that drugs are, there is huge variation in quality and, quite possibly, safety. In 2017–2018, counterfeit CBD oil was found that contained synthetic cannabinoids and led to a poisoning outbreak in Utah.

Testing shows purity and dosage can be unreliable in many products. One study found less than a third of the products tested had the amount of CBD shown on the label. Another study of 84 CBD products bought online showed that more than a quarter of the products contained less CBD than stated. In addition, THC (the component that can make you feel high) was found in 18 products.

Does CBD cause side effects?

CBD can cause side effects like dry mouth, diarrhea, reduced appetite, and drowsiness. Additionally, it can interact with certain medicines, such as blood thinners and antiseizure drugs. If you would like to start using CBD products, it’s best to first talk to your doctor.

The takeaway

There are a lot of extravagant product claims out there about the benefits of CBD for women, but little high-quality research supports them. CBD oil and other CBD products aren’t well regulated. It’s possible what you are buying is counterfeit or contaminated. Before using CBD — especially if you plan to vape or ingest it — first talk with your doctor or healthcare provider to learn whether it could be safe and helpful for you.

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Think your child has ADHD? What your pediatrician can — and should — do

ADHD, or attention deficit hyperactivity disorder, is the most common neurobehavioral disorder of childhood. It affects approximately 7% to 8% of all children and youth in the US. As the American Academy of Pediatrics (AAP) pointed out in their recent clinical practice guideline for ADHD, that’s more than the mental health system can handle, which means that pediatricians need to step up and help out.

So, if your child is having problems with attention, focus, hyperactivity, impulsivity, or some combination of those, and is at least 4 years old, your first step should be an appointment with your child’s primary care doctor.

What steps will your pediatrician take?

According to the AAP, here’s what your doctor should do:

Take a history. Your doctor should ask you lots of questions about what is going on. Be ready to give details and examples.

Ask you to fill out a questionnaire about your child. Your doctor should also give you a questionnaire to give to your child’s teacher or guidance counselor.

A diagnosis of ADHD is made only if a child has symptoms that are

• present in more than one setting: For most children, that would be both home and school. If symptoms are only present in one setting, it’s less likely to be ADHD and more likely to be related to that setting. For example, a child who only has problems at school may have a learning disability.
• causing a problem in both of those settings: If a child is active and/or easily distracted, but is getting good grades, isn’t causing problems in class, and has good relationships in school and at home, there is not a problem. It bears watching, but it could be just personality or temperament.

There are ADHD rating scales that have been studied and shown to be reliable, such as the Vanderbilt and the Conners assessments. These scales can be very helpful, not just in making diagnoses, but also in following the progress of a child over time.

Screen your child for other problems. There are problems that can mimic ADHD, such as learning disabilities, depression, or even hearing problems. Additionally, children who have ADHD can also have learning disabilities, depression, or substance use. It’s important to ask enough questions and get enough information to be sure.

Discussing treatment options for ADHD

If a diagnosis of ADHD is made, your pediatrician should discuss treatment options with you.

• For 4- and 5-year-olds: The best place to begin is really with parent training on managing behavior, and getting support in the classroom. Medications should only be considered in this age group if those interventions don’t help, and the child’s symptoms are causing significant problems.
• For 6- to 12-year-olds: Along with parent training and behavioral support, medications can be very helpful. Primary care providers can prescribe one of the FDA-approved medications for ADHD (stimulants, atomoxetine, guanfacine, or clonidine). In this age group, formal classroom support in the form of an Individualized Education Program or a 504 plan should be in place.
• For 12- to 18-year-olds: The same school programs and behavioral health support should be in place. Medications can be helpful, but teens should be part of that decision process; shared decision-making is an important part of caring for teens and for getting them ready to take on their own care when they become adults.

Follow-up care for a child with ADHD

Your pediatrician also should follow up with you and your child. Early on, there should be frequent visits while you figure out the diagnosis, as well as any other possible problems. And if medication is prescribed, frequent visits are needed initially as you figure out the best medication and dose and monitor for side effects.

After that, the frequency of the visits will depend on how things are going, but appointments should be regular and scheduled, not just made to respond to a problem. ADHD can be a lifelong problem, bringing different challenges at different times, and it’s important that you, your child, and your doctor meet regularly so that you can best meet those challenges.

Because together, you can.

Follow me on Twitter @drClaire

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Chronic fatigue syndrome: Gradually figuring out what’s wrong

In 1983, a health professional in her 30s walked into my office and said, “I’ve been healthy all of my life. A year ago, I came down with some kind of virus — sore throat, aching muscles, swollen lymph glands, fever. My fatigue was so bad I was in bed for nearly a week. Many of the symptoms gradually improved, but the terrible fatigue and difficulty thinking have not gotten better. They’re so bad I can’t fulfill my responsibilities at home or at work. This illness is affecting my brain, stealing my energy, and affecting my immune system. It’s keeping me from realizing my dreams.”

There’s a piece of advice attributed to a famous physician, William Osler, that every medical student probably has heard: “Listen to your patient. The patient is telling you the diagnosis.” But I wasn’t sure it applied in this case.

What we knew then

First of all, the textbooks of medicine didn’t describe an illness like this. In addition, all the usual laboratory tests to screen for various diseases came back normal. At this point, a doctor has two choices: decide to believe the patient and keep searching to find what is wrong, or to tell the patient, “There is nothing wrong.” Indeed, some doctors seeing people like my patient did just that, adding insult to injury.

Fortunately, many physicians and biomedical scientists around the world became interested in this illness, and over 9,000 scientific studies have been published in the past 35 years. The Institute of Medicine has concluded that the condition, now called myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) “is a serious, chronic, complex systemic disease that often can profoundly affect the lives of patients.” It affects up to 2.5 million people in the United States, and generates direct and indirect expenses of approximately $17 to $24 billion annually.

What we know now

As I discussed in a recent article in the journal JAMA, research has documented underlying biological abnormalities involving many organ systems in people with ME/CFS, compared with healthy controls. Here’s an overview of what the current science suggests.

The brain. Tests of brain hormones, formal tests of thinking, magnetic resonance imaging (MRI), and positron emission tomography (PET) scans of the brain are abnormal in a substantial fraction of patients with ME/CFS. Tests of the autonomic nervous system, which controls vital functions including body temperature, blood pressure, heart rate, breathing rate, and movement of the intestines and bladder, also are abnormal. Not all of these abnormalities of the brain are present in every person with ME/CFS, and they appear to come and go.

Energy metabolism. We are alive because the cells of our body are alive. And they’re alive because they can make energy, and use that energy to do their jobs and remain alive. Our cells make energy out of the oxygen in the air we breathe, and out of the sugars, fats, and proteins we eat. In ME/CFS, research has shown that the cells have trouble both making and using energy. That is, people with ME/CFS feel they don’t have enough energy because their cells are not making enough, nor using what they make efficiently. The ability of cells to extract oxygen from the blood and use it to make energy appears particularly defective after physical and mental exertion.

Immune system. The immune system is complicated, containing many different kinds of cells that make many different kinds of chemical signals to talk to each other. Hundreds of studies have found evidence that in people with ME/CFS, the immune system is chronically activated, as if it is fighting something, and that parts of the immune system are exhausted by the fight.

Activation of “hunkering-down” systems. Animals, including humans, have systems to protect them during times of major threats. For example, worms and bears that are faced with a shortage of food “hunker down”: they activate systems that focus the energy they are able to make on the processes necessary to stay alive. Nonessential, energy-requiring activities are minimized. Humans who are seriously injured or sick also activate various hunkering-down systems. Some evidence suggests that in ME/CFS the hunkering-down systems may have been turned on, and remain inappropriately stuck. Research teams are trying to figure out how to turn off the hunkering-down systems.

Continued research should lead to better understanding and treatments

A great deal more is known about ME/CFS today than 35 years ago. With continued and expanded support from the NIH, CDC, and private foundations dedicated to ME/CFS, I expect a lot of progress in the coming decade. Instead of doctors saying, “The tests came back normal, there is nothing wrong,” they will say, “Tests showed us what was wrong, and we have treatments to fix it.”

And doctors will recognize the wisdom of the wise advice we all learned in medical school: “Listen to your patient. The patient is telling you the diagnosis.”

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Straight talk on planking

The best exercise I do only takes a minute.

Granted, it is often the longest and most grueling 60 seconds of my life. I sweat, I shake, and I often collapse in relief when it’s over. But spending quality time in a plank pose always pays off.

The plank pose is where you hold a push-up position while resting on your forearms. This simple move is the ideal exercise for strengthening crucial core muscles. As you go about your day, almost every move you make revolves around your core — from picking up items on the floor to twisting to see if the coast is clear when driving.

Why is it important to have a strong core?

Your core is made up of several muscle groups and covers your abdominals, back, hips, pelvis, and buttocks. A weak core can cause all kinds of problems. It can lead to poor posture, and inevitably to neck and shoulder pain. Sore knees and hips often can be traced to a weak core.

But the biggest issue with core weakness is low back pain. Back muscles and your core help to stabilize your body before any movement. If your core is weak, the other surrounding muscles have to compensate. Over time, these muscles can suffer strain, which leads to lingering pain.

Strike a pose instead of a sit-up

The standard sit-up is often the go-to core strengthener, but it has limits. “It only targets a portion of the core musculature, and the bending-forward motion can strain the neck and lower back,” says Eric L’Italien, a physical therapist with Harvard-affiliated Spaulding Rehabilitation Center.

By comparison, the plank pose activates all the core muscles at once, and doesn’t require extra movements that can cause stress or injury. “And because it has many modifications, it can be done by almost anyone, regardless of current fitness level,” says L’Italien.

How long should you hold a plank?

The world record for holding a plank is more than four hours, but thankfully, you don’t need to devote that much time. Most experts suggest anywhere from 10 up to 30 seconds is plenty. “Focus on doing multiple sets of smaller amounts of time,” says L’Italien.

As you progress, you can extend your plank for up to one or even two minutes, but don’t go beyond that. “Two minutes is often considered the maximum, and you don’t get much more benefit after that,” says L’Italien.

How often should you do planks?

You can perform a plank every day, on alternate days, or simply as part of your regular workouts. (I sometimes like to do mine during workday breaks.)

How to do a plank correctly

Here’s how to do a plank correctly:

• Lie facedown with your forearms on the floor, with your legs extended and your feet together. You can use a mat or towel to make this more comfortable.
• Push into your forearms as you raise your body so it forms a straight line from your head and neck to your feet. (Do not let your hips rise or sag.)
• Keep your gaze down and hold this position as you engage your abdominal muscles. Take steady, even breaths.
• Try to maintain the position for up to 30 seconds and then lower your body and rest. This completes one set. Work toward completing two to three sets.

When you first start to do planks, you may not be able to hold the correct position for very long. Keep practicing and you’ll find it becomes easier to do.

If resting on your forearms is uncomfortable, do the plank from a push-up position, with your arms fully extended. If you have back pain or other back issues, either do the plank on your knees or stand straight and lean against a counter so your body is at a 45° angle.

If you need more of a challenge, try alternating leg lifts during the pose: raise one leg for a second or two, and then repeat with the other leg.

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Curcumin for arthritis: Does it really work?

Osteoarthritis is a degenerative joint disease that is the most common type of arthritis. Usually, it occurs among people of advanced age. But it can begin in middle age or even sooner, especially if there’s been an injury to the joint.

While there are treatments available — exercise, braces or canes, loss of excess weight, various pain relievers and anti-inflammatory medicines — these are no cures, and none of the treatments are predictably effective. In fact, often they don’t work at all, or help only a little. Injected steroids or synthetic lubricants can be tried as well. When all else fails, joint replacement surgery can be highly effective. In fact, about a million joint replacements (mostly knees and hips) are performed each year in the US.

So, it’s no surprise that people with osteoarthritis will try just about anything that seems reasonably safe if it might provide relief. My patients often ask about diet, including anti-inflammatory foods, antioxidants, low-gluten diets, and many others. There’s little evidence that most of these dietary approaches work. When there is evidence, it usually demonstrates no consistent or clear benefit.

That’s why a new study is noteworthy: it suggests that curcumin, a naturally occurring substance found in a common spice, might work for osteoarthritis.

A new study of curcumin for osteoarthritis of the knee

In the study, researchers enrolled 139 people with symptoms of knee osteoarthritis. Their symptoms were at least moderately severe and required treatment with a nonsteroidal anti-inflammatory drug (NSAID). For one month, they were given the NSAID diclofenac (50 mg, twice daily) or curcumin (500 mg, three times daily).

Why curcumin? It’s a naturally occurring substance, found in the spice turmeric, that has anti-inflammatory effects. Its use has been advocated for cardiovascular health, arthritis, and a host of other conditions. However, well-designed studies of its health benefits are limited.

Here’s what this study found:

• Both treatments relieved arthritis symptoms and helped to a similar degree: 94% of those taking curcumin and 97% of those taking diclofenac reported at least 50% improvement.
• People reported fewer side effects with curcumin. For example, none of the study subjects taking curcumin needed treatment for stomach trouble, but 28% of those taking diclofenac needed treatment.
• Those taking curcumin lost, on average, nearly 2% of their body weight in just four weeks — that’s 3.5 pounds for a 175-pound person.

Ready to start taking curcumin?

Not so fast. It’s rare that a single study can change practice overnight, and this one is no exception. A number of factors give me pause:

• The study was small and only lasted a month.
• Only osteoarthritis of the knee was studied. We should not assume that other types of arthritis or that osteoarthritis of other joints would respond similarly.
• Curcumin was compared with only one possible dosage level of diclofenac (not the highest advisable dose). In addition, the diclofenac used in this study was uncoated (even though there is a coated formulation designed to be easier on the stomach). The results of this study might have been different if another NSAID or a different dose or formulation of diclofenac had been compared with curcumin.
• The study was unblinded — that is, study participants and researchers knew who was getting curcumin and who was getting the NSAID. This can sometimes bias the results by changing expectations of side effects or benefit.
• We don’t know how well curcumin would work, or if it would be safe, for the types of people excluded from this study. For example, this study enrolled adults ages 38 to 65 and excluded those with significant kidney or stomach disease. For younger or older people, those with other medical problems, or those taking multiple medications, the results might have been different.
• Over-the-counter dietary supplements (“nutriceuticals”) are not tested or regulated the way prescription drugs are. So, information regarding purity, strength, and potential interaction with other medications or diseases is typically limited for treatments like curcumin. It’s worth noting that reports of lead contamination in turmeric have been recently published.
• Weight loss as a side effect of taking curcumin might be a problem for those who are already lean.

The bottom line

Studies of this sort are vitally important in trying to understand whether dietary changes can be helpful for arthritis. While this new study provides support for curcumin as a treatment for osteoarthritis of the knee, I’d like to see more and longer-term studies in osteoarthritis and other types of joint disease, as well as more extensive testing of its safety, before recommending it to my patients.

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What is palliative care, and who can benefit from it?

The American population is getting older and sicker. More Americans are facing life-threatening illness when approaching end of life. Palliative care has grown to meet the complex needs of this population.

And yet, according to a 2017 article in the journal Palliative Care, many people living with a chronic life-threatening illness either do not receive any palliative care, or receive services only in the last phase of their illness. The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care also addressed this issue, stating that a goal of their recently updated guidelines is “to improve access to quality palliative care for all people with serious illness regardless of setting, diagnosis, prognosis, or age.”

There may be many reasons why patients do not access palliative care services. But it’s likely that greater awareness of what palliative care is, and who can benefit from it, may lead to greater adoption of these services.

The philosophy of palliative care

Palliative care improves the quality of life, comfort, and resilience of seriously ill patients as well as their families. Seriously ill patients are those with life-threatening medical conditions, like cancer, organ failure, or dementia, that negatively impact the patient’s daily life or result in a high level of stress for the caregiver.

Palliative care utilizes an interdisciplinary team of physicians, nurses, social workers, and chaplains to assess and manage the physical, psychological, social, and spiritual stressors associated with serious illness. It can be provided by primary care physicians, specialists like cancer or heart doctors, palliative care specialists, home health agencies, private companies, and health systems.

Palliative care can look very different from patient to patient. For a patient with cancer, for example, the palliative care team collaborates with the cancer doctors to manage the pain caused by the cancer, the side effects caused by treatment, and the anxiety and spiritual suffering of having a cancer diagnosis. For a patient with heart failure, the team collaborates with the heart doctors to manage the shortness of breath that makes it hard to walk to the bathroom, the financial stress of being too sick to work, and the social isolation of not engaging in their usual activities. For a patient with dementia, the team collaborates with the primary care doctor to manage the patient’s confusion and agitation while harnessing community resources such as a home health aide or visiting nurse to provide respite and support for the family.

This interdisciplinary approach can be provided throughout the course of an illness and across health care settings. It can span hospitals, clinics, long-term care, assisted living, rehabilitation, and correction facilities, as well as homeless shelters.

Who can benefit from palliative care?

Palliative care is available to all patients with serious illness regardless of age, prognosis, disease stage, or treatment choice. It is ideally provided early and throughout the illness, together with life-prolonging or curative treatments. In other words, patients don’t have to choose between treatment for their illness and palliative care; they can have both.

Palliative care not only improves the quality of life of patients and their families, reducing mental and physical distress and discomfort, but can help patients live longer. The prolonged survival is thought to be due to improved quality of life, appropriate administration of disease-directed treatments, and early referral to hospice for intensive symptom management and stabilization.

Palliative care and hospice care: Not one and the same

Although the overarching philosophy is similar, palliative and hospice care are distinct services. Hospice care is provided to patients near the end of life, with a high risk of dying in the next six months and who will no longer benefit from or have chosen to forego further disease-related treatment.

The focus switches from life-prolonging or curative treatment to comfort care. The interdisciplinary team provides quality medical care to make the patient as comfortable as possible, while supporting loved ones during the dying process and with bereavement support after death.

Hospice care can be provided in an individual’s home, assisted living, long-term care, hospice facility, and in hospitals. Hospice care will neither hasten nor prolong the dying process; instead it will optimize the quality of life for the time remaining.

Making the most of palliative care services

If you or a loved one is living with serious illness, ask your primary or specialty care doctor for a palliative care referral. If palliative services are not available locally, your doctor may explore your palliative or hospice needs with you directly.

Use this discussion and the resulting services as an opportunity to:

• Assess and manage poorly controlled physical, psychological, social, and spiritual stressors.
• Understand your illness, its expected trajectory, and treatment options.
• Explore your hopes, worries, goals, and values; cultural or religious beliefs that impact your care or treatment decisions; treatments you may or may not want; what quality of life means to you.
• Discuss and document your health care proxy and end of life preferences, including medical interventions you do or do not want.

It is never too early to ask how palliative services can help you or your loved one live well. Learn more from the Center to Advance Palliative Care.

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HPV and cancer: The underappreciated connection

Did you know that a viral infection can lead to a number of different types of cancer? If that comes as a surprise to you, you’re not alone. In fact, according to a new study, many people have no idea that a common viral infection called human papilloma virus (HPV) can cause cancer of the genitals, anus, mouth, and throat, as well as cervical cancer.

Viral infections and cancer

The connection between certain viral infections and cancer has been recognized for many years. Some of the most well-established examples include hepatitis C, human immunodeficiency virus (HIV), and human papillomavirus (HPV). One thing these viruses have in common is that the immune system may have trouble fighting them off, allowing an infection to become chronic.

HPV and cancer

According to the CDC, HPV causes about 44,000 cancers in men and women each year in the US. The connection between HPV and cancer is particularly important to know about, because there is an approved vaccine to prevent many strains of HPV infection most closely linked to cancer. And it works: since the approval of the initial vaccine in 2006, rates of HPV infection and cervical cancer have dropped significantly.

Unfortunately, far too few kids and young adults receive the vaccine. Perhaps a lack of awareness of the link to different cancers is one reason for the low numbers, even though the connection has been known for many years. Besides cervical cancer, HPV can also cause cancers of the

• mouth and throat
• penis
• anus
• vagina and vulva.

It would help if many more people understood the link between HPV and cancer. A study recently published in JAMA Pediatrics surveyed more than 6,200 adults in the US about their knowledge of HPV and cancer. Here’s what the researchers found.

• Two-thirds of women and one-third of men ages 18 to 26 knew that HPV can cause cervical cancer.
• 80% of women and 75% of men between the ages of 18 to 26 knew that HPV plays a role in cancers of the penis, anus, and mouth.
• But, among adults of all age groups, more than 70% did not know about the link between HPV and penile, anal, and oral cancers.

Clearly, there is a large knowledge gap regarding HPV and the serious problems it can cause. The findings among young adults are particularly notable. As they become parents in the years ahead, they’ll be the ones making decisions for their kids about vaccination.

Who should receive the HPV vaccination?

Current recommendations advise vaccination for all boys and girls ages 11 to 12, though it can be given as early as age 9. It can also be given after age 12, but if one waits until age 15 or older, three doses (instead of two) are recommended. Ideally, the vaccination happens before any exposure to the HPV virus occurs during sexual activity, so delaying vaccination is not advised.

What if a person isn’t vaccinated at this time? The CDC recommends catch-up vaccinations for everyone through age 26. People between 27 and 45 may also receive the vaccine, although they may already have been exposed to HPV and may be less likely to benefit. Talk to your doctor about your situation and preferences.

The bottom line

Currently, only about half of eligible teens have received the HPV vaccination as recommended. Hopefully, more widespread recognition of the connection between HPV and different types of cancer will increase vaccination rates. Those who were not vaccinated as teens may benefit from the vaccine as adults.

Talk to your doctor about which vaccinations are recommended for you. While we usually think of vaccinations as a way to prevent infection, in the case of HPV, vaccination may also prevent several types of cancer.

Reference

Public Knowledge of Human Papillomavirus and Receipt of Vaccination Recommendations. JAMA Pediatrics, September 16, 2019.

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Stopping the vicious cycle of rebound headaches

Rebound headaches, also known as medication overuse headaches, are caused by the frequent or excessive use of pain-relieving and/or antimigraine drugs to treat headache attacks that are already in progress. (Note that these are not the same as oral prophylactic or preventive medicines, which should be taken daily.) In other words, the same medications that initially relieve headache pain can themselves trigger subsequent headaches if they are used too often. Medication overuse headaches can be disabling, forcing people with this condition to take sick leave and to be less productive at work and home.

To be diagnosed with medication overuse headaches, a person must experience headaches on more than 15 days per month for at least three months while taking pain relieving and/or antimigraine drugs. In addition to headache, other symptoms can include nausea, vomiting, light sensitivity, sound sensitivity, irritability, difficulty concentrating, insomnia, restlessness, and constipation.

Medication overuse headache is a common headache disorder. Approximately one to two out of every 100 people has experienced medication overuse headache in the past year. This headache is more common in women, and in people with chronic pain conditions and who have depression and anxiety.

Medication, then medication overuse headache: a vicious cycle

Pain relieving or antimigraine medications may stop headache attack when taken as needed to relieve headache. But if a person with a primary headache disorder, such as migraine or tension-type headache, takes these headache-relieving medications more than two to three days a week, they may trigger medication overuse headache.

A variety of medications can lead to rebound headaches. For example, people with migraine who take over-the-counter pain-relieving medications such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin), or naproxen (Aleve) on more than 15 days per month are at risk for medication overuse headache. So are people who take combination medications such as Excedrin, which contains caffeine, aspirin, and acetaminophen; people who take combination medications that contain the barbiturate butalbital; and those who take triptans, including sumatriptan (Imitrex), ergots, or opioids, if they take these medications on more than 10 days per month. In fact, butalbital-containing medications and opioids have been shown to increase the risk of a person’s migraine progressing from episodic (occurring zero to 14 days per month) to chronic (occurring 15 or more days per month).

Interestingly, the same pain-relieving medications taken for other conditions such as back pain, neck pain, or arthritis usually do not trigger medication overuse headache in people without a pre-existing primary headache disorder.

Treating rebound headaches

Medication overuse headaches usually stop when a person stops taking the headache medication. It may be difficult in the beginning, because once you stop your medication, your headache is likely to get worse before it gets better. But medications that prevent headaches, and nonmedical therapies such as biofeedback and avoiding headache triggers, can help get a person through this medication withdrawal period.

Some headache medications can be discontinued abruptly, while others may need to be tapered slowly. For example, following long-term use, opioids and butalbital-containing medications should not be stopped abruptly. Doing so may lead to withdrawal symptoms such as sweating, shaking, nausea, vomiting, diarrhea, body aches, anxiety, irritability, or runny nose. Abrupt discontinuation of butalbital may result in seizures. Some people may benefit from discontinuing these medications in an inpatient setting. If you are taking opioids or butalbital-containing medications, talk to your doctor.

How can I prevent rebound headaches?

The following steps can help stave off rebound headaches.

• Limit the use of any headache medications taken as needed to relieve headache pain to no more than two to three days per a week (or less than 10 days per month).
• Contact your doctor if you need to take headache medications more than two days per week.
• Contact your doctor if you have headache more than four days per month. You may need to be on headache preventive medication.
• Avoid using butalbital-containing medications or opioids.
• Control and avoid anything that triggers your headaches. Common triggers include dehydration, hunger, lack of sleep, stress, and certain foods and drinks.

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In defense of the salt shaker

Sherry B, a healthy and active 61-year-old woman, came to my office several months ago. She had noted an unusually fast heart rate during exercise, and felt lightheaded when standing in line at the grocery store or after finishing her five-mile run. She carried a water bottle with her and drank from it throughout our meeting. “I don’t understand!” she said, “I’m always thirsty, even though I drink water constantly.” Most of her symptoms had started the previous year when she decided to “clean up” her lifestyle, began to exercise more regularly, and stopped eating out. She added proudly that she had thrown away her salt shaker.

After ruling out diabetes, weak heart, anemia, and other medical conditions, I suspected that Sherry was one of the few Americans who may actually not consume enough salt in their daily diet.

The dangers of insufficient sodium

Those at higher risk for getting insufficient salt (sodium) in their diet include people who sweat heavily with exercise or at work, have normal or low blood pressure, have normal heart and kidney function, and consume a very-low-sodium diet. In addition to an inappropriately fast heart rate and lightheadedness with standing, other symptoms can include constipation, fatigue, headaches, and even fainting. In extreme cases, excessive sodium restriction can cause brain swelling. There is no simple way to diagnose this problem; routine blood tests, including measurement of sodium levels in the blood, are typically normal.

We all know that too much salt is bad for our health. Excess sodium intake causes elevated blood pressure and increases the risk of cardiovascular disease (CVD). But consuming too little salt can also be harmful.

When we do not replace the salt we lose every day in our urine and feces, exhaled breath, and sweat, we cannot retain sufficient water to properly regulate our blood volume. This is because our kidneys precisely regulate the sodium concentration in our blood so that it matches the concentration in our cells. If we drink too much water without consuming enough sodium, our blood becomes more diluted than our cells. This forces the kidneys to eliminate the excess water as dilute urine. As a result, we can become “dehydrated,” no matter how much water we drink.

How much sodium do we need?

Individual sodium needs vary, but most people require at least 1,500 milligrams (mg) of sodium every day (roughly 2/3 of a teaspoon of table salt), with an additional 300 mg added per hour of exercise. When sodium intake is extremely restricted, the body compensates by increasing production of hormones called renin and aldosterone, which signal the blood vessels to narrow, and tell the kidneys to retain salt and water in an attempt to maintain balance. When sodium intake is so low that blood pressure drops when we stand (orthostatic hypotension), the body produces more norepinephrine, a “fight or flight” hormone that tells the heart to beat more quickly and forcefully.

Many studies have shown that consuming more than 5,000 mg of sodium per day is associated with increased risk for CVD. The PURE study, the largest international study to examine the relationship between sodium intake and health, looked at the relationship between sodium consumption and CVD risk in over 95,000 people from the general population. The authors reported a J-shaped association, with the lowest risk of CVD events in those with moderate sodium consumption (about 4,500 mg per day). Both higher and lower consumption (less than 3,000 mg per day) was associated with increased risk. (The study accounted for those who consume very little salt due to other illnesses.)

Moderation is key

The great majority of Americans consume excessive amounts of sodium, mostly in the form of commercially processed foods. Approximately 80% of our sodium intake comes from processed and restaurant foods, another 15% from foods that contain sodium such as olives and pickles, and only about 5% from salt added in the home.

From a CVD standpoint, the ideal diet would be comprised mainly of home-cooked, plant-based foods, but with a modest amount of added salt. With this strategy it is almost impossible to exceed the (somewhat arbitrary) 2,300 mg upper limit recommended by the American Heart Association.

Without a doubt, the typical Western diet, heavy in processed foods and extremely high in sodium, is contributing to excess CVD risk in the majority of Americans. However, we also need to keep in mind that a modest amount of sodium is essential for proper regulation of blood volume and nervous system function. In otherwise healthy people, there is no proven benefit, and possible harm, from overly restricting salt intake.

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